"TB patients: Some don’t... some do, Some won’t... some will"

We read with interest the International Standards for Tuberculosis Care (ISTC) published in the November, 2006 issue of The Lancet Infectious Diseases (1). Focusing primarily on essential activities that all practitioners - public and private- should endorse regarding the management of patients diagnosed with suspected or confirmed tuberculosis, the ISTC brings to the forefront the responsibilities of all providers in delivering quality care to their patients. However, of equal interest is the recent publication of The Patients Charter for Tuberculosis Care (2) which addresses the rights and responsibilities of patients diagnosed with tuberculosis and which was developed in tandem with the ISTC.

In Tuberculosis Control we have much experience with patient non-adherence and of the issues surrounding a patient’s inability or unwillingness to follow through on program directives. As a result, we have become undaunted by the reality that patient non-adherence is commonplace in the world of TB. However, it also should be acknowledged that patients who often demonstrate adherent behavior are rarely discussed and virtually never reported. The following case report is of a patient’s remarkable determination to keep his scheduled appointment in an out-patient TB clinic and demonstrates how his actions may serve as a symbol of The Charter.

On July 5, 2005, patient CT submitted to a medical examination in Taiwan for travel clearance to the US. Diagnosed with Inactive Pulmonary TB, he arrived in New Jersey in November, 2005. After visiting with relatives for one week, CT decided to return to Taiwan. Because of unspecified delays, immigration papers were forwarded to the local TB Control jurisdiction in March, 2006. Unaware that he already returned to Taiwan and believing that this was a recently arrived immigrant, the local TB program initiated a field investigation to begin the process of locating and referring CT for medical evaluation. Field visits proved unsuccessful in contacting this individual. A certified letter was mailed informing him of an appointment for April 28. On the appointment date, CT appeared at the clinic.

A chest x-ray taken that day was negative. Accompanying CT were English-speaking relatives who acted as interpreters. During discussions between the physician and interpreters, CT’s US travel history emerged. It was revealed that not only did he return to Taiwan in November, but he remained there until the day before his scheduled clinic visit in NJ when, as requested in the certified letter forwarded by his family in the US to Taiwan, he flew from Taiwan to Newark to keep his appointment at the TB clinic. Profuse apologies were offered to CT for the inconvenience and unfortunate misunderstanding that occurred. When asked why he felt the need to fly to the US to keep his appointment CT replied "because it sounded important".

So the thought that lingers is how interesting it is that someone could justify flying 24 hours from across the world to keep an appointment at a TB clinic while someone else living across town can justify reasons for not keeping an appointment. This is an extreme example of adherence but one that perhaps makes the more typical excuses offered by non-adherent patients seem quite shameful.

1 Hopewell PC, Pai M, Maher D, Uplekar M, Raviglione MC. International Standards for Tuberculosis Care. Lancet Infec Dis 2006;6(11): 710-725.
2 The Patients Charter for Tuberculosis Care 2006 World Care Council/Conseil Mondial de Soins www.worldcarecouncil.org/

Mark Wolman
Program Manager
Tuberculosis Control

Lee Reichman MD MPH
Professor of Medicine
New Jersey Medical School
Executive Director
Global Tuberculosis Institute

Grant Support:
Mr. Wolman and Dr. Reichman are supported by both the New Jersey Department of Health &Senior Services and The Centers for Disease Control and Prevention

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"TB patients: Some don’t... some do, Some won’t... some will"

Action for Global Health has been started simultaneously in Brussels, France, Germany, Italy, Spain and the UK. They are monitoring how the actions and policies of European governments affect health in developing countries. They are inviting other NGOs and civil society organisations to join with them to build a European campaign to ensure that governments, the private sector and European institutions fulfil the promises they have made to reduce the rates of infant and maternal mortality and slowing down the spread of transmissible diseases in the world's poorest countries. To find out more click the link above.

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