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tation vouchers, assistance with child care, or the use of extended clinic hours.
Incentives (defined as “something which will motivate the patient to take his medicine, keep clinic appointments or do anything else that is necessary to successfully carry out program goals” [Frieden et al., 1995]). These may include food stamps, coupons for fast-food restaurants, assistance with finding housing, etc. Incentives are tailored to meet the needs of the individual and, therefore, must be valued by that individual. This may vary considerably among patients as well as among communities.
Alternate treatment delivery sites, such as workplaces, park benches, street corners, ferry and subway stations.
Directly-observed therapy (where providers observe the patient ingesting the medication).
Outreach workers whose responsibilities may include adherence monitoring, sputum collection, education, contact investigation assistance, social service assistance, translation, and so forth.
Use of strategies that are specifically designed to overcome the social or cultural obstacles to treatment completion.
Treatment plans are developed in conjunction with the patient, the physician or nurse, a social worker (as necessary), and other team members, as appropriate. The plan is reviewed periodically and revised as needed through meetings between the patient and the assigned provider and often more formally through case and cohort reviews. The reviews must include the entire team providing care to the patient, including physicians, nurses, social workers, outreach workers, and so forth. A continuum of increasingly restrictive measures is used beginning with the use of the least restrictive measure (such as monthly monitoring in the outpatient setting) to the most restrictive measure (legally required hospitalization). These measures are invoked in a stepwise fashion to ensure that the needs and the rights of the patient are taken into account and the public's health is protected as well.
The second tuberculosis control priority is contact investigation and follow-up. Every individual with an infectious case or a suspected case of tuberculosis (index case) should prompt a thorough epidemiological investigation to identify other individuals who have potentially been exposed and who are therefore at high risk of having been infected by the index patient. These individuals should be evaluated for latent tuberculosis infection, and if they are found to have latent tuberculosis infection they should be placed on treatment and monitored until completion of therapy. Chapter 4 highlights the subject of contact investigations, their current use, and suggestions for improvement.
The final priority for health departments is the identification of per