**6.4 Community-based programs**

An innovative community-based intervention to improve TB treatment outcomes was conducted in Sidama zone, Ethiopia [98, 99]. The core health workers mainly responsible for delivering the intervention to the grass-root level were called the health extension workers (HEWs). The HEWs were trained and salaried female health workers from the respective intervention regions. Active case finding and sputum smear preparation were conducted by the HEWs. The supervisors process the smears and initiate anti-TB treatment. Again, HEWs provide treatment support which includes provision and monitoring of treatment. Evaluation of the program over 4.5 years revealed that the proportion of patients lost to follow-up decreased significantly up to 3% [99]. The authors concluded that

*"We have thus demonstrated that bringing simple services that detect disease and provide treatment support close to where patients live is critical to increase access to TB diagnosis and treatment adherence and minimise the number of patients LTFU."*

Therefore, such community-based programs should be implemented in modified forms in different countries around the world to reduce the proportion of LTFU. Another important thing to note is that both this program and eCompliance mentioned above employed 'task shifting' toward basic health workers (CHWs and HEWs) to support TB treatment at the grass-root level, not the experts.

### **6.5 Social support programs**

In 2013, a novel social support program was developed in India by forming groups called "treatment support group (TSG)" [100].

*"A TSG is a non-statutory body of socially responsible citizens and volunteers to provide social support to each needy TB patient safeguarding his dignity and confidentiality by ensuring access to information, free and quality services and social welfare programs, empowering the patient for making decision to complete the treatment successfully."*

A TSG supports the various needs of the patient so that they can complete the anti-TB treatment without any worries. The package includes transportation service, treatment counseling, emotional and spiritual support, and providing accommodation for homeless TB patients. After the program was implemented, the rate of LTFU fell until it strikes zero in the latest cohorts. It is because it tackles the social dimension associated with LTFU. This is one program that the interviewed patients from Ethiopia, who were LTFU, had hoped for [101].

#### **6.6 Legislation**

In some countries, under certain circumstances, law enforcement is controversially used to solve the problem of LTFU. Usually, the patients who were LTFU were isolated in hospitals, but in some countries, they were isolated in prisons. Usually, this method was used against patients who were homeless and had a history of alcohol abuse [102]. When all the other methods fail, the medical officer, with the power given by the health laws, has to conduct a short-term incarceration of the patients who were LTFU.

Detention of patients includes ethical and human right problems. The controversy surrounding this issue has been discussed in detail in a review article by Mburu et al. [103]. They discussed that the primary reason for detention is to protect public health, according to the Siracusa Principles adopted by the UN Economic and Social Council. However, they argued that this conflicts with the international human right laws and the 1979 Alma-Ata Declaration.

*"…incarceration and detention approaches curtail the rights to health, informed consent, privacy, freedom from non-consensual treatment, freedom from inhumane and degrading treatment, and freedom of movement of people lost to follow-up. Detention could also worsen social inequalities and lead to a paradoxical increase in TB incidence."*

In the light of this information, the interventions which tackle the risk factors associated with LTFU are far superior to detention, which provides just a temporary solution to the problem, not a permanent one.

Another form of federal public health intervention is used in the USA to solve the problem of LTFU among the migrants [65]. These tools called the Do Not Board (DNB) and Border Lookout (BL) list are managed by the Department of Homeland Security (DHS) according to requests from the Centers for Disease Control and Prevention (CDC) Travel Restriction and Intervention expert workgroup. They are designed to detect land border travelers who were LTFU from TB treatment. State health departments and local health jurisdictions supply the list of patients and were reviewed under the following criteria:

*"(1) infectiousness or potential infectiousness with a communicable disease that would pose a public health threat if the individual travelled internationally;*

*(2) the person is unaware of his/her diagnosis, fails to adhere to public health recommendations, including treatment, or public health authorities are unable to locate the person; and*

*(3) the person poses a risk to travel internationally or on a commercial flight" [65].*

**121**

provided the original work is properly cited.

University of Medicine 1, Yangon, Myanmar

\*Address all correspondence to: kyawsanlin25@gmail.com

*Loss to Follow-Up (LTFU) during Tuberculosis Treatment*

to the program is still needed to handle this problem.

should be taken to reduce the number of LTFU patients up to 0%.

Myanmar for reviewing the chapter and giving helpful comments.

I would like to thank Dr. Pa Pa Soe, associate professor, Department of Preventive and Social Medicine, University of Medicine 1, Yangon, for her invaluable advice on writing this book chapter. I am also truly grateful to Dr. Kyaw Khan Zaw, Technical Support Officer, Population Services International, Yangon,

Analysis revealed that most of the patients from this list were successfully treated but most of the migrants remain LTFU, suggesting that some improvement

LTFU from treatment is a serious problem that cannot be ignored. Throughout this chapter, the consequences of LTFU, the magnitude of this problem in different countries, and the underlying factors have been discussed. Various researchers have designed potentially powerful interventions to tackle LTFU. But, we still need further evidence and actions to be able to successfully lower the number of patients that are LTFU. With these points in mind, it is suggested that an ambitious approach

*DOI: http://dx.doi.org/10.5772/intechopen.81900*

**7. Conclusion**

**Acknowledgements**

**Conflict of interest**

None declared.

**Author details**

Kyaw San Lin

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Analysis revealed that most of the patients from this list were successfully treated but most of the migrants remain LTFU, suggesting that some improvement to the program is still needed to handle this problem.
