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Contact InvestigationSalina, Kansas
March 29 31 2010March 29-31, 2010
TB Contact Investigation Basics
Jessica Quintero, BAAS
March 31, 2010
TB Contact Investigation Basics
Jessica Quintero, BAAS
Education Specialist
Heartland National TB Center
March 31, 2010
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Cutting out the Fat
• Initiation of a contact i ti tiinvestigation
• The investigation process
• Treatment
• Special circumstances
What is Contact Investigation and why should I care?
• Contact investigation are complicated activities that
irequire– Many interdependent decisions
– Time consuming interventions
• It is the 2nd priority in TB Elimination.
• Tool in prevention of future• Tool in prevention of future cases of TB disease by identifying people who were exposed to someone with infectious TB disease.
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The decision to initiate a contact investigation is based on the likelihood of transmission
which include…
A i l i f di• Anatomical site of disease
• Sputum Bacteriology
• Radiographic findings
• Behaviors that increase aerosolization of secretions
• Age
• HIV Status
• Administration of effective treatment
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Investigating the Index Case
• Health department’s responsibility.
• Written policies provide efficiency and uniformity.
• Trained staff should be assigned.
• Interviews should be in primary language of the intervieweelanguage of the interviewee.
• Interview in person within one day for symptomatic patients and three days for others.
The many stages on an interview
• Pre interview
– Medical records
– Attending RN or MDAttending RN or MD
• Interview
– Build report
– Education
– Information exchange
• Post interview
– Prioritize contacts
– Investigation plan
– Follow up
– Data reporting
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Confidentiality and Consent in CI
• Develop policies for release of information based on HIPAA and consult with legal.P ti t fid ti lit i• Patient confidentiality requires training on policies and laws.
• Discuss patient beliefs about confidentiality.
• Explain measures that will be taken to protect confidentiality often.
• Prepare for protecting• Prepare for protecting confidentiality at each visit (this can be problematic in some cases).
• Confidentiality applies to all private and medical information in addition to TB.
Don’t Forget About the Field Visit
• Residence of index case should be visited within three days of initial interview.
• All potential transmission sites should be visited and environment evaluated.
• Information learned in interview and site visits lead to investigation plan.g p
• Investigation plan will be a work‐in‐progress and should be reassessed continually.
• It becomes part of the permanent record.
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What is the infectious period?
• Open
– 3 months before diagnosis
– Earlier with known symptoms
• Close
– Effective treatment > 2 weeks
– Diminished symptoms
Mycobacteriologic response– Mycobacteriologic response
• Break in contact (BIC)
– 8‐10 weeks after last contact
– 8‐10 weeks after close of infectious period
Assigning Priorities to Contacts
• Prioritization identified as high, medium, or low based on:
– Likelihood of infection
– Potential hazard to the individual contact if infected.
• Characteristics of contacts
– Age
– Immune status
– Other medical conditions
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Testing and Treatment of Identified Contacts
• Evaluation
– Symptoms review
– Face to face assessment
– TST or CXR
– HIV testing recommended
• Treatment
– LTBI
– Window Treatment
Interpreting Skin Test Reaction
• ≥5 mm induration is positive for any contactfor any contact
• Do not use two‐step testing
• A positive BIC TST should be classified as recently infected
• Expectant mothers okay to test
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HIV Prevention Counseling and Testing
• Educate ALL contacts that HIV is the greatest known risk for disease progression and ASK if they have beenand ASK if they have been HIV tested.
• Offer HIV counseling and testing to contacts who do not know their current HIV status.
• Treatment for LTBI and continued evaluation iscontinued evaluation is recommended for HIV+ contacts even without TST+ result.
• Remember confidentiality of patients!
Evaluation of immunosuppressed contacts
– Automatically prioritized as highas high.
– CXR recommended in addition to medical history, exam and skin test.
– Sputum collection for any symptomatic contact or if CXR has abnormality that could be TB related.
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Evaluation and Follow‐up of Children <5 Years
• Always assigned a high priority
• Full diagnostic medical evaluation
• If TST <5 mm of induration and last exposure <8 weeks, Window‐Period Prophylaxis recommended
• Second TST 8–10 weeks after exposure; decision to treat is reconsidered– Negative TST – treatment discontinued
– Positive TST – treatment continued
Treatment for Contacts With LTBI
• Treatment to completion is the health department’s
ibilitresponsibility.
• LTBI contacts from high incidence countries should be treated regardless of BCG.
• Treatment offered to all with LTBI.
• Full LTBI treatment recommended for all HIV/immune‐suppressed regardless of prior treatment history.
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When to Expand a Contact Investigation
• Inclusion of low priorities not indicated until high and medium guidelines are met.
• Consider expanding according to extent of recent transmission.
• Review of data guides expansion.
C ll f h l if• Call for help if resources are exhausted and data indicates need to expand.
Data Management and Evaluation of CI
• Collect specific data needed for evaluation.
• Collect on standardized forms.
• Use specified standardized data definitions and formats when possible (simplicitywhen possible (simplicity vs. completeness).
• Electronic storage recommended.
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Staffing and Training for CI
• Some functions require state licensure especially for
i li d f i dspecialized functions and skills.
• Preparatory training and direct observation of new staff.
• Support staff need to understand the overallunderstand the overall purpose of the investigation.
• Health department responsibility for assuring sufficient skills of external staff (diagnosis etc.).
Congregate settings
– Correctional Facilities
– WorkplacesWorkplaces
– Hospitals and other health‐care settings
– Schools
– Shelters and other settings providing services for homelessfor homeless
– Transportation modes
– Drug and alcohol usage sites
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Source Case Investigations
• Reverse of a CI.
• Only recommended when all infectious case investigation gobjectives are being met including treatment completion of contacts.
• If done, recommended for cases of children under 5.
• Data should be reviewed for determining local valuedetermining local value.
• Searching for unexplained LTBI is generally not recommended and if done should be limited to LTBI in children younger than 2.
Cultural Competence
• Knowledge and interpersonal skills that allow health‐care providers to appreciate and work with persons from cultures other than their own.
• Ability to understand cultural norms and to bridge gaps g g prequires training and experience.
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Social Network Analysis
• Social Network – linkage of persons and places where M t b l i i d iM. tuberculosis is spread via shared air space.
• Social Network Analysis –methodology of visualizing and quantitating the relative importance of members in a social network .network .
• Social Network Analysis assumes there is some detectable patterning of the TB cases and their contacts in a community.
Benefits of Using the Social Network Analysis
• Provides a systematic method to deal with datamethod to deal with data already gathered in routine contact investigations.
• Analysis of the network can help identify important contacts (i.e., those most likely to be infected)likely to be infected).
• Real‐time monitoring of network growth may facilitate early detection of outbreaks.
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Initiating an Investigation Summary
• Consider if index patient has – Confirmed or suspected pulmonary, laryngeal, or pleural TBp p y y g p
– Chest radiograph consistent with pulmonary TB
• Recommended if– Sputum smear has AFB on microscopy
– Chest radiograph indicates presence of cavities in the lung (AFB sputum smear negative)
• Not indicated if
– Sputum smear has AFB on microscopy and nucleic acid amplification (NAA) tests for M.tuberculosis are negative
Testing and Treatment Summary
• Symptoms review
f• Face to face assessment
• TST or CXR
• Window‐Period
• Prophylaxis
• LTBI
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Foundation Summary
• Confidentiality
• Infectious Period• Infectious Period– 3 months before diagnosis– Effective treatment for > 2 weeks with diminished symptoms
• Data Collectionf– Important for organization
and reporting
Interview Summary
• Interview
– Preparation– Preparation
– Guidelines
– Follow up
• Prioritize contacts
– High g
– Medium
– Low
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C_N_A_T I_V_S_I_A_I_N
25% 25%25%25%25% 25%25%25%
1. U R I C J X O D C
2. U G U T L P I K R
3 T T E T N C G O O
1 2 3 4
3. T T E T N C G O O
4. A M X E B P J I K
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People exposed to someone with infectious TB disease are called the?
1 Local Community20% 20%
1. Local Community
2. Index Patient
3. Contact
4. Secondary Case0%
20%
20%
4. Secondary Case
5. Source Patient
How much higher is the rate of having TB disease for contacts versus the general
population?
20%
20%20%
20%
1. 15 times higher
2. 25 times higher
3. 50 times higher
20%
1 2 3 4 5
4. 75 times higher
5. 100 times higher
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“Are there any children in the home?” is an example of an open ended question
50%50% 50%50%1. True
2. False
Open ended questions begin with:
1 2
Who?What?When?Where?Why?How?
Which of the following is NOT a reason why contact investigation is important?
1 Find contacts who have TB disease
25%
25%
1. Find contacts who have TB disease.
2. Find contacts who have LTBI.
3. Because we are curious.
25%
25%
4. Find contacts at high risk.
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Who is responsible for contact investigations?
25% 25%25%25%25% 25%25%25%
1. Diagnosing physician
2. Patient
3 Health Department
1 2 3 4
3. Health Department
4. Anyone but me
Do you agree, LTBI Contacts from high incidence countries should be treated regardless of BCG ?
50%50%
1. Yes
2. No
1 2
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On average how many contacts are listed for each person with a case of infectious TB
in the United States?
25%25%
1. Two
2. Four
3. Eight
4. Ten
25%25%
1 2 3 4
When is the best time to build a relationship with congregate settings such as schools, jails,
shelters, etc…
20% 20% 20%20%20%
1. On Mondays
2. In the spring
3. Before conducting
4. After conducting
1 2 3 4 5
5. As soon as this training is over
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Completing the test on the MMWR on Contact Investigation Guidelines is sufficient training
for conducting contact investigations?
50%50%
A. True
B. False
A. B.
B. False
A source case investigation is used when..
25% 25%25%25%25% 25%25%25%
1. The patient has expired
2. The patient does not speak English
3. The patient is a child
1 2 3 4
3. The patient is a child
4. Anyone positive for LTBI
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Any Questions?
“It takes a village”
Practice, Practice, Practice
Education is keyEducation is key
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Acknowledgements and Credits
Center for Disease Control and Prevention (CDC)
Phil Griffin, TB Controller, Kansas Department of Health and Environment
Domingo J. Navarro, MBA, STD/HIV/TB Program Manager, City of San Antonio Metropolitan Health DistrictSan Antonio Metropolitan Health District