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1 Contact Investigation Salina, Kansas March 29 31 2010 March 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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TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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Page 1: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

1

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

Page 2: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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.

Page 3: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 4: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 5: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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. 

Page 6: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 7: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 8: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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.

Page 9: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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.

Page 10: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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.

Page 11: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 12: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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.

Page 13: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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.

Page 14: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 15: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 16: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 17: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 18: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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.

Page 19: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 20: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 21: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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

Page 22: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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Any Questions?  

“It takes a village”

Practice, Practice, Practice

Education is keyEducation is key

Page 23: TB Contact Investigation · PDF fileTB Contact Investigation Basics Jessica Quintero, BAAS March 31, 2010 TB Contact Investigation Basics Jessica Quintero, BAAS Education Specialist

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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