1. Contact Investigations
WHO ?
WHERE ?
WHEN ?
HOW
LONG ?
WHY ?
HOW ?

2. WHO ? IS RESPONSIBLE FOR CONTACT INVESTIGATION?
YOU ARE!!!!!!

3. ROLE OF HEALTH DEPARTMENT
TO ENSURE THAT ALL PERSONS WHO ARE SUSPECTED OF HAVING TUBERCULOSIS ARE IDENTIFIED AND EVALUATED PROMPTLY AND THAT AN APPROPERIATE COURSE OF TREATMENT IS PRESCRIBED AND COMPLETED SUCCESSFULLY
MMWR TREATMENT OF TB pg.15

4. Health departments are responsible for ensuring contact investigations
Public health officials must decide which
Contact investigations should be assigned a higher priority
Contacts to evaluation first
Decision to investigate an index patient depends on presence of factors used to predict likelihood of transmission

5. WHY? IDENTIFY TB EXPOSURE IDENTIFY TRANSMISSION PREVENT TB DISEASE
We are looking for those who are at the greatest risk of exposure…length of exposure, where that exposure occurred………we do baseline testing and repeat testing at 10 weeks after exposure is broken which tells us if transmission has occurred…..we treat all positive TST thus preventing future cases.

6. Purpose of Contact Investigation
Identify, evaluate and treat individuals who may have been infected with TB by a person with active, infectious TB
Detect additional cases of active TB
Identify and treat contacts with LTBI to prevent TB disease

7. VIRGINIA’S STANDARD OF CARE
TB CASES/TB SUSPECTS - the initial interview will be conducted within 3 days
At least 90% of newly reported AFB smear + cases will have contacts identified and at least 95% of the contacts will be evaluated for disease and/or infection
Initial interview will be conducted within 3 days for 95%

8. Contact investigation will be initiated within 3 days of the first notification and completed within three months
85% of contacts found to be infected with Mtb infection will complete a full coarse of recommended treatment

9. HOW?
“Contact investigations are complicated undertakings that typically require hundreds of interdependent decisions, the majority of which are made on the basis of incomplete data, and dozens of time-consuming interventions…..”

10. CASE MANAGEMENT SKILLS
EFFECTIVE COMMUNICATION
CONFIDENTIALITY
THOROUGHNESS
PERSISTANCE

11. Evaluation of the Index Patient
Comprehensive information regarding the index patient is the foundation of a contact investigation
Requires review of medical records and patient interview(s)
Requires systematic collection and management of data

12. Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis 2005

13. Guidelines for Investigation of Contacts
Identification, evaluation and treatment of contacts is element of case management
Characteristics of case determine need for and extent of contact investigation
Contact investigation activities should be planned, prioritized to ensure identification and treatment of highest risk contacts
Putting all of the pieces of the puzzle together…Have CI in your mind as you start that first interview with the client….are there children in the home??? Is there anyone here who is immune compromised????..be flexible….things change at least on a daily basis….use your
ORW as your eyes and ears…often the client tells us only what they want us to know and we find out later that what we thought was happening isn’t what is going on at all.

14. Probability of TB Transmission
Transmission dependent on three factors
Infectiousness of the person with TB
Environment in which the transmission occurs
Duration of the exposure to TB bacteria

15. Infectiousness of patient
Pulmonary, laryngeal, or pleural
AFB on sputum smear (1+ or 4+)
Cavitation on x-ray,
Adolescent or adult
Period of infectiousness
Environment – activities leading to aerosolization
Inspect home, work and social environment
Duration of exposure – proximity, small space, limited ventilation - increase chance that susceptible contact will breathe AFB into lungs

16. Decisions to Initiate a Contact Investigation

17. NOT EVERY TB CASE REQUIRES A CONTACT INVESTIGATION

18. Additional considerations….
Pulmonary, laryngeal or pleural TB
Pleural is now grouped with pulmonary because sputum cultures can yield M. tuberculosis even when no lung abnormalities are apparent on x-ray
AFB smears should always be done when diagnosis is pleural TB (suspected or confirmed) because parenchyma abnormalities may be hidden by fluid

19. Additional considerations….
Consider contact investigation for TB case with extra pulmonary disease if there were procedures that generate aerosols (i.e. autopsy, embalming, wound irrigation or manipulation of a draining abscess)

20. Additional considerations….
If original specimens were from
bronchoscopy/bronchial washings:
Guidelines recommend equating results of AFB microscopy on bronch washings to sputum
VDH recommends that sputum be collected and assessment of infectiousness be based on sputum AFB results
If unable to collect sputum, use results of bronchial washings

21. Additional considerations….
Available resources should be focused on identifying, evaluating and treating exposed persons who are more likely to be infected or to become ill with TB disease if they are infected
Persons with longest, closest contact
Infants, young children , immunocompromised, persons with serious underlying medical conditions

22. Concentric Circle
Work/School
Household
Social/
Community

23. Additional considerations
Do we suspect the base case to be MDR?
Contacts of MDR need to be continually re-assessted
Potential for prolonged periods of infectiousness

24. INDEX CASE
THE FIRST PERSON WITH TB DISEASE WHO IS IDENTIFIED IN A PARTICULAR SETTING

25. SOURCE CASE
THE PERSON OR CASE THAT WAS THE ORIGINAL SOURCE OF THE INFECTION
TWO CIRCUMSTANCES FOR SOURCE INVESTIGATION
WHEN CONGREGATE LIVING SETTING DETECTS AN UNEXPLAINED CLUSTER OF TST CONVERSIONS
WHEN LTBI OR TB DISEASE IS DIAGNOSED IN A YOUNG CHILD

26. Evaluation of the Index Patient and Possible Sites of Transmission
Elements of the patient investigation
Pre-interview phase
Background information (case report, records, laboratory results, x-rays)
Patient characteristics (language, severity of illness, ability to cooperate)
Determination of infectious period (preliminary)

27. Determining the Infectious Period
Above is a starting point for estimating the period of likely infectiousness.
Interview the patient and/or review medical records to determine duration of symptoms.
If estimates vary, use the longer time.

28. Interviewing the Patient
Recommendation that interview occur < 1 business day for persons considered to be infectious and < 3 business days for others
Interview conducted in person (face-to-face, not phone!), by prepared interviewer with requisite skills
Second interview 1-2 weeks later
Interview process continues throughout course of treatment

29. Interviewing the Patient
Language of patient’s choice; interpreter if required
Assurance of confidentiality and privacy
Review and verify information gathered from other sources
Infectious period
Potential transmission settings – patient’s ADL
Day, night, work, school, social, health care, travel
Refer to calendar, use holidays as reminders
List of contacts
Names, including street names,types, frequencies and duration of exposure,
Use a standard form to record information
If no names, ask about “groups”, social network

30. WHERE ?
WHERE ARE WE GOING TO LOOK FOR PEOPLE WHO HAVE SHARED AIRSPACE WITH OUR TB CASE?
REMEMBER, YOUR CONTACT LIST WILL CHANGE, CI IS AN ONGOING PROCESS
USE YOU ORW AS A SOURCE OF INFORMATION FOR CONTACTS

31. Field Investigation Site visits
First visit to site should be to gather information; second and subsequent visits should be done after specific investigation plan is in place
Each site will have it’s own culture
Should be made within 3 days of initial interview
Media concerns

32. Field Investigation/Site Visits
Complimentary/supplementary to interviews
All possible sites of transmission should be evaluated
May identify additional contacts
May identify high-risk contacts (children)
Size, ventilation characteristics may help estimate level of exposure
May raise additional questions for re-interview of patient
Likely to attract attention, raise questions
Requires planning, anticipation of questions

33. “Specific Investigation Plan”
The final step in the evaluation of the index patient and possible sites of transmission
Summarize information from interviews, site visits
Make a decision on need for/extent of contact investigation
If a contact investigation is indicated
List contacts and assign priorities
Establish time line
Develop list of resource requirements and staffing plan
If a contact investigation is not required
Summary of available information and reason for decision
Include investigation plan in permanent record

34. “Priorities” Is the contact investigation high priority?
Is the contact high risk and therefore high priority?

35. Assigning Priorities to Contacts
Occurs after contact investigation decisions
Characteristics of the index patient
Availability of resources
Priority/order for investigation of contacts
Characteristics of contacts
Age, immune status, underlying medical conditions
Estimated level of exposure
Proximity, duration, volume of space (small room vs. large), ventilation

36. Priority for evaluation evaluation of contacts: AFB smear positive laryngeal/pulmonary/pleural TB
High
Under age 5
Medical risk factors
HIV
Immunosuppressive agents (steroids, cancer chemotherapy, anti-rejection drugs for organ transplants, tumor necrosis factor alpha agents)
Other medical risk factors (silicosis, renal disease, diabetes, gastrectomy)
Exposure during medical procedure (bronchoscopy, autopsy, sputum induction)
Exposure in congregate setting

37. Priority for evaluation evaluation of contacts: AFB smear positive laryngeal/pulmonary/pleural TB
Medium
Aged 5-15
Exposure exceeds time/space/ventilation limits recommended by state or local TB program
Estimate of exposure by setting
Time at location
Size/volume of shared airspace
Ventilation – windows, fans
May be up or downgraded depending on results of testing of higher priority contacts

38. Priority for evaluation evaluation of contacts: AFB smear negative laryngeal/pulmonary/pleural TB
High
Contacts < age 5
Medical risk factor
Exposure during medical procedure
Medium
Household
Exposure in congregate setting
Exceeds duration/environmental limits

39. Priority for evaluation of contacts: Suspected pulmonary TB, AFB negative with abnormal chest x-ray not consistent with TB
High
None
Medium
Household
Age < 5 years
Medical risk factor
Exposure during medical procedure

41. Timeline for Contacting/Evaluation of Contacts
Establish after assignment to high, medium or low priority category
High or medium priority should be contacted within 3 days and evaluated within < 7 days for high priority and < 14 days for medium priority contacts
Symptomatic contacts should be evaluated immediately

42. Diagnostic and Public Health Evaluation of Contacts
Remember priority assignment
Highest risk = highest priority = major effort to contact and complete evaluation
Initial assessment for all high and medium priority contacts
Screen for symptoms of active disease; proceed immediately to x-ray and sputum collection if symptomatic; do not wait for results of TST
Children <5 and immunocompromised adults should be evaluated and have chest x-ray, whether symptomatic or not

43. Diagnostic and Public Health Evaluation of Contacts
Others (high and medium priority contacts) should receive TST ASAP if not already TST positive
Two step TST procedure should not typically be used for testing contacts
BCG exposure should be recorded, but is not a contra-indication to testing
> 5mm induration is considered to be a positive TST in a contact investigation
Individuals with positive TST require further evaluation
Chest x-ray
Sputum smears and culture if indicated (abnormal x-ray, symptoms)
Individuals who are previously TST positive should be screened for symptoms, further evaluated only if indicated by screening

44. Tuberculin Skin Testing of Contacts
Repeat testing
Estimated interval between infection and detectible skin test reactivity is 2-12 weeks
Reinterpretation of data previously collected indicates that 8 week is outer limits of window period.
CDC & NTCA recommendation that window period be decreased to 8-10 weeks
VIRGINIA – WINDOW PERIOD DEFINED AS 10 WEEKS FOR VIRGINIA CONTACT INVESTIGATIONS

45. HOW LONG? EXPANDING THE CONTACT INVESTIGATION
FINDING NEW CONTACTS NOT IDENTIFIED IN THE BEGINNING

46. Should be considered only after results of investigation of high and medium priority contacts is complete and results have been evaluated
Infection rates are higher than expected
Evidence of secondary transmission
TB disease is found ( source vs. secondary)
Requires careful consideration – may require new contact investigation rather than expansion of initial investigation
TST conversions occur between first and second TST

47. INCIDENT COMMAND
VDH DDP-TB ENCOURAGES THIS MODEL IN ALL LARGE CONTACT INVESTIGATIONS
WE ARE AVAILABLE TO ANSWER YOUR QUESTIONS AND TO PROVIDE ASSISTANCE

48. DOES ANYONE HAVE AN UNUSUAL CONTACT INVESTIGATION TO SHARE???
Prince William concerning flight risk….Va. Beach MDR and school (PI)….Henrico large pop with BCG, QFI, expanding the CI

49. Required Documents
Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis,
December 16, 2005; Volume 54, # RR-15.
Treatment of Tuberculosis, June 20, 2003;
Volume 52, # RR-11.
Controlling Tuberculosis in the United States, March 2005.
Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, 2005.
Virginia’s CI Nursing Directive/Guideline

50. Questions?

51. HAPPY CONTACT INVESTIGATIONS !
Hopefully, it won’t come to this…….with good case management, we hope to prevent this from happening!
This was an actual CI with 32 additional TB cases found
Creative questioning and detective work