Presentation on theme: "Contact Investigations"— Presentation transcript:
1 Contact Investigations WHO ?WHERE ?WHEN ?HOWLONG ?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 SUCCESSFULLYMMWR TREATMENT OF TB pg.15
4 Health departments are responsible for ensuring contact investigations Public health officials must decide whichContact investigations should be assigned a higher priorityContacts to evaluation firstDecision 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 TBDetect additional cases of active TBIdentify 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 daysAt 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 infectionInitial 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 months85% 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 COMMUNICATIONCONFIDENTIALITYTHOROUGHNESSPERSISTANCE
11 Evaluation of the Index Patient Comprehensive information regarding the index patient is the foundation of a contact investigationRequires 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 managementCharacteristics of case determine need for and extent of contact investigationContact investigation activities should be planned, prioritized to ensure identification and treatment of highest risk contactsPutting 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 yourORW 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 factorsInfectiousness of the person with TBEnvironment in which the transmission occursDuration of the exposure to TB bacteria
15 Infectiousness of patient Pulmonary, laryngeal, or pleuralAFB on sputum smear (1+ or 4+)Cavitation on x-ray,Adolescent or adultPeriod of infectiousnessEnvironment – activities leading to aerosolizationInspect home, work and social environmentDuration of exposure – proximity, small space, limited ventilation - increase chance that susceptible contact will breathe AFB into lungs
17 NOT EVERY TB CASE REQUIRES A CONTACT INVESTIGATION
18 Additional considerations…. Pulmonary, laryngeal or pleural TBPleural is now grouped with pulmonary because sputum cultures can yield M. tuberculosis even when no lung abnormalities are apparent on x-rayAFB 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 frombronchoscopy/bronchial washings:Guidelines recommend equating results of AFB microscopy on bronch washings to sputumVDH recommends that sputum be collected and assessment of infectiousness be based on sputum AFB resultsIf 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 infectedPersons with longest, closest contactInfants, young children , immunocompromised, persons with serious underlying medical conditions
23 Additional considerations Do we suspect the base case to be MDR?Contacts of MDR need to be continually re-assesstedPotential for prolonged periods of infectiousness
24 INDEX CASETHE FIRST PERSON WITH TB DISEASE WHO IS IDENTIFIED IN A PARTICULAR SETTING
25 SOURCE CASETHE PERSON OR CASE THAT WAS THE ORIGINAL SOURCE OF THE INFECTIONTWO CIRCUMSTANCES FOR SOURCE INVESTIGATIONWHEN CONGREGATE LIVING SETTING DETECTS AN UNEXPLAINED CLUSTER OF TST CONVERSIONSWHEN 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 investigationPre-interview phaseBackground 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 othersInterview conducted in person (face-to-face, not phone!), by prepared interviewer with requisite skillsSecond interview 1-2 weeks laterInterview process continues throughout course of treatment
29 Interviewing the Patient Language of patient’s choice; interpreter if requiredAssurance of confidentiality and privacyReview and verify information gathered from other sourcesInfectious periodPotential transmission settings – patient’s ADLDay, night, work, school, social, health care, travelRefer to calendar, use holidays as remindersList of contactsNames, including street names,types, frequencies and duration of exposure,Use a standard form to record informationIf 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 PROCESSUSE 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 placeEach site will have it’s own cultureShould be made within 3 days of initial interviewMedia concerns
32 Field Investigation/Site Visits Complimentary/supplementary to interviewsAll possible sites of transmission should be evaluatedMay identify additional contactsMay identify high-risk contacts (children)Size, ventilation characteristics may help estimate level of exposureMay raise additional questions for re-interview of patientLikely to attract attention, raise questionsRequires planning, anticipation of questions
33 “Specific Investigation Plan” The final step in the evaluation of the index patient and possible sites of transmissionSummarize information from interviews, site visitsMake a decision on need for/extent of contact investigationIf a contact investigation is indicatedList contacts and assign prioritiesEstablish time lineDevelop list of resource requirements and staffing planIf a contact investigation is not requiredSummary of available information and reason for decisionInclude 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 decisionsCharacteristics of the index patientAvailability of resourcesPriority/order for investigation of contactsCharacteristics of contactsAge, immune status, underlying medical conditionsEstimated level of exposureProximity, duration, volume of space (small room vs. large), ventilation
36 Priority for evaluation evaluation of contacts: AFB smear positive laryngeal/pulmonary/pleural TB HighUnder age 5Medical risk factorsHIVImmunosuppressive 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 MediumAged 5-15Exposure exceeds time/space/ventilation limits recommended by state or local TB programEstimate of exposure by settingTime at locationSize/volume of shared airspaceVentilation – windows, fansMay 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 HighContacts < age 5Medical risk factorExposure during medical procedureMediumHouseholdExposure in congregate settingExceeds duration/environmental limits
39 Priority for evaluation of contacts: Suspected pulmonary TB, AFB negative with abnormal chest x-ray not consistent with TBHighNoneMediumHouseholdAge < 5 yearsMedical risk factorExposure during medical procedure
41 Timeline for Contacting/Evaluation of Contacts Establish after assignment to high, medium or low priority categoryHigh or medium priority should be contacted within 3 days and evaluated within < 7 days for high priority and < 14 days for medium priority contactsSymptomatic contacts should be evaluated immediately
42 Diagnostic and Public Health Evaluation of Contacts Remember priority assignmentHighest risk = highest priority = major effort to contact and complete evaluationInitial assessment for all high and medium priority contactsScreen for symptoms of active disease; proceed immediately to x-ray and sputum collection if symptomatic; do not wait for results of TSTChildren <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 positiveTwo step TST procedure should not typically be used for testing contactsBCG exposure should be recorded, but is not a contra-indication to testing> 5mm induration is considered to be a positive TST in a contact investigationIndividuals with positive TST require further evaluationChest x-raySputum 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 testingEstimated interval between infection and detectible skin test reactivity is 2-12 weeksReinterpretation 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 weeksVIRGINIA – 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 evaluatedInfection rates are higher than expectedEvidence of secondary transmissionTB disease is found ( source vs. secondary)Requires careful consideration – may require new contact investigation rather than expansion of initial investigationTST conversions occur between first and second TST
47 INCIDENT COMMANDVDH DDP-TB ENCOURAGES THIS MODEL IN ALL LARGE CONTACT INVESTIGATIONSWE 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 DocumentsGuidelines 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
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 foundCreative questioning and detective work