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10 January 2007 Contact Investigation for Tuberculosis Control Tim Epps & Bill White Division of Disease Prevention-TB Virginia Department of Health.

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Presentation on theme: "10 January 2007 Contact Investigation for Tuberculosis Control Tim Epps & Bill White Division of Disease Prevention-TB Virginia Department of Health."— Presentation transcript:

1 10 January 2007 Contact Investigation for Tuberculosis Control Tim Epps & Bill White Division of Disease Prevention-TB Virginia Department of Health

2 10 January 2007 Learning Objectives At the end of this lecture, the participants will be able to: 1. Describe the situations in which a contact investigation should be done; 2. Describe how to prioritize a contact investigation; 3. Describe the steps in a contact investigation; 4. Determine the infectious period, and; 5. Identify the contacts who should be considered high-priority

3 10 January 2007 Decision to Initiate a Contact Investigation ** ***

4 10 January 2007 Investigating the index patient and sites of transmission Pre-interview phase * Determination of infectious period * Interviewing the patient * Field investigation * Specific investigation plan *

5 10 January 2007 Determining the Infectious Period AboveAbove 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.

6 10 January 2007 Interviewing the Patient Language of patients choice; interpreter if required Assurance of confidentiality and privacy Review and verify information gathered from other sources – Infectious period Potential transmission settings – patients 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

7 10 January 2007 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 Should be made < 3 days of initial interview May suggest additional questions for re-interview of patient Likely to attract attention, raise questions Requires planning, anticipation of questions First visit to site should be to gather information; second and subsequent visits should be done after specific investigation plan is in place

8 10 January 2007 Assigning Priorities (First things first) Priority of contact investigation (smear positive pulmonary > smear negative pulmonary > extra-pulmonary) Priority of investigation of contacts (close, small children, immunocompromised > > less close, older, healthy)

9 10 January 2007 Specific Investigation Plan Final step in investigating the index patient and sites of transmission section – Summary of information from interviews, site visits – List of contacts and their assigned priorities – Time line – Resource requirements/staffing plan – Becomes part of the permanent record

10 10 January 2007 Index Case - Definition A person with suspected or confirmed TB disease who is the initial case reported to the health department is called the index patient

11 10 January 2007 Source Patient – Definition A person with infectious TB disease who is responsible for transmitting M. tuberculosis to another person or persons

12 10 January 2007 Contact – Definition Contact – People exposed to someone with infectious TB disease, generally including family members, roommates or housemates, close friends, coworkers, classmates, and others – A high-priority group for treatment for LTBI because they are at high risk of being infected with M. tuberculosis, and if infected, they are at high risk of developing disease

13 10 January 2007 Close Contact – Definition Close Contact – A person who had prolonged, frequent, or intense contact with a person with TB while he or she was infectious. > 8 hrs./day. – More likely to become infected with TB than contacts who see the patient less often

14 10 January 2007 Contact Investigation – Definition A procedure for identifying people exposed to someone with infectious TB, evaluating them for latent TB infection (LTBI) and TB disease, and providing appropriate treatment for LTBI or TB disease

15 10 January 2007 Importance of a Contact Investigation Important to find contacts who: – Have TB disease so that they can be given treatment, and further transmission can be stopped – Have LTBI so that they can be given treatment for LTBI – Are at high risk of developing TB disease and may need treatment for LTBI until it becomes clear whether they have TB infection

16 10 January 2007 When to Do a Contact Investigation? Whenever a patient is found to have or is suspected of having infectious TB disease When TB is confirmed or there is a high clinical suspicion of TB

17 10 January 2007 How Quickly Should a Contact Investigation be Done? Close contacts should be examined within 7 working days after the index case has been diagnosed The sooner contacts are identified and evaluated, and can begin appropriate therapy, the less likely it is that transmission will continue

18 10 January 2007 Prioritizing Contact Investigations Laryngeal TB or positive sputum smear pulmonary TB most infectious. CI immediately required. Negative sputum smear pulmonary TB CI recommended. Extrapulmonary TB does not carry any risk for transmission and contact investigations are not performed. CI not performed for people with diseases caused by nontuberculous mycobacteria only, such as M. avium.

19 10 January 2007 HIGH PRIORTY CONTACTS Children < 5 years of age Immune compromised individuals Those exposed during medical procedures Exposure > 8 hrs per day Those exhibiting TB symptoms

20 10 January 2007 Who Is Responsible for a CI? The health department is legally responsible for ensuring that a complete contact investigation is done for the TB cases reported in its area – Identifying and evaluating contacts – Treating any contacts found to have TB disease – Offering treatment for LTBI to infected contacts – Monitoring adherence to prescribed regimens and ensuring a system is in place to assess completion of treatment

21 10 January 2007 Organizing a Contact Investigation Prioritization of field activities Consideration of geography Prior knowledge of patients likely whereabouts at specific times of the day

22 10 January 2007 Steps in a Contact Investigation 1. Medical record review 2. Patient interview 3. Field investigation 4. Risk assessment for M. tuberculosis transmission 5. Decision about priority of contacts 6. Evaluation of contacts 7. Treatment and follow-up for contacts 8. Decision about whether to expand testing 9. Evaluation of contact investigation activities

23 10 January 2007 Records Search Saves valuable time and effort in the field Medical records should be checked for prior visits or locating information Referrals done by a colleague could provide information

24 10 January 2007 Information To Be Collected Site of TB disease TB symptoms and approximate date symptoms began Sputum smear and culture results, including the dates of specimen collection Results of nucleic acid amplification testing (if available) Chest x-ray results and date TB treatment (medications, dosage, and date treatment was started) Method of treatment administration (DOT or self administered)

25 10 January 2007 Information To Be Collected For suspected TB cases the following information should also be collected: – Medical risk factors that may increase the risk for development of TB disease – History of tuberculin skin test results – History of previous treatment for TB disease or TB infection

26 10 January 2007Interview Infectious period – Brings focus to the interview – Start/end point of probable transmission Transmission probability assessment – Identifies contact tracing priorities – Person – Place – Time

27 10 January 2007 Person Characteristics Clinical DataHigh Likelihood of Transmission Low Likelihood of Transmission Disease location Laryngeal Pulmonary Extrapulmonary alone Smear StatusPositiveNegative Smear sourceSpontaneous specimen Induced or clinical (bronchoscopy, etc.) Chest X-rayCavitaryNon-cavitary SymptomsCoughNo cough Anti-TB DrugsNoYes (2 weeks or more)

28 10 January 2007 Contact Characteristics Age Health status Lifestyle

29 10 January 2007 Time Characteristics Duration of Exposure Frequency of exposure

30 10 January 2007 Evaluation of Contacts Evaluated for LTBI and TB disease. This evaluation includes at least: – A medical history – A Mantoux tuberculin skin test (unless there is a previous documented positive reaction)

31 10 January 2007 When To Expand Testing Evidence of recent transmission, the next highest-priority group should be evaluated Expand to the next group of contacts each time there is evidence of transmission in the group being tested

32 10 January 2007 Treatment and Follow-Up of Contacts Treatment for LTBI: – Contacts who have a positive tuberculin skin test reaction and no evidence of TB disease – High-risk contacts who have a negative tuberculin skin test reaction, such as children under 5 years of age, HIV-infected people, and other high-risk contacts who may develop TB disease very quickly after infection

33 10 January 2007 Secondary Case of TB When a contact develops TB disease as a result of transmission from an index patient Conduct a contact investigation immediately around any source case or secondary case or cases discovered during another investigation

34 10 January 2007 Professional Thoroughness Utilize all locating resources available to you Motivate patients to seek medical attention Ensure that patient receives medical care Follow-up with patients to reinforce their compliance with medical recommendations

35 10 January 2007 Effective Communication Be specific and efficient when communicating Have ability to problem solve when speaking Use open-ended questions Be assertive, not aggressive Have ability to sense problems and address them immediately

36 10 January 2007Persistence Make multiple attempts to locate patient, if patient not found in first attempt Recognize that patients may not respond to first referral to visit the clinic Be prepared to make necessary additional actions (i.e., visits, telephone calls, referrals, etc.) Be level-headed and calm when dealing with difficult patients

37 10 January 2007 Patient Confidentiality Assure the patient that all information, including the patients name, will be kept confidential

38 10 January 2007 Success of a Contact Investigation Infected contacts should begin and complete a regimen of treatment for LTBI Interrupt transmission and prevent future cases of disease

39 10 January 2007 Communicating through the media – Involve your PIO early and routinely – Media can help in a large investigation

40 10 January 2007 Other Topics Cultural competence Social network analysis Use of blood tests for detection of LTBI – Quanti-FERON-TB test

41 10 January 2007 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 Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, 2005.

42 10 January 2007 CDC Contact Investigation Slideset Link: contactinv/default.htm

43 10 January 2007Questions?

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