Investigation of Contacts of Persons with Infectious Tuberculosis, 2005 Division of Tuberculosis Elimination Centers for Disease Control and Prevention National Tuberculosis Controllers Association Centers for Disease Control and Prevention

Investigation of Contacts of Persons with Infectious Tuberculosis, 2005 CHALLENGE: How to fit 50 pages of NEW recommendations into 15 minutes?? 5

Contents – “Soup to nuts” Purpose Summary 1.Introduction and Background7. Expanding Contact Investigations 2.Decision to Initiate a Contact Investigation 8. Data Management and Evaluation 3.Investigation of the Presenting Patient9. Confidentiality and Consent 4.Prioritization of Contacts 10. Staffing and Training for Contact Investigations 5.Evaluation of Contacts11. Contact Investigations in Special Circumstances 6. Medical Management of Contacts12. Source Case Investigations 13. Special Topics

Decisions to Initiate a Contact Investigation

Decision to Initiate a TB Contact Investigation *Acid-fast bacilli † Nucleic acid assay § Approved indication for NAA ¶ Chest radiograph 18

Investigating the Index Patient and Sites of Transmission

PHASES Pre-interview Determining the infectious period Interviewing the patient Proxy interview Field investigation Follow up steps Specific investigation plan

Estimating the Beginning of the Infectious Period Characteristic of Index Case TB symptomsAFB sputum smear positive Cavitary chest radiograph Likely period of infectiousness YesNo 3 months before symptom onset or 1 st positive finding consistent with TB disease, whichever is longer Yes 3 months before symptom onset or 1 st positive finding consistent with TB disease, whichever is longer No 4 weeks before date of suspected diagnosis NoYes 3 months before positive finding consistent with TB SOURCE: California Department of Health Services Tuberculosis Control Branch; California Tuberculosis Controllers Association. Contact Investigation Guidelines. Berkley, CA: California Department of Health Services;

PHASES Pre-interview Determining the infectious period Interviewing the patient Proxy interview Field investigation - potential sites of transmission Follow up steps - frequent reassessments Specific investigation plan

Exposure Period for Contacts Determined by: how much time the contact spent with the index patient during the infectious period 28

Goal = PREVENTION

Assigning Priorities to Contacts Priorities should be assigned to contacts and resources allocated to complete all investigative steps for high-and medium- priority contacts. Any contact not classified as high or medium priority is assigned a low priority.

Factors for Assigning Contact Priorities Characteristics of the index patient Characteristics of contacts Age Immune status Other medical conditions Exposure

Prioritization of Contacts (1) Patient has pulmonary, laryngeal, or pleural TB with cavitary lesion on chest radiograph or is AFB sputum smear positive Household contactHigh Contact <5 years of ageHigh Contact with medical risk factor (HIV or other medical risk factor) High Contact with exposure during medical procedure (bronchoscopy, sputum induction, or autopsy) High Contact in a congregate settingHigh Contact exceeds duration/environment limits (limits per unit time established by the health department for high-priority contacts) High Contact is ≥ 5 years and ≤ 15 years of ageMedium Contact exceeds duration/environment limits (limits per unit time established by the health department for medium-priority contacts) Medium Any contact not classified as high or medium priority is assigned a low priority. 41

Prioritization of Contacts (2) Patient is a suspect or has confirmed pulmonary/pleural TB – AFB smear negative, abnormal chest radiograph consistent with TB disease, may be NAA and/or culture positive Contact <5 years of ageHigh Contact with medical risk factor (e.g., HIV)High Contact with exposure during medical procedure (bronchoscopy, sputum induction, or autopsy) High Household contactMedium Contact exposed in congregate settingMedium Contact exceeds duration/environment limits (limits per unit time established by the local TB control program) Medium Any contact not classified as high or medium priority is assigned a low priority. 42

Diagnostic and Public Health Evaluation of Contacts

Initial Assessment of Contacts Should be accomplished within 3 working days of the contact having been listed in the investigation Gathers background health information Permits face-to-face assessment of person’s health 45

Tuberculin Skin Testing All high or medium priority contacts who do not have a documented previous positive tuberculin skin test (TST) or previous TB disease should receive a TST at the initial encounter. If not possible, TST should be administered –≤7 working days of listing high-priority contacts –≤14 days of listing medium-priority contacts

Postexposure Tuberculin Skin Testing Window period is 8–10 weeks after exposure ends Contacts who have a positive result after a previous negative result are said to have had a change in tuberculin status from negative to positive

Medical Evaluation All contacts whose skin test reaction induration is ≥5 mm or who report any symptoms consistent with TB disease should undergo further examination and testing for TB 53

Evaluation and Follow-up of Children <5 Years of Age Always assigned a high priority as contacts Should receive full diagnostic medical evaluation, including a chest radiograph If TST ≤5 mm of induration and last exposure <8 weeks, LTBI treatment recommended (after TB disease excluded) Second TST 8–10 weeks after exposure; decision to treat is reconsidered –Negative TST – treatment discontinued –Positive TST – treatment continued See Figure 7 (algorithm)

Evaluation and Follow-up of Immunosuppressed Contacts Should receive full diagnostic medical evaluation, including a chest radiograph If TST negative ≥8 weeks after end of exposure, full course of treatment for LTBI recommended (after TB disease is excluded) See Figure 6 (algorithm)

Medical Treatment for Contacts with LTBI

Window-Period Prophylaxis The frequency, duration, and intensity of exposure Corroborative evidence of transmission from the index patient Decision to treat contacts with a negative skin test result should take the following factors into consideration

Health Department Responsibilities Focusing resources on contacts in most need of treatment Monitoring treatment, including that of contacts who receive care outside the health department Providing directly observed therapy (DOT), incentives, and enablers

Selecting Contacts for Directly Observed Therapy Contacts aged <5 years Contacts who are HIV infected or otherwise substantially immunocompromised Contacts with a change in their tuberculin skin test status from negative to positive Contacts who might not complete treatment because of social or behavior impediments

When to Expand a Contact Investigation

Achievement of program objectives with high and medium priority contacts Extent of recent transmission  Unexpectedly high rate of infection or TB disease in high priority contacts (e.g. 10% or at least twice the rate of a similar population without recent exposure, whichever is greater)  Evidence of secondary transmission  TB disease in any contact who had been assigned a low priority  Infection of contacts aged <5 years and  Contacts with change of skin test status from negative to positive between their first and second TST

Communicating Through the News Media

Data Management and Evaluation of Contact Investigations

Second TST Reminder Preventive Therapy Review – high priority contacts not started on Rx Contact Progress Reports –3 & 6 months Contact Line Listing Semi-Annual Report CDC Contact Report REPORTS What, where, when, ?…

Data Management and Evaluation of Contact Investigations Table 4: Index patient minimal recommended data Table 5: contact minimal recommended data Box 2: Recommended contact investigation objectives by key indicators Methods for data collection and storage

Confidentiality and Consent in Contact Investigations

Staffing and Training for Contact Investigations

Box 3: Specialized functions for contact investigations (e.g. interviewing, case management, etc.) Box 4: Positions and titles used

Contact Investigations in Special Circumstances

Definition of an Outbreak During (and because of) a contact investigation, 2 or more contacts are found to have active TB, regardless of their assigned priority; or Any 2 or more cases occurring within a year of each other, discovered to be linked, and the linkage is established outside of a contact investigation

Congregate Settings Substantial number of contacts Incomplete information regarding contact names and locations Incomplete data for determining priorities Difficulty in maintaining confidentiality Collaboration with officials and administrators who are unfamiliar with TB Legal implications Media coverage Concerns associated with congregate settings

Correctional Facilities Establish preexisting formal collaboration between correctional and public health officials Trace high-priority contacts who are transferred, released, or paroled before medical evaluation for TB Low completion rate is anticipated unless follow-through supervision can be arranged for released or paroled inmates

Workplaces Duration and proximity of exposure can be greater than for other settings Details to gather from index patient during initial interview include –Employment hours –Working conditions –Workplace contacts Occasional customers of workplace should be designated as low priority

Hospitals and Other Health-Care Settings Personnel collaborating with hospitals and other health-care agencies should have knowledge of legal requirements Plan investigation jointly with health department and setting (division of responsibilities) Majority of health-care settings have policies for testing employees for M. tuberculosis infection

Schools Early collaboration with school officials and community members is recommended Issues of consent, assent, and disclosure of information more complex for minors Site visits should be conducted to check indoor spaces, observe general conditions, and interview maintenance personnel regarding ventilation

Shelters and Other Settings Providing Services for Homeless Persons Challenges include –Locating the patient and contacts if mobile –Episodic incarceration –Migration from one jurisdiction to another –Psychiatric illnesses –Preexisting medical conditions Site visits and interviews are crucial Work with setting administrators to offer onsite supervised intermittent treatment

Interjurisdictional Contact Investigations Requires joint strategies for finding contacts, having them evaluated, treating infected contacts, and gathering data Health department that counts index patient is responsible for leading the investigation and notifying health departments in other jurisdictions

Source-Case Investigations

Child with TB Disease Source-case investigations considered for children <5 years of age May be started before diagnosis of TB confirmed 94

Child with LTBI Search for source of infection for child is unlikely to be productive Recommended only with infected children <2 years of age, and only if data are monitored to determine the value of the investigation

Cultural Competency and Social Network Analysis

“Every encounter between a health care provider and a patient is a cross-cultural experience.” Dr. Arthur Kleinman, Harvard psychiatrist and anthropologist

A Social Network with A Place Bill Juan Rose Ted Ali Moe Rita Mel’s Bar

Investigation of Contacts of Persons with Infectious Tuberculosis, 2005 CHALLENGE: How to fit 50 pages of NEW recommendations into 15 minutes?? 5

Investigation of Contacts of Persons with Infectious Tuberculosis, 2005 Division of Tuberculosis Elimination Centers for Disease Control and Prevention National Tuberculosis Controllers Association Centers for Disease Control and Prevention