Investigation of Contacts of Persons with Infectious Tuberculosis, 2005

1
Investigation of Contacts of Persons with
Infectious Tuberculosis, 2005
National Tuberculosis Controllers
Association Centers for Disease Control and
Prevention

• Division of Tuberculosis Elimination
• Centers for Disease Control and Prevention

2
Investigation of Contacts of Persons with
Infectious Tuberculosis, 2005
5

• CHALLENGE
• How to fit 50 pages of
• NEW recommendations
• into 15 minutes??

3
Contents Soup to nuts

•  
• Purpose
•  
• Summary
•  
• Introduction and Background 7. Expanding Contact
  Investigations
• Decision to Initiate a Contact
• Investigation 8. Data Management and
  Evaluation
• Investigation of the Presenting Patient 9.
  Confidentiality and Consent
• Prioritization of Contacts 10. Staffing and
  Training for Contact Investigations
• Evaluation of Contacts 11. Contact
  Investigations in Special
  Circumstances
• 6. Medical Management of Contacts 12. Source
  Case Investigations

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Decisions to Initiate a Contact Investigation
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Decision to Initiate a TB Contact Investigation
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Acid-fast bacilli Nucleic acid assay Approved
indication for NAA Chest radiograph
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Investigating the Index Patient and Sites of
Transmission
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PHASES

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

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Estimating the Beginning of the Infectious Period
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Characteristic of Index Case Characteristic of Index Case Characteristic of Index Case
TB symptoms AFB sputum smear positive Cavitary chest radiograph Likely period of infectiousness
Yes No No 3 months before symptom onset or 1st positive finding consistent with TB disease, whichever is longer
Yes Yes Yes 3 months before symptom onset or 1st positive finding consistent with TB disease, whichever is longer
No No No 4 weeks before date of suspected diagnosis
No Yes Yes 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 1998. SOURCE California Department of Health Services Tuberculosis Control Branch California Tuberculosis Controllers Association. Contact Investigation Guidelines. Berkley, CA California Department of Health Services 1998. SOURCE California Department of Health Services Tuberculosis Control Branch California Tuberculosis Controllers Association. Contact Investigation Guidelines. Berkley, CA California Department of Health Services 1998. SOURCE California Department of Health Services Tuberculosis Control Branch California Tuberculosis Controllers Association. Contact Investigation Guidelines. Berkley, CA California Department of Health Services 1998.
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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

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

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(No Transcript)
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Goal PREVENTION
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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.

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Factors for Assigning Contact Priorities

• Characteristics of the index patient
• Characteristics of contacts
• Age
• Immune status
• Other medical conditions
• Exposure

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Prioritization of Contacts (1)
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Patient has pulmonary, laryngeal, or pleural TB with cavitary lesion on chest radiograph or is AFB sputum smear positive Patient has pulmonary, laryngeal, or pleural TB with cavitary lesion on chest radiograph or is AFB sputum smear positive
Household contact High
Contact lt5 years of age High
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 setting High
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 age Medium
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. Any contact not classified as high or medium priority is assigned a low priority.
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Prioritization of Contacts (2)
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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 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 lt5 years of age High
Contact with medical risk factor (e.g., HIV) High
Contact with exposure during medical procedure (bronchoscopy, sputum induction, or autopsy) High
Household contact Medium
Contact exposed in congregate setting Medium
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. Any contact not classified as high or medium priority is assigned a low priority.
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Diagnostic and Public Health Evaluation of
Contacts
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Initial Assessment of Contacts
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• 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 persons health

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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

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Postexposure Tuberculin Skin Testing

• Window period is 810 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

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Medical Evaluation
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• 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

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Evaluation and Follow-up of Children lt5 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 lt8
  weeks, LTBI treatment recommended (after TB
  disease excluded)
• Second TST 810 weeks after exposure decision to
  treat is reconsidered
• Negative TST treatment discontinued
• Positive TST treatment continued
• See Figure 7 (algorithm)

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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)

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Medical Treatment for Contacts with LTBI
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Window-Period Prophylaxis
Decision to treat contacts with a negative skin
test result should take the following factors
into consideration

• The frequency, duration, and intensity of
  exposure
• Corroborative evidence of transmission from the
  index patient

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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

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Selecting Contacts for Directly Observed Therapy

• Contacts aged lt5 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

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When to Expand a Contact Investigation
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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 lt5 years and
• Contacts with change of skin test status from
  negative to positive between their first and
  second TST

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Communicating Through the News Media
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Data Management and Evaluation of Contact
Investigations
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REPORTS
What, where, when, ?

• 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

33
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

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Confidentiality and Consent in Contact
Investigations
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Staffing and Training for Contact Investigations
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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

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Contact Investigations in Special Circumstances
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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

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Congregate Settings
Concerns associated with 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

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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

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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

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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

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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

44
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

45
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

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Source-Case Investigations
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Child with TB Disease
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• Source-case investigations considered for
  children lt5 years of age
• May be started before diagnosis of TB confirmed

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Child with LTBI

• Search for source of infection for child is
  unlikely to be productive
• Recommended only with infected children lt2 years
  of age, and only if data are monitored to
  determine the value of the investigation

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Cultural Competency and Social Network Analysis
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Every encounter between a health care provider
and a patient is a cross-cultural
experience. Dr. Arthur Kleinman, Harvard
psychiatrist and anthropologist
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A Social Network with A Place
Mels Bar
Ali
Rita
Moe
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Investigation of Contacts of Persons with
Infectious Tuberculosis, 2005
5

• CHALLENGE
• How to fit 50 pages of
• NEW recommendations
• into 15 minutes??

53
Investigation of Contacts of Persons with
Infectious Tuberculosis, 2005
National Tuberculosis Controllers
Association Centers for Disease Control and
Prevention

• Division of Tuberculosis Elimination
• Centers for Disease Control and Prevention
• http//www.cdc.gov/nchstp/tb