Medical Management of Contacts to Infectious Pulmonary Tuberculosis

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Medical Management of Contacts to Infectious
Pulmonary Tuberculosis

• Alfred Lardizabal, MD
• New Jersey Medical School
• Global Tuberculosis Institute

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Continuing Education Statement

• The University of Medicine and Dentistry of New
  Jersey Center for Continuing and Outreach
  Education (UMDNJ-CCOE) designates this
  educational activity for a maximum of 1.5 AMA PRA
  Category 1 Credits.  Physicians should only claim
  credit commensurate with the extent of their
  participation in the activity.
• UMDNJ-CCOE certifies that this continuing
  education offering meets the criteria for up to
  .15 Continuing Education Units, as defined by the
  National Task Force on the Continuing Education
  Unit (CEU), provided the activity is completed as
  designed. One CEU is awarded for 10 contact hours
  of instruction.

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Faculty Disclosure

• Alfred Lardizabal has expressed that his
  presentation does not include discussion of
  commercial products or services, or an unapproved
  or uninvestigated use of a commercial product.
  He has no significant financial relationships to
  disclose.
• Lillian Pirog has expressed that her presentation
  does not include discussion of commercial
  products or services, or an unapproved or
  uninvestigated use of a commercial product. She
  has no significant financial relationships to
  disclose.

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Background (1)

• 1962 Isoniazid (INH) demonstrated to be
  effective in preventing tuberculosis (TB) among
  household contacts of persons with TB disease
• Investigation and treatment of contacts with
  latent TB infection (LTBI) quickly becomes
  strategy in TB control and elimination in the
  U.S.
• 1976 American Thoracic Society (ATS) published
  guidelines for investigation, diagnostic
  evaluation, and medical treatment of TB contacts

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Background (2)

• 2005 National TB Controllers Association (NTCA)
  and CDC release guidelines on the investigation
  of contacts of persons with infectious TB
• Expanded guidelines on investigation of TB
  exposure and transmission, and prevention of
  future TB cases through contact investigations
• Standard framework for assembling information and
  using findings to inform decisions

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Contact Investigations A Crucial Prevention
Strategy

• On average, 10 contacts are identified for each
  person with infectious TB in the U.S.
• 2030 of all contacts have LTBI
• 1 of contacts have TB disease
• Of contacts who will ultimately have TB disease,
  approximately one-half develop disease in the
  first year after exposure

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Decisions to Initiate a Contact Investigation

• Public health officials must decide which
• Contact investigations should be assigned a
  higher priority
• Contacts to evaluate first
• Decision to investigate an index patient depends
  on presence of factors used to predict likelihood
  of transmission
• Site of disease
• Positive sputum bacteriology
• Radiographic findings

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Determining the Infectious Period

• Focuses investigation on contacts most likely to
  be at risk for infection
• Sets time frame for testing contacts
• Information to assist with determining infectious
  period
• Approximate dates TB symptoms were noticed
• Bacteriologic results
• Extent of disease

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Start of Infectious Period

• Cannot be determined with precision estimation
  is necessary
• Start is 3 months before TB diagnosis
  (recommended)
• Earlier start should be used in certain
  circumstances (e.g., patient aware of illness for
  longer period of time)

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Closing the Infectious Period
Infectious period closed when all the following
criteria are met

• Effective treatment for 2 weeks,
• Diminished symptoms, and
• Bacteriologic response

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Assigning Priorities to Contacts
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Prioritization of Contacts (1)
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)
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 Evaluation of Contacts
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Information to Collect During Initial Assessment
(1)

• Previous M. tuberculosis infection or disease and
  related treatment
• Contacts verbal report and documentation of
  previous TST results
• Current symptoms of TB illness

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Information to Collect During Initial Assessment
(2)

• Medical conditions making TB disease more likely
• Mental health disorders
• Type, duration, and intensity of TB exposure
• Sociodemographic factors

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Information to Collect During Initial Assessment
(3)

• HIV status contacts should be offered HIV
  counseling and testing if status unknown
• Information regarding social, emotional, and
  practical matters that might hinder participation

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Reassess Strategy After Initial Information
Collected

• After initial information collected
• Priority assignments should be reassessed
• Medical plan for diagnostic tests and possible
  treatment can be formulated for high- and
  medium-priority contacts

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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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Interpreting Skin Test Reaction

• 5 mm induration is positive for any contact
• Two-step procedure should not be used for testing
  contacts
• A contact whose second TST is positive after
  initial negative result should be classified as
  recently infected

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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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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

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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)

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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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Prophylactic Treatment
Prophylactic treatment (after TB disease is
excluded) of presumed M. tuberculosis infection
recommended for persons

• With HIV infection
• Taking immunosuppressive therapy for organ
  transplant
• Taking anti-tumor necrosis factor alpha (TNF-a)
  agents

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Treatment After Exposure to Drug-Resistant TB

• Consultation with physician with MDR expertise
  recommended for selecting a LTBI regimen
• Contacts should be monitored for 2 years after
  exposure

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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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Source-Case Investigations
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Source-Case Investigations

• Seeks the source of recent M.tuberculosis
  infection
• In the absence of cavitary disease, young
  children usually do not transmit M.tuberculosis
  to others
• Recommended only when TB control program is
  achieving its objectives when investigating
  infectious cases

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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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Procedures for Source-Case Investigation

• Same procedure as standard contact investigation
• Patient or guardians best informants (associates)
• Focus on associates who have symptoms of TB
  disease
• Should begin with closest associates

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Contact Investigations
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Background 1

• 6/14/04 39 year-old female admitted to the
  hospital with complaints for approximately one
  month of cough, fever, decreased appetite, night
  sweats and 23 lb weight loss
• 6/17 Chest x-ray cavitary disease consistent with
  TB
• 6/17 Bronchial wash AFB smear positive (3)

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Background - 2

• 6/19 Treatment (RIPE) initiated
• 6/21 Suspected case of tuberculosis verbally
  reported by hospital infection control to the
  local health department

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Background 3

• 6/21 LHD informed TB Control of suspected case
  adding the following information
• Presenting patient was a volunteer at a daycare
  center
• Director of center is the sister of patient
• Name, address and telephone of daycare center
  provided

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Background 4

• 6/21 Telephone call to director of daycare center
  from TB controller
• Purpose to set up a meeting to discuss potential
  exposure to children and staff
• Conduct on-site exposure assessment of center
• Provide TB education to the director
• Identify high-priority contacts during infectious
  period established at 2/146/14/04

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Background - 5

• During telephone conversation, the following was
  indicated by the director
• Index patient was a part-time volunteer
• a couple of hours (2-5) per week
• Secretary with little or no exposure to children

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Background - 6

• Near the conclusion of telephone call the
  following exchange occurred
• Director So, should my daughter be tested?
• TB Control Tell me about your daughter and how
  much exposure she had to your sister
• Director Not too much. She doesnt attend the
  daycare but we do spend some time socially (maybe
  5 hours) together on the weekends going to the
  mall

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Background - 7

• TB Control How old is your daughter?
• Director 6 months
• TB Control Ill make arrangements for your
  daughter to be tested tomorrow morning
• TB Control By the way, how is your daughter
  feeling?
• Director Well, she was diagnosed with
  bronchitis a few weeks ago and is still coughing

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• Final culture result MTB

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Contact Investigation

• 6/22 First of 4 TB interviews with the patient
  conducted by HCW in hospital revealed
• Infectious period confirmed at 2/14-6/14/04
• Patient may have spent more time in daycare than
  originally described
• Patient indicates not much contact with children
  at daycare
• 8 high priority contacts identified
• 2 household
• 6 social
• 6/23 Initiation of on-site assessment of daycare
  center

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Contact Investigation

• As a result of on-site assessment 35 high
  priority contacts identified
• 30 children ages 3-4 years
• 5 staff members
• Notification process begins for testing
• Education sessions provided to parents of daycare
  children
• During these sessions it is learned that the 6
  month old infant, directors daughter, was at
  daycare center on regular basis

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Contact Investigation

• 6/23 6 month old infant (directors daughter)
  evaluated at clinic
• TST 15 mm
• CXR hilar adenopathy with suspected miliary TB
• Admitted to hospital with diagnosis of suspected
  miliary TB

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Contact Investigation

• 6/25 Field visit to social contact residence by
  HCW identifies a second 6 mo. old infant not
  named on initial interview
• 70 hours exposure per week during infectious
  period
• Diagnosed with pneumonia 3 weeks ago
• HCW TB Controller consult with pediatric nurse
  practitioner at Lattimore and infant is referred
  to ED and is admitted with a diagnosis of
  suspected pulmonary TB

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Medical Evaluation

• 6/29 - 6/30 Tuberculin skin tests administered
  on all 35 daycare contacts and chest x-rays taken
  on all 30 children from daycare
• Extra clinic sessions scheduled in addition to 3
  evening clinics at local health department where
  most contacts reside to accommodate the medical
  evaluations of the 30 children

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Contact Investigation Initial Infection Disease
Results Household and Social Contacts

• Total 9 high priority contacts identified
• 4 children/5 adults
• TST () 5/9 (56)
• TB disease 2/9 (22)
• 2 infants
• TST (-) 4/9 (44)

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Contact Investigation Infection Disease
Results Daycare
Children 30 (3-4 years of age)
TST () TST () w/ disease 11/30 (37) 5/11 (45)
TST (-) TST (-) w/ disease 19/30 (63) 2/19 (11)
Staff 5
TST () TST (-) 3/5 (60) - 2 adolescents 2/5 (40) No disease
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Contact Investigation Results Totals After
Initial Testing
Investigation Totals 44 32 4 yrs old
TST () 19/44 (43)
TST (-) 25/44 (57)
TB disease 9/44 (20) All 4 yrs old
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Prevention of Tuberculosis in Children Missed
Opportunities

• Failure to find and appropriately manage adult
  source cases (Case finding)
• Delay in reporting the initial diagnosis of TB
• Contact investigation interview failure
• Delay in evaluation of exposed children
• Failure to completely evaluate exposed children
• Failure to maintain a contact under surveillance
• LTBI diagnosed treatment not prescribed
• Failure to complete treatment for LTBI
  (Adherence)

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Contact Investigations Lessons Learned

• Importance of on-site assessment
• Re-interviews of presenting patients strongly
  recommended to allow a complete and accurate
  assessment of exposure
• Different interviewers if no contacts, rapport
  issue
• Despite the rapidity of the CI process 9 cases of
  disease occurred
• Children develop disease soon after infection so
  it is imperative to move quickly
• Local pediatricians are generally not familiar
  with the evaluation recommended for and the
  prophylactic treatment of children exposed to
  tuberculosis

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Medical Management of TB Contacts from a Nursing
Perspective

• Lillian Pirog, RN, PNP
• Nurse Manager-Lattimore Practice
• NJMS Global Tuberculosis Institute

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The Role of the Nurse Case Manager with Respect
to TB Contacts

• Interview the index case for contacts
• Administer and read the TST
• Educate the contacts
• Monitor contacts at monthly interval
• Ensure treatment adherence

Note Not all duties discussed today will apply
to all nurses, and some duties performed by TB
nurse case managers may not be discussed
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Interviewing the Index Case

• Interviewing the index case for contacts should
  be done on more than one occasion
• On the initial visit
• On subsequent visits until you are satisfied all
  the contacts have been identified
• A visit to the site of exposure will help provide
  important information regarding possible
  transmission and contacts

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Past Medical History

• Obtain contacts past medical history
• Ask the contact
• Have you ever been diagnosed with tuberculosis?
• Have you ever had a TB skin test?
• If yes why, when, where, and what was the result
• Ask about medical conditions that may elevate the
  contacts status to high risk
• Ask about behaviors that may elevate the
  contacts status to high risk
• Ask about TB symptoms
• Ask about previous HIV testing

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Contact Education

• Explain the following
• Transmission and Pathogenesis
• TST (how it is performed)
• TST results and what they mean
• Retesting (if necessary)
• Always give the contact an opportunity to ask
  questions
• And ask them to tell you in their own words what
  theyve
• learned

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Contact Education cont.

• The evaluation process
• TST
• If you are tested you must be available for the
  reading in 48-72 hours
• X-ray
• Medical examination
• Treatment if necessary
• Importance of adherence with treatment
• Provide literature

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TST

• Administer the TST
• Explain the procedure
• Explain that PPD is not a live bacteria. It can
  not give you TB
• Explain how to care for the site
• Do not place a bandage on the site
• Do not scratch
• Pat it with cold cloth
• Can rub it with ice
• Its okay to bathe and wash the site

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TST cont.

• Results
• Explain a positive result
• It only tell us that the germ is in your body
  nothing more. Further medical evaluation is
  needed
• Explain a negative result
• Explain the need for retesting (if necessary)
• Explain window prophylaxis (if necessary)

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Monthly Follow up Visits

• First visit
• Review test results
• Blood
• Sputum
• Explain how medications are taken
• Explain possible adverse reactions to medication
• Provide clinic telephone number and an emergency
  telephone numbers for after clinic hours and
  weekends.

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Monthly Follow up Visits

• First visit cont.
• Reiterate the importance of medication adherence
  and follow up appointments
• Offer HIV test (if HIV status is unknown)
• HIV testing should be offered to all contacts

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Subsequent Follow up Visits

• Ask about medication side effects
• Observe for possible adverse reactions
• Reiterate importance of compliance with treatment
  and follow up visits
• Review medication regimen
• Give follow up appointment (in a month)

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High Risk Contacts

• HIV
• Children lt5 years old
• Those with Other medical conditions

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Window Period

• The window period is the eight to ten week period
  after last exposure
• Window Prophylaxis
• Treatment doing the window period has been
  recommended for susceptible and vulnerable
  contacts to prevent rapidly emerging of TB disease

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Signs of Adherence Problems

• Missed follow up appointments
• Not picking up medication refill from pharmacy
• Finding too many pills when conducting a pill
  count
• Unaddressed adverse reactions

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Addressing Adherence Problems

• Identify adherence problems and try to resolve
  them
• Reeducate
• Free medication (Gratis Medication Program)
• DOT for contacts (If funding permits)

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Dont Underestimate the Power of a Smile

• Build a rapport
• Show you care

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Any Questions?