Contact InvestigationsContact Investigations

WHO ?

WHERE ?

WHEN ?HOW

LONG ?

WHY ?

HOW ?

WHO ?WHO ? IS RESPONSIBLE FORIS RESPONSIBLE FOR

CONTACT INVESTIGATION?CONTACT INVESTIGATION?

YOU YOU ARE!!!!!!ARE!!!!!!

ROLE OF HEALTH ROLE OF HEALTH DEPARTMENTDEPARTMENT

TO ENSURE THAT ALL PERSONS WHO TO ENSURE THAT ALL PERSONS WHO ARE SUSPECTED OF HAVING ARE SUSPECTED OF HAVING TUBERCULOSIS ARE IDENTIFIED AND TUBERCULOSIS ARE IDENTIFIED AND EVALUATED PROMPTLY AND THAT AN EVALUATED PROMPTLY AND THAT AN APPROPERIATE COURSE OF APPROPERIATE COURSE OF TREATMENT IS PRESCRIBED AND TREATMENT IS PRESCRIBED AND COMPLETED SUCCESSFULLYCOMPLETED SUCCESSFULLY

MMWR TREATMENT OF TB pg.15MMWR TREATMENT OF TB pg.15

Health departments are responsible for Health departments are responsible for ensuring contact investigationsensuring contact investigations

Public health officials must decide whichPublic health officials must decide which Contact investigations should be assigned a Contact investigations should be assigned a

higher priorityhigher priority Contacts to evaluation firstContacts to evaluation first

Decision to investigate an index patient Decision to investigate an index patient depends on presence of factors used to depends on presence of factors used to predict likelihood of transmissionpredict likelihood of transmission

WHY?WHY? IDENTIFY TB EXPOSUREIDENTIFY TB EXPOSURE

IDENTIFY TRANSMISSIONIDENTIFY TRANSMISSION

PREVENT TB DISEASEPREVENT TB DISEASE

Purpose of Contact InvestigationPurpose of Contact Investigation

Identify, evaluate and treat individuals Identify, evaluate and treat individuals who may have been infected with TB by who may have been infected with TB by a person with active, infectious TBa person with active, infectious TB

Detect additional cases of active TBDetect additional cases of active TB

Identify and treat contacts with LTBI to Identify and treat contacts with LTBI to prevent TB diseaseprevent TB disease

VIRGINIA’S STANDARD OF VIRGINIA’S STANDARD OF CARECARE

TBTB CASES/TBCASES/TB SUSPECTSSUSPECTS - the initial - the initial interview will be conducted within 3 interview will be conducted within 3 daysdays

At least 90% of newly reported AFB At least 90% of newly reported AFB smear + cases will have contacts smear + cases will have contacts identified and at least 95% of the identified and at least 95% of the contacts will be evaluated for disease contacts will be evaluated for disease and/or infectionand/or infection

Contact investigation will be Contact investigation will be initiated within 3 days of the first initiated within 3 days of the first notification and completed within notification and completed within

three months three months

85% of contacts found to be 85% of contacts found to be infected with Mtb infection will infected with Mtb infection will complete a full coarse of complete a full coarse of recommended treatmentrecommended treatment

““Contact investigations are complicated Contact investigations are complicated undertakings that typically require undertakings that typically require hundreds of interdependent decisions, hundreds of interdependent decisions, the majority of which are made on the the majority of which are made on the basis of incomplete data, and dozens of basis of incomplete data, and dozens of time-consuming interventions…..”time-consuming interventions…..”

HOW?HOW?

CASE MANAGEMENT CASE MANAGEMENT SKILLSSKILLS

EFFECTIVE COMMUNICATIONEFFECTIVE COMMUNICATION

CONFIDENTIALITYCONFIDENTIALITY

THOROUGHNESSTHOROUGHNESS

PERSISTANCEPERSISTANCE

Evaluation of the Index Evaluation of the Index PatientPatient

Comprehensive information regarding Comprehensive information regarding the index patient is the foundation of the index patient is the foundation of a contact investigationa contact investigation Requires review of medical records Requires review of medical records

and patient interview(s)and patient interview(s) Requires systematic collection and Requires systematic collection and

management of datamanagement of data

Guidelines for the Guidelines for the Investigation of Contacts of Investigation of Contacts of Persons with Infectious Persons with Infectious TuberculosisTuberculosis20052005

Guidelines for Investigation of ContactsGuidelines for Investigation of Contacts

Identification, evaluation and treatment Identification, evaluation and treatment of contacts is element of case of contacts is element of case managementmanagement

Characteristics of case determine need Characteristics of case determine need for and extent of contact investigation for and extent of contact investigation

Contact investigation activities should Contact investigation activities should be planned, prioritized to ensure be planned, prioritized to ensure identification and treatment of highest identification and treatment of highest risk contactsrisk contacts

Probability of TB Probability of TB TransmissionTransmission

Transmission dependent on Transmission dependent on three factorsthree factors Infectiousness of the person Infectiousness of the person

with TBwith TB Environment in which the Environment in which the

transmission occurstransmission occurs Duration of the exposure to Duration of the exposure to

TB bacteriaTB bacteria

Infectiousness of patient Infectiousness of patient Pulmonary, laryngeal, or pleuralPulmonary, laryngeal, or pleural AFB on sputum smear (1+ or 4+)AFB on sputum smear (1+ or 4+) Cavitation on x-ray,Cavitation on x-ray, Adolescent or adultAdolescent or adult Period of infectiousnessPeriod of infectiousness Environment – activities leading to aerosolization Environment – activities leading to aerosolization Inspect home, work and social environmentInspect home, work and social environment

Duration of exposure – proximity, small space, Duration of exposure – proximity, small space, limited ventilation - increase chance that limited ventilation - increase chance that susceptible contact will breathe AFB into lungssusceptible contact will breathe AFB into lungs

Decisions to Initiate a Contact InvestigationDecisions to Initiate a Contact Investigation

NOT EVERY TB NOT EVERY TB CASE REQUIRES CASE REQUIRES A CONTACT A CONTACT INVESTIGATIONINVESTIGATION

Additional considerations….Additional considerations….

Pulmonary, laryngeal or pleural TBPulmonary, laryngeal or pleural TB

Pleural is now grouped with pulmonary Pleural is now grouped with pulmonary because sputum cultures can yield because sputum cultures can yield M. M. tuberculosistuberculosis even when no lung abnormalities even when no lung abnormalities are apparent on x-rayare apparent on x-ray

AFB smears should always be done when AFB smears should always be done when diagnosis is pleural TB (suspected or diagnosis is pleural TB (suspected or confirmed) because parenchyma abnormalities confirmed) because parenchyma abnormalities may be hidden by fluidmay be hidden by fluid

Additional considerations….Additional considerations….

Consider contact investigation for TB case Consider contact investigation for TB case with extra pulmonary disease if there were with extra pulmonary disease if there were procedures that generate aerosols (i.e. procedures that generate aerosols (i.e. autopsy, embalming, wound irrigation or autopsy, embalming, wound irrigation or manipulation of a draining abscess)manipulation of a draining abscess)

Additional considerations….Additional considerations…. If original specimens were from If original specimens were from bronchoscopy/bronchial washings:bronchoscopy/bronchial washings:

Guidelines recommend equating results of Guidelines recommend equating results of AFB microscopy on bronch washings to AFB microscopy on bronch washings to sputumsputum

VDH recommends that sputum be collected VDH recommends that sputum be collected and assessment of infectiousness be based and assessment of infectiousness be based on sputum AFB results on sputum AFB results

If unable to collect sputum, use results of If unable to collect sputum, use results of bronchial washingsbronchial washings

Additional considerations….Additional considerations…. Available resources should be focused on Available resources should be focused on

identifying, evaluating and treating identifying, evaluating and treating exposed persons who are more likely to be exposed persons who are more likely to be infected or to become ill with TB disease if infected or to become ill with TB disease if they are infectedthey are infected

Persons with longest, closest contactPersons with longest, closest contact Infants, young children , immunocompromised, Infants, young children , immunocompromised,

persons with serious underlying medical persons with serious underlying medical conditions conditions

Concentric CircleConcentric Circle

Work/School

Social/Community

Household

Additional considerationsAdditional considerations

Do we suspect the base case to be Do we suspect the base case to be MDR?MDR?

Contacts of MDR need to be Contacts of MDR need to be continually re-assesstedcontinually re-assessted

Potential for prolonged periods of Potential for prolonged periods of infectiousnessinfectiousness

INDEX CASEINDEX CASE

THE FIRST PERSON WITH TB DISEASE THE FIRST PERSON WITH TB DISEASE WHO IS IDENTIFIED IN A PARTICULAR WHO IS IDENTIFIED IN A PARTICULAR SETTINGSETTING

SOURCE CASESOURCE CASE THE PERSON OR CASE THAT WAS THE THE PERSON OR CASE THAT WAS THE

ORIGINAL SOURCE OF THE INFECTIONORIGINAL SOURCE OF THE INFECTION

TWO CIRCUMSTANCES FOR SOURCE TWO CIRCUMSTANCES FOR SOURCE INVESTIGATIONINVESTIGATION

WHEN CONGREGATE LIVING SETTING DETECTS WHEN CONGREGATE LIVING SETTING DETECTS

AN UNEXPLAINED CLUSTER OF TST CONVERSIONSAN UNEXPLAINED CLUSTER OF TST CONVERSIONS WHEN LTBI OR TB DISEASE IS DIAGNOSED IN A WHEN LTBI OR TB DISEASE IS DIAGNOSED IN A

YOUNG CHILD YOUNG CHILD

Evaluation of the Index Patient and Evaluation of the Index Patient and Possible Sites of TransmissionPossible Sites of Transmission

Elements of the patient investigationElements of the patient investigation Pre-interview phase Pre-interview phase

Background information (case report, records, Background information (case report, records, laboratory results, x-rays)laboratory results, x-rays)

Patient characteristics (language, severity of Patient characteristics (language, severity of illness, ability to cooperate)illness, ability to cooperate)

Determination of infectious period Determination of infectious period (preliminary)(preliminary)

Determining the Infectious Determining the Infectious PeriodPeriod

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.

Interviewing the PatientInterviewing the Patient

Recommendation that interview occur Recommendation that interview occur << 1 1 business day for persons considered to be business day for persons considered to be infectious and infectious and << 3 business days for others 3 business days for others

Interview conducted in person (face-to-face, not Interview conducted in person (face-to-face, not phone!), by prepared interviewer with requisite phone!), by prepared interviewer with requisite skillsskills

Second interview 1-2 weeks laterSecond interview 1-2 weeks later Interview process continues throughout course Interview process continues throughout course

of treatmentof treatment

Interviewing the PatientInterviewing the Patient Language of patient’s choice; interpreter if requiredLanguage of patient’s choice; interpreter if required Assurance of confidentiality and privacyAssurance of confidentiality and privacy Review and verify information gathered from other Review and verify information gathered from other

sourcessources Infectious periodInfectious period

Potential transmission settings – patient’s ADLPotential transmission settings – patient’s ADL Day, night, work, school, social, health care, travelDay, night, work, school, social, health care, travel Refer to calendar, use holidays as remindersRefer to calendar, use holidays as reminders

List of contactsList of contacts Names, including street names,types, frequencies Names, including street names,types, frequencies

and duration of exposure, and duration of exposure, Use a standard form to record informationUse a standard form to record information If no names, ask about “groups”, social networkIf no names, ask about “groups”, social network

WHERE ?WHERE ? WHERE ARE WE GOING TO LOOK FOR WHERE ARE WE GOING TO LOOK FOR

PEOPLE WHO HAVE SHARED PEOPLE WHO HAVE SHARED AIRSPACE WITH OUR TB CASE?AIRSPACE WITH OUR TB CASE?

REMEMBER, YOUR CONTACT LIST REMEMBER, YOUR CONTACT LIST WILL CHANGE, CI IS AN ONGOING WILL CHANGE, CI IS AN ONGOING PROCESSPROCESS

USE YOU ORW AS A SOURCE OF USE YOU ORW AS A SOURCE OF INFORMATION FOR CONTACTSINFORMATION FOR CONTACTS

Field InvestigationField Investigation

Site visits Site visits First visit to site should be to gather First visit to site should be to gather

information; second and subsequent visits information; second and subsequent visits should be done after specific investigation should be done after specific investigation plan is in placeplan is in place

Each site will have it’s own cultureEach site will have it’s own culture Should be made within 3 days of initial Should be made within 3 days of initial

interviewinterview Media concernsMedia concerns

Field Investigation/Site Field Investigation/Site VisitsVisits

Complimentary/supplementary to interviewsComplimentary/supplementary to interviews All possible sites of transmission should be evaluatedAll possible sites of transmission should be evaluated May identify additional contactsMay identify additional contacts May identify high-risk contacts (children)May identify high-risk contacts (children) Size, ventilation characteristics may help estimate Size, ventilation characteristics may help estimate

level of exposurelevel of exposure May raise additional questions for re-interview of May raise additional questions for re-interview of

patientpatient Likely to attract attention, raise questionsLikely to attract attention, raise questions Requires planning, anticipation of questionsRequires planning, anticipation of questions

““Specific Investigation Specific Investigation Plan”Plan”

The final step in the evaluation of the index patient and The final step in the evaluation of the index patient and possible sites of transmissionpossible sites of transmission Summarize informationSummarize information from interviews, site visits from interviews, site visits Make a decisionMake a decision on need for/extent of contact investigation on need for/extent of contact investigation If a contact investigation is indicatedIf a contact investigation is indicated

List contactsList contacts and and assign prioritiesassign priorities Establish time lineEstablish time line Develop list of resource requirements and staffing planDevelop list of resource requirements and staffing plan

If a contact investigation is not requiredIf a contact investigation is not required Summary of available information and reason for Summary of available information and reason for

decisiondecision Include investigation plan in permanent recordInclude investigation plan in permanent record

““Priorities”Priorities”

Is the contact investigation high priority?Is the contact investigation high priority?

Is the contact high risk and therefore high Is the contact high risk and therefore high priority?priority?

Assigning Priorities to ContactsAssigning Priorities to Contacts

Occurs after contact investigation decisionsOccurs after contact investigation decisions Characteristics of the index patientCharacteristics of the index patient Availability of resourcesAvailability of resources

Priority/order for investigation of contactsPriority/order for investigation of contacts Characteristics of contactsCharacteristics of contacts

Age, immune status, underlying medical conditionsAge, immune status, underlying medical conditions

Estimated level of exposure Estimated level of exposure Proximity, duration, volume of space (small room vs. large), Proximity, duration, volume of space (small room vs. large),

ventilationventilation

Priority for evaluation evaluation of contacts: Priority for evaluation evaluation of contacts: AFB smear positive AFB smear positive

laryngeal/pulmonary/pleural TBlaryngeal/pulmonary/pleural TB HighHigh

Under age 5Under age 5 Medical risk factorsMedical risk factors

HIVHIV Immunosuppressive agents (steroids, cancer Immunosuppressive agents (steroids, cancer

chemotherapy, anti-rejection drugs for organ chemotherapy, anti-rejection drugs for organ transplants, tumor necrosis factor alpha transplants, tumor necrosis factor alpha agents)agents)

Other medical risk factors (silicosis, renal Other medical risk factors (silicosis, renal disease, diabetes, gastrectomy)disease, diabetes, gastrectomy)

Exposure during medical procedure Exposure during medical procedure (bronchoscopy, autopsy, sputum induction)(bronchoscopy, autopsy, sputum induction)

Exposure in congregate settingExposure in congregate setting

Priority for evaluation evaluation of contacts: Priority for evaluation evaluation of contacts: AFB smear positive AFB smear positive

laryngeal/pulmonary/pleural TBlaryngeal/pulmonary/pleural TB MediumMedium

Aged 5-15Aged 5-15 Exposure exceeds time/space/ventilation Exposure exceeds time/space/ventilation

limits recommended by state or local TB limits recommended by state or local TB programprogram

Estimate of exposure by settingEstimate of exposure by setting Time at locationTime at location Size/volume of shared airspaceSize/volume of shared airspace Ventilation – windows, fansVentilation – windows, fans

May be up or downgraded depending on results of May be up or downgraded depending on results of testing of higher priority contactstesting of higher priority contacts

Priority for evaluation evaluation of contacts: Priority for evaluation evaluation of contacts: AFB smear negative AFB smear negative

laryngeal/pulmonary/pleural TBlaryngeal/pulmonary/pleural TB HighHigh

Contacts < age 5Contacts < age 5 Medical risk factorMedical risk factor Exposure during medical procedureExposure during medical procedure

MediumMedium HouseholdHousehold Exposure in congregate settingExposure in congregate setting Exceeds duration/environmental limitsExceeds duration/environmental limits

Priority for evaluation of contacts: Priority for evaluation of contacts: Suspected pulmonary TB, AFB negative Suspected pulmonary TB, AFB negative with abnormal chest x-ray not consistent with abnormal chest x-ray not consistent

with TBwith TB HighHigh

NoneNone MediumMedium

HouseholdHousehold Age < 5 yearsAge < 5 years Medical risk factorMedical risk factor Exposure during medical procedureExposure during medical procedure

Timeline for Contacting/Evaluation Timeline for Contacting/Evaluation of Contactsof Contacts

Establish after assignment to high, Establish after assignment to high, medium or low priority categorymedium or low priority category

High or medium priority should be High or medium priority should be contacted within 3 days and evaluated contacted within 3 days and evaluated within within << 7 days for high priority and 7 days for high priority and << 14 14 days for medium priority contactsdays for medium priority contacts Symptomatic contacts should be evaluated Symptomatic contacts should be evaluated

immediatelyimmediately

Diagnostic and Public Health Diagnostic and Public Health Evaluation of ContactsEvaluation of Contacts

Remember priority assignmentRemember priority assignment Highest risk = highest priority = major effort to Highest risk = highest priority = major effort to

contact and complete evaluationcontact and complete evaluation Initial assessment for all high and medium priority Initial assessment for all high and medium priority

contactscontacts Screen for symptoms of active disease; proceed Screen for symptoms of active disease; proceed

immediately to x-ray and sputum collection if immediately to x-ray and sputum collection if symptomatic; do not wait for results of TSTsymptomatic; do not wait for results of TST

Children <5 and immunocompromised adults should be Children <5 and immunocompromised adults should be evaluated and have chest x-ray, whether symptomatic or notevaluated and have chest x-ray, whether symptomatic or not

Diagnostic and Public Health Diagnostic and Public Health Evaluation of ContactsEvaluation of Contacts

Others (high and medium priority contacts) should receive Others (high and medium priority contacts) should receive TST ASAP if not already TST positiveTST ASAP if not already TST positive Two step TST procedure should not typically be used for testing Two step TST procedure should not typically be used for testing

contactscontacts BCG exposure should be recorded, but is not a contra-indication to BCG exposure should be recorded, but is not a contra-indication to

testingtesting > > 5mm induration is considered to be a positive TST in a contact 5mm induration is considered to be a positive TST in a contact

investigationinvestigation Individuals with positive TST require further evaluationIndividuals with positive TST require further evaluation

Chest x-rayChest x-ray Sputum smears and culture if indicated (abnormal x-ray, symptoms)Sputum smears and culture if indicated (abnormal x-ray, symptoms)

Individuals who are previously TST positive should be screened for Individuals who are previously TST positive should be screened for symptoms, further evaluated only if indicated by screeningsymptoms, further evaluated only if indicated by screening

Tuberculin Skin Testing of Tuberculin Skin Testing of ContactsContacts

Repeat testingRepeat testing Estimated interval between infection and detectible Estimated interval between infection and detectible

skin test reactivity is 2-12 weeksskin test reactivity is 2-12 weeks Reinterpretation of data previously collected indicates Reinterpretation of data previously collected indicates

that 8 week is outer limits of window period.that 8 week is outer limits of window period. CDC & NTCA recommendation that window period be CDC & NTCA recommendation that window period be

decreased to 8-10 weeksdecreased to 8-10 weeks VIRGINIA – WINDOW PERIOD DEFINED AS 10 VIRGINIA – WINDOW PERIOD DEFINED AS 10

WEEKS FOR VIRGINIA CONTACT WEEKS FOR VIRGINIA CONTACT INVESTIGATIONSINVESTIGATIONS

HOW LONG?HOW LONG?

EXPANDING THE CONTACT EXPANDING THE CONTACT INVESTIGATIONINVESTIGATION

FINDING NEW CONTACTS NOT FINDING NEW CONTACTS NOT IDENTIFIED IN THE BEGINNINGIDENTIFIED IN THE BEGINNING

Should be considered only after results of Should be considered only after results of investigation of high and medium priority investigation of high and medium priority contacts is complete and results have contacts is complete and results have been evaluatedbeen evaluated Infection rates are higher than expectedInfection rates are higher than expected Evidence of secondary transmissionEvidence of secondary transmission TB disease is found ( source vs. secondary)TB disease is found ( source vs. secondary)

Requires careful consideration – may require Requires careful consideration – may require new contact investigation rather than expansion new contact investigation rather than expansion of initial investigationof initial investigation

TST conversions occur between first and TST conversions occur between first and second TSTsecond TST

INCIDENT COMMANDINCIDENT COMMAND

VDH DDP-TB ENCOURAGES THIS VDH DDP-TB ENCOURAGES THIS MODEL IN ALL LARGE CONTACT MODEL IN ALL LARGE CONTACT INVESTIGATIONSINVESTIGATIONS

WE ARE AVAILABLE TO ANSWER WE ARE AVAILABLE TO ANSWER YOUR QUESTIONS AND TO PROVIDE YOUR QUESTIONS AND TO PROVIDE ASSISTANCEASSISTANCE

DOES ANYONE HAVE AN DOES ANYONE HAVE AN UNUSUALUNUSUAL

CONTACT INVESTIGATION CONTACT INVESTIGATION TO SHARE???TO SHARE???

Required DocumentsRequired Documents

Guidelines for the Investigation of Contacts Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosisof Persons with Infectious Tuberculosis,,

December 16, 2005; Volume 54, # RR-15.December 16, 2005; Volume 54, # RR-15. Treatment of TuberculosisTreatment of Tuberculosis, June 20, 2003;, June 20, 2003; Volume 52, # RR-11.Volume 52, # RR-11. Controlling Tuberculosis in the United Controlling Tuberculosis in the United

StatesStates, March 2005., March 2005. Targeted Tuberculin Testing and Treatment Targeted Tuberculin Testing and Treatment

of Latent Tuberculosis Infectionof Latent Tuberculosis Infection, 2005., 2005. Virginia’s CI Nursing Directive/Guideline Virginia’s CI Nursing Directive/Guideline

http://vdhweb/nursing/documents.asphttp://vdhweb/nursing/documents.asp

Questions?Questions?

HAPPY CONTACT INVESTIGATIONS !HAPPY CONTACT INVESTIGATIONS !