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TB Contact Investigation Interviewing Skills Course

Day 1: Introduction to Contact Investigation Process (106 slides)

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Slide Number

508 Compliance Text  

1

(Title Slide).  Introduction to Contact Investigation Process

2

Learning Objectives

After this session, participants will be able to:

1.     Explain the purpose of a TB contact investigation

2.     Describe core concepts and skills that are required to conduct a TB contact investigation

3.     Determine when to initiate a TB contact investigation

4.     Describe the systematic approach to conducting a TB contact investigation

3

Priority TB Control Activities

1.     Identify and treat persons who have active TB disease

2.     Find and evaluate persons who have been in contact with TB cases and provide appropriate latent TB infection (LTBI) or TB disease treatment as needed

3.     Use targeted testing strategies to identify and treat persons with LTBI at risk for developing TB disease

4.     Identify settings at high risk for transmission of M. tuberculosis and apply effective infection-control measures

4

Contact Investigations: A Priority TB Control Activity

       Conducting contact investigations (CIs) is one of the highest priorities for TB programs in the United States

      Second in importance only to
detection and treatment of TB disease

[IMAGE:  A man and a woman having a discussion while sitting in chairs facing each other.]

5

What is a Contact Investigation?

A systematic process to:

       Identify persons (contacts) exposed to cases of infectious TB disease

       Assess contacts for infection with M. tuberculosis and TB disease

       Provide appropriate treatment for contacts with LTBI or TB disease

[IMAGE: Ten black spokes radiating from a pink circle.]

6

Who are TB Contacts?

Contacts are persons who have shared airspace with a person with infectious TB disease. This might include

       Household members

       Friends

       Co-workers

       Others (e.g., cellmates, shelter residents)

[IMAGE: A circle with a TB case in the middle showing people the case might encounter at work, home, and/or leisure activities around the circle.]

7

Why is it Important to Conduct TB Contact Investigations? (1)

CIs help to:

  • Interrupt spread of TB
  • Prevent outbreaks of TB
  • Ensure appropriate treatment for LTBI or TB disease

8

Why is it Important to Conduct TB Contact Investigations? (2)

·       On average, 10 contacts are identified for each case

      20% to 30% of household contacts have LTBI

      1% of contacts have TB disease

9

Who is Responsible for TB Contact Investigations?

       State and local health departments have legal responsibility to

      Investigate TB cases reported in their jurisdiction

      Evaluate effectiveness of TB investigations

       Although the health department maintains legal responsibility, some CI steps may be delegated

      For example, with worksite exposures,  occupational health offices are often involved

10

Group Discussion

·       Share a few examples from your CI experience when you successfully identified active TB cases.

·       What are some barriers to conducting CIs in your area?

11

(Title Slide). Core Concepts and Skills Required for Conducting TB Contact Investigations

12

What Core Concepts and Skills are Required to Conduct TB Contact Investigations?

  • Knowledge of TB transmission
  • Knowledge of TB pathogenesis

      Difference between LTBI  and TB disease

      Risk factors for progressing to TB disease

      Effective interviewing skills

  • Data management and analysis skills

13

Contact Investigation Core Concepts

TB Transmission

14

Remember: TB is Transmitted
Person to Person!

Every TB case Began as a TB contact

[IMAGE: Stick people showing how TB can be transmitted.]

15

TB Transmission

  • When a person with infectious TB disease coughs, sneezes, speaks, or sings, tiny particles containing M. tuberculosis (droplet nuclei) may be expelled into the air.
  • If another person inhales droplet nuclei, transmission may occur; however, not everyone who is exposed to TB becomes infected with TB.

       [IMAGE: A person with infectious TB expels tiny particles containing M. tuberculosis (droplet nuclei) into the air and infects another person.]

16

What Factors Influence TB Transmission?

The probability that TB will be transmitted depends on the following factors:

    1. Infectiousness of person with TB disease
    2. Duration and frequency of exposure
    3. Environment in which exposure occurred    

17

1.     Infectiousness of Person with TB Disease

Characteristics associated with  infectiousness:

       TB of the lungs, airway, or larynx

       Presence of cough

       Positive sputum smear

       Cavity on chest x-ray

       Positive cultures

       Not covering mouth when coughing

       Not receiving adequate treatment

      Undergoing cough inducing procedures

[IMAGE: A woman coughing into her cupped hands.]

[IMAGE: An x-ray of lungs with an arrow pointed at the diseased area of the lungs.]

18

2.     Duration and Frequency of Exposure

Contacts at higher risk for TB
infection are those who:

       Frequently spend a lot of time* with the case

       Have been physically close to the case


* “A lot of time” is difficult to define, but may be determined locally based on experience

[IMAGE: A smiling man and woman sitting close and drinking a beverage.]

19

3.     Environment in Which Exposure Occurred

Environmental characteristics that increase chances of TB transmission: 

·      Small or crowded rooms

·      Areas that are poorly ventilated

·      Rooms without air-filtering systems

[IMAGE: A House.]

20

STOP the Chain of Transmission

The BEST way to stop transmission is to

       Identify and isolate infectious persons

       Start infectious persons on effective treatment for TB disease

[IMAGE: Male and female stick people handing hands.]

21

Contact Investigation Core Concepts

TB Pathogenesis

22

What Happens Once Someone is Exposed To TB?

       Not every person who is exposed to TB becomes infected

       Persons who become infected will generally have a positive

      Tuberculin skin test (TST)

Or

      Blood test (interferon gamma release assay [IGRA])

       Persons who become infected can have either:

      LTBI

      Active TB disease

23

Latent TB Infection (LTBI)

       LTBI - immune system keeps  tubercle bacilli under control

       LTBI characteristics

      Usually positive TST or IGRA

      Not infectious

      No symptoms

      Normal chest x-ray

      Sputum smears and cultures are negative

       Not a “case” of TB

[IMAGE: A granuloma surrounding tubercle bacilli.]

24

Active TB Disease

       TB disease - immune system cannot stop tubercle bacilli from multiplying leading to active TB disease

       Usually affects lungs, but can affect other areas of the body

       Characteristics usually include:

       Positive TST or IGRA

       Infectious (before treatment)

       Symptoms

       Abnormal chest x-ray

       Positive sputum smear and culture

       Considered a “case” of TB 

[IMAGE: A granuloma opened up and releasing tubercle bacilli.]

25

What are Symptoms of TB Disease?

       Cough lasting 3 or more weeks

       Coughing up sputum or blood

       Fever

       Chills

       Night sweats

       Weight loss

       Appetite loss

       Fatigue

       Malaise

       Chest pain

[IMAGE: A man coughing into his hand.]

26

 

LTBI

TB Disease (in the lungs)

Inactive tubercle bacilli in the body

Active tubercle bacilli in the body

TST or IGRA usually positive

TST or IGRA usually positive

Chest x-ray usually normal

Chest x-ray usually abnormal

Sputum smears and cultures negative

Sputum smears and cultures usually positive

No symptoms

Symptoms such as cough, fever, weight loss

Not infectious

Often infectious before treatment

Not a case of TB

A case of TB

[IMAGE: Table of LTBI vs. TB Disease]

27

Conditions that Increase Risk of Progressing to TB Disease

       Children younger than 5 years of age

       Weakened immune systems

      Infection with HIV

      Diabetes mellitus

      Organ transplant

      Silicosis

      Severe kidney disease

      Certain types of cancer

      Certain intestinal conditions

      Prolonged therapy with corticosteroids and other immunosuppressive therapy, such as prednisone and tumor necrosis factor-alpha [TNF-α] antagonists

      Chest x-ray findings suggestive of previous TB

      Low body weight

      Cigarette smokers and persons who abuse drugs and/or alcohol

      Recent TB infection (within past 2 years)

28

LTBI Progressing to TB Disease

       Risk of developing TB disease is highest in the first 2 years after infection (or, if foreign-born, first 2 years after immigration)

       People with LTBI can be treated to prevent development of TB disease

       Detecting LTBI early and providing treatment helps prevent new cases of TB disease

29

Contact Investigation Core Concepts

Effective Interviewing Skills

30

Effective Interviewing

       Effective interviewing skills are essential for eliciting information from cases and their contacts

       Interview skills can be taught

       Interview skills improve with practice

 

The focus of this course is on building these skills

[IMAGE: Cover of Effective TB Interviewing for Contact Investigation: Self –Study Modules.

31

Contact Investigation Core Concepts

Data Management and Analysis Skills

32

Use of Data in TB Contact Investigations (1)

Collecting and analyzing data in a systematic way helps determine the effectiveness of CI efforts

[IMAGE: Example of a CI form used by a state.]

33

Use of Data in TB Contact Investigations (2)

Data can be used for

       Case and contact follow-up and management

       Analysis of findings to help assess CI strategy

      Contacts identified

      Contacts evaluated who have TB disease

      Contacts evaluated who have LTBI

       Number who started and completed LTBI treatment

34

Decision to Initiate a Contact Investigation

35

When is a TB Contact Investigation Necessary? (1)

Confirmed TB Cases

A full CI is required for all confirmed cases that have infectious forms of TB disease

      Generally, TB of lungs, airway, or larynx

36

When is a TB Contact Investigation Necessary? (2)

Suspect TB Cases

       A CI should be started for persons suspected of having infectious TB disease if they have

       Positive sputum smears*

       Cavities on chest x-ray

       Assessment of priority contacts can begin before case is confirmed

       If case is eventually confirmed, continue with full CI

       If person is found to NOT have infectious TB disease, stop the CI process

* Provided nucleic acid amplification (NAA) test, if conducted, is also positive

[IMAGE: Asterisk next to “Positive sputum smears” and “Provided nucleic acid amplification (NAA) test, if conducted, is also positive.”]

37

When is a TB Contact Investigation Necessary? (3)

Suspect TB Cases

       For all other suspect cases, collect preliminary information about contacts (name, locations, and TB risk factors)

       Assess contacts at high-risk for progressing to TB disease without waiting for case confirmation

      If case is eventually confirmed, continue with full CI

      If person is found to NOT have infectious TB disease, stop the CI process

38

When is a TB Contact Investigation NOT Necessary?

TB CI is generally NOT necessary if a case

       Has positive sputum smears and a negative nucleic acid amplification (NAA) test
 

       Has a noninfectious form of TB disease (extrapulmonary disease) with no pulmonary involvement

        Is a child under 10 years of age

      However, if case less than 5 years of age, a source case investigation may be necessary

39

Prioritizing Among Contact Investigations

       If faced with multiple TB cases, health departments may have to decide which cases should be a higher priority for conducting CIs

       Decision will be influenced by:

      Likelihood of transmission (e.g., sputum smear positive*, cavity on chest x-ray, cough, and exposure environment)

      Risk of contacts rapidly progressing to TB disease  (e.g., contacts in daycare, HIV care-settings, and dialysis centers)

      Resources available

* Transmission is still possible for cases with negative sputum smears

[IMAGE: Asterisk next to “Positive sputum smears” and “Transmission is still possible for cases with negative sputum smears.”]

40

Why is it Important to Promptly Start a Contact Investigation?

       Some contacts may develop TB disease soon after exposure and infection, especially

      Infants and children younger than 5 years of age

      HIV-infected or other persons with weakened immune systems

       All contacts need to be found and evaluated promptly

      As time increases, some contacts might be more difficult to locate (e.g., homeless or transient persons)

       There could be ongoing transmission of M.tuberculosis

41

Exercise: Decision to Initiate a Contact Investigation

Refer to Appendix E

42

(Title Slide). Systematic Approach to TB Contact Investigations

43

How Do You Conduct a Contact Investigation?

       TB programs should use a systematic approach to conduct CIs

       Using a systematic approach helps to ensure the CI is carried out effectively and efficiently

44

Systematic Approach to Contact Investigations (1)

The systematic approach includes 10 steps:

  1. Review existing information about the case
  2. Determine an initial estimate for the infectious period and estimate the degree of infectiousness
  3. Interview the case
  4. Review information and develop a plan for the investigation
  5. Refine the infectious period and degree of infectiousness  

45

Systematic Approach to Contact Investigations (2)

  1. Prioritize contacts
  2. Conduct field visits
  3. Conduct contact assessments
  4. Determine whether to expand or conclude an  investigation
  5. Evaluate the CI activities

46

Systematic Approach to TB Contact Investigations

1. Review Existing Information about the Case

47

Review Existing Information

       The process of reviewing existing information is sometimes called the pre-interview phase

       Reviewing information before the initial interview can ensure the right questions are being asked

48

Information to Collect and Review Before the Initial Interview (1)

Become familiar with the case’s social history

       Case name(s), aliases, date of birth, gender, all known addresses, telephone number(s), preferred language

       Substance abuse, mental illness, or other issues that could affect the interview or contact investigation

       Social, or behavioral risk factors increasing the risk of TB

       Known contact names, particularly children or persons with weakened immune systems

       History of jail or homelessness

       History of immigration or travel

49

Information to Collect and Review Before the Initial Interview (2)

Become familiar with case’s medical history

       Current site(s) of TB disease

       Current TB treatment regimen

       TB symptoms and estimated onset date

       Chest x-rays and/or other diagnostic imaging dates and results

       TST or IGRA dates and results

       Sputum smear and culture dates and results

       NAA test dates and results

       Genotype results (if available)

50

Information to Collect and Review Before the Initial Interview (3)

Become familiar with case’s medical history (cont.)

       HIV test dates and results

       Details about prior diagnosis with LTBI or TB disease, and any treatment

       Medical risk factors that could have increased the case’s risk for infection with M. tuberculosis or development of TB disease

51

Sources of Information for TB Case

       Medical records

       Public health records

      Cross-check case name with local TB registries and databases to determine if previous diagnosis of  LTBI or TB

      Cross-check with STD and HIV registries, if possible

       Case’s clinician

       Report of Verified Case of Tuberculosis (RVCT)

       TB Genotyping Information Management System (TB GIMS)

[IMAGE: A man and a woman looking at x-rays.]

[IMAGE: Report of Verified Case of Tuberculosis (RVCT) Form.]

52

Systematic Approach to TB Contact Investigations

2. Determine an Initial Estimate for the Infectious Period and Estimate the Degree of Infectiousness

53

 [IMAGE: Table Estimating the Degree of Infectiousness]

 

Factors Associated with Infectiousness

Factors Associated with Noninfectiousness

Presence of a cough

No cough

Cavity in the lung

No cavity in the lung

Acid–fast bacilli on sputum smear

No acid–fast bacilli on sputum smear

TB of the lungs, airway, or larynx

Most extrapulmonary (non-respiratory)

Patient not covering mouth or nose when coughing

Patient covering mouth or nose when coughing

Not receiving adequate treatment

Receiving adequate treatment for 2 weeks or longer

Undergoing cough–inducing procedures

Not undergoing cough–inducing procedures

Positive sputum cultures

Negative sputum cultures

54

What is the Infectious Period?

The time period during which a TB case is able to transmit M. tuberculosis

[IMAGE: A calendar.]

55

Why is it Important to Estimate
 the Infectious Period?

       Focuses investigation on contacts most at risk for exposure

      Especially important if the investigation involves congregate settings

       Sets the time frame for contact assessment

      Contacts with an initial negative test will need a 2nd TST or IGRA at least 8 weeks after date of last exposure

56

Estimating the Start of the Infectious Period

57

Ending the Infectious Period

Biologically, a case’s infectious period ends with:

1)    Effective treatment for 2 weeks or more,

2)    Diminished symptoms, and

3)    Mycobacteriologic response*

*A case returning to a congregate setting should have 3 or more consecutive negative sputum smears

However, for CI purposes effective isolation can also end the infectious period since the case is not likely to be in contact with additional persons

[IMAGE: Asterisk next to “Mycobacteriologic response” and “A case returning to a congregate setting should have 3 or more consecutive negative sputum smears.”]

58

Exercise: Determining the Infectious Period

Refer to Appendix F

59

Systematic Approach to TB Contact Investigations

3. Interview the Case

60

What is the Main Goal of a TB Interview?

The main goal of a TB interview is to identify contacts.  

Why?

So you can assess them for TB disease and infection and start them on appropriate treatment.

[IMAGE: Five stick people in a circle.]

61

How Do You Identify Contacts?

Ask the case about the following during their infectious period:

       Places WHERE they spent time

       Persons with WHOM they spent time

       Participation in activities and events (WHAT and WHEN)

62

What are the Other Objectives of the TB Interview?*

       Establish rapport

       Educate about TB and CI process

       Discuss confidentiality

       Gather and confirm information

* These objectives will be discussed in more detail later in the course

[IMAGE: Asterisk next to “What are the Other Objectives of the TB Interview?” and “These objectives will be discussed in more detail later in the course.”]

63

How Many Interviews Should be Conducted?

       Two interviews is the minimum (initial interview and re-interview)

      May need more interviews to develop rapport

      Often need to build on previously collected information

      Additionally, every DOT encounter is an opportunity to learn about more contacts

      Especially helpful for finding children
(e.g., toys around? photos on display?)

64

When Should Interviews be Conducted?

       Initial interview should be conducted

      Within 1 business day of reporting for infectious cases

      Within 3 business days for others

       Second interview (re-interview) conducted 1 to 2 weeks later

65

Initial Interview with the TB Case

Initial case interview should be conducted:

       In-person

       At a hospital, TB clinic, case’s home, or any convenient location that allows for privacy

       In case’s primary language

       With cultural sensitivity

       Using appropriate infection control measures (e.g., respirators, masks, and ventilation) 

66

Systematic Approach to TB Contact Investigations

Review Information and Develop a Plan for the Investigation

67

Review Information and Develop a Plan for the Investigation

       After conducting an interview with the case, the investigator should meet with his/her supervisor or the contact investigation team to

      Review all of the information obtained thus far

      Develop a plan on how to proceed

68

Contact Investigation Team

CI team may include

       Case managers

       Public health investigators

       Surveillance coordinators

       Program managers

       DOT workers

       Disease intervention specialists (DIS)

[IMAGE: Three women and one man sitting at a table talking.]

69

Developing an Investigation Plan (1)

To develop a plan for the investigation, the team should do the following activities:

       Refine the infectious period and degree of infectiousness for the case as necessary

       Prioritize identified contacts for assessment

       Prioritize identified places to conduct field visits

70

Developing an Investigation Plan (2)

Additional activities that are a part of developing a plan:

       Establish a communication plan

       Clarify any jurisdictional issues

       Establish timeframes and methods for investigation activities, data collection, and management

       Identify stakeholders

       Determine potential media interest

       Establish a schedule for meetings to review challenges and progress

71

Systematic Approach to TB Contact Investigations

5. Refine the Infectious Period and Degree of Infectiousness 

72

Refining the Infectious Period and Degree of Infectiousness

       It is often necessary to refine the infectious period

       Initial interview should

      Provide more information to help refine estimate of infectious period

      Help to further estimate degree of infectiousness

       Refined infectious period information can be used during the re-interview to elicit more contacts if needed

73

Exercise: Refining the Infectious Period

Refer to Appendix G

74

Systematic Approach to TB Contact Investigations

6. Prioritize Contacts

75

Assigning Priority to Contacts

       Once a list of contacts is obtained, the contacts should be prioritized to determine who should be immediately located and assessed for TB disease or infection.

       The priority assigned to individual contacts should be based on the following:

      Likelihood of transmission from the case

      Contact’s risk for development of TB disease

76

Which Contacts Should be Given Priority for TB Assessment?

Priority should be given to contacts who

       Have symptoms of TB disease

       Are at risk for rapid development of TB disease

       Had repeated or extended exposure to the case

       Were exposed to a case in an environment where transmission was likely, such as a small, crowded, or poorly ventilated room or vehicle

       Were exposed to a case undergoing medical procedures that can release substantial numbers of M. tuberculosis into the air (e.g., bronchoscopy)

77

Concentric Circle Tool

The concentric circle should only be used as a secondary tool to help further prioritize contacts based on exposure (duration, frequency, and distance)  

[IMAGE: A circle with the TB case in the middle and the words, “high,” “medium,” and “low” written on successive bands of the circle radiating outward.]

78

Later (Re)Prioritization of Contacts

       Re-examine priority level assigned to contacts throughout the investigation

      If evidence of significant transmission has occurred in priority contacts, CI may need to be expanded to additional contacts

      However, investigation should not expand to additional contacts if doing so would compromise TB program’s ability to assess and treat the known priority contacts

79

Exercise: Prioritization of Contacts

Refer to Appendix H

80

Systematic Approach to TB Contact Investigations

7. Conduct Field Visits

81

What is a Field Visit?

Field Visit

       Visiting a case’s residence, congregate settings, and other places the case spent time while infectious

       Complementary to interviewing

       Information obtained can inform CI activities

       Should be made within 3 days after initial interview

[IMAGE: A residence, congregate setting, and church.]

82

Purpose of a Field Visit

Four main functions

    1. Identify additional cases of TB disease
    2. Identify additional contacts
    3. Provide additional information about environmental characteristics of places where exposure occurred
    4. Lay a foundation for additional CI activities at those locations, if needed

83

What to do During a Field Visit?

       Refer persons with TB symptoms for medical assessment

       Observe environmental characteristics

       Look for evidence of other contacts

       Obtain list of clients, employees, volunteers, and others who frequented location during infectious period 

       Explore possibility of offering TB testing onsite at that location 

84

Field Visit Safety

       Have identification badge

       Work in pairs when visiting potentially dangerous areas

       Have working cell phone

       Inform coworkers of itinerary and expected return time

       Practice appropriate infection control precautions as needed

[IMAGE: A woman greeting another woman in a doorway.]

85

Group Discussion

       What safety and health concerns do you have when going out into the field?

       How do you address these concerns?

86

Systematic Approach to TB Contact Investigations

8. Conduct Contact Assessments

87

What Happens After Contacts Have Been Identified and Prioritized?

After contacts have been identified and prioritized:

       Contacts should be located

       Contact assessments should be conducted

88

Why Conduct a Contact Assessment?

Allows for

       Determination of contacts’ potential TB symptoms

       Gathering of social and medical information*

       Referral or in-person testing for TB infection with a TST or IGRA

       Provision of treatment as indicated

* Key information to collect during contact assessment  will be discussed later in the course

       [IMAGE: Asterisks after “Gathering of social and medical information” and “Key information to collect during contact assessment will be discussed later in the course.”]

89

When and How Should a Contact Assessment be Conducted?

       The initial contact assessment should be within 3 working days of the contact having been identified

       Should be conducted in-person

       Investigator should use effective communication skills

[IMAGE: A woman greeting another woman in a doorway.]

90

Initial Contact Assessment: Contacts with TB Symptoms

During the initial assessment, all contacts with symptoms of TB disease should be immediately examined by a medical professional

[IMAGE: Two men looking at an x-ray with a pointer.]

91

Initial Contact Assessment: Testing for TB Infection - TST or IGRA

       Contacts should receive a TST or IGRA unless a previous, documented positive result exists

       A TST induration of 5 mm or larger is positive

       A contact with a

      Positive TST or IGRA should  be medically examined for TB disease

      Negative TST or IGRA should
be re-tested 8 to 10 weeks after date of last exposure to the case

[IMAGE: A tuberculin skin test.]

92

Window Period

       The window period is the time span between the contact’s last exposure to the case and when a TST or IGRA can reliably detect infection

       It takes 2 to 10 weeks after TB infection for the body to mount an immune response that is detectable by a TST*

       Therefore, it is recommended to repeat a TST or IGRA for contacts 8 to 10 weeks after date of last exposure to a TB case

* Data on the timing of IGRA conversion after a new infection are not currently available; however, it is recommended to follow TST guidelines.

[IMAGE: Asterisk next to second bullet and last sentence.]

93

Calculating the Window Period (1)

       What was the date of the contact’s last exposure to the case?

      Identify the infectious period of the case

      Identify when each contact had last exposure

       Calculate 8 to 10 weeks from last exposure

      Administer a TST or IGRA for each contact who tested negative

94

Calculating the Window Period (2)

[IMAGE: Table linking critical time periods for calculating the Window Period.]

95

What if a Contact has LTBI or TB Disease?

       The decision to test a contact is a commitment to offer treatment

       If TB disease is ruled out, contacts with a positive TST or IGRA should be offered LTBI treatment

       Regardless of whether they received BCG vaccine in the past

       Unless there is a compelling reason not to treat

       Contacts with TB disease need to be treated under DOT

96

Assessment and Management of Children

       After ruling out TB disease, contacts younger than 5 years of age should start treatment for LTBI even if they have a negative initial TST or IGRA result

       LBTI treatment can be stopped if a second TST or IGRA done 8 to 10 weeks after exposure is negative

      However, if contact is under 6 months of age, LTBI treatment should be continued until contact reaches 6 months of age and a second TST/IGRA is negative

97

Assessment and Management of Contacts with Weakened Immune Systems

       A full medical evaluation, including a chest x-ray, should be given to contacts 

      With HIV/AIDS

      On immunosuppressive therapy for organ transplant

      Taking anti-tumor necrosis factor alpha (TNF-α) agents

       If both initial and follow-up TST/IGRA are negative, a full course of prophylactic LTBI treatment is recommended (after TB disease is excluded)

       Expert consultation should be sought for contacts with other immunocompromising conditions  

98

Systematic Approach to TB Contact Investigations

9. Determine Whether to Expand or Conclude an Investigation

99

When Can you Close a Contact Investigation?

A CI can be closed if

       Identified contacts have been assessed for TB in accordance with local policy

      At some point, the TB program must decide when all reasonable investigative efforts have been exhausted

       Contacts with LTBI have completed or are close  to completing treatment

       No additional active TB cases among contacts

100

When Should a Contact Investigation be Expanded?

Sometimes a CI has to be expanded if there is evidence of recent transmission

       Unexpectedly high TB disease or LTBI rates among priority contacts

       Large number of contacts with change in infection status from negative to positive

       TB disease in any contacts who had been assigned low priority or TB disease in those previously not identified as contacts

       Infection in any contacts younger than 5 years of age

101

Expanding a Contact Investigation

       Decision to expand CI should be based on the investigation data

      Results should be reviewed weekly

      Decision should be made by supervisory staff

       In the absence of recent transmission, the investigation should not be expanded to lower-priority groups

102

Other Important Considerations During a Contact Investigation

       If a second TB case is found during the CI, this second case needs their own CI.

       If a case is considered highly infectious and you find few contacts and/or find little evidence of transmission, you may need to go back and review your records and determine if a re-interview is needed.

103

Systematic Approach to TB Contact Investigations

10. Evaluate the Contact Investigation Activities

104

Evaluating Contact Investigation Activities (1)

The purpose of evaluating the activities of the CI is to determine:

       If an appropriate number of contacts were identified

       How many contacts were identified with LTBI

       How many contacts with LTBI completed treatment

       How many additional cases of TB disease were identified

105

Evaluating Contact Investigation Activities (2)

       How many contacts were not located

       How many contacts were located but did not complete assessment

       Timeliness of identifying and assessing contacts, and starting them on treatment

       If the CI was performed in all necessary settings

       If the CI was expanded appropriately

       If secondary cases completed treatment for TB disease

106

Review

What are the 10 steps of the systematic approach to conducting a CI?

 
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