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Effective TB Interviewing for Contact Investigation: Facilitator Led Training Guide 2006

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10. Course Activities

Facilitator

Activity 3:  Prioritization Exercise

Objectives

 

  • To look critically at patient medical information for transmission assessment
  • To understand the priority order in which patients should be interviewed based on infectiousness, length of treatment, and type of disease
  • To apply recommendations for TB interviewing
Time Allotted 35 minutes total

  • 5 minutes for instructions and dividing participants into groups
  • 15 minutes of individual group work
  • 15 minutes of large group discussion
Materials Needed Easel and marker; copies of “Prioritization Exercise” on page 38 (one for each participant)

Procedure
  1. Ask participants to count themselves off by threes (i.e., 1, 2, 3…)

  2. Designate three places in the room where each group should meet. Ask all 1s, 2s, and 3s to form groups and go to the designated meeting areas.

  3. Pass out copies of the sheet on page 38.  Explain that all of the patients described in the list require a TB interview.  It is the job of each group to come up with a priority order in which to interview patients.  Even though there may not be agreement within the group, they must come to a consensus with one order.

  4. Give each group 15 minutes to work on this activity.  Provide a verbal warning when they have 5 minutes left to work.

  5. While the group is working, draw a grid (Figure 6) on the easel.

Figure 6. Priority Grid

Patient Group 1 Group 2 Group 3 Your answers
A        
B        
C        
D        
E        
F        
G        
H        

Procedure (continued) 1. After 15 minutes, ask one person from each group to verbally call out, by numbers 1-8, the order in which they ranked each patient, starting with patient A and ending with patient H.  Tell them that their answers cannot be changed after seeing any other group’s answers.

2. Discuss any major deviations between each group.  For example, if one group ranked a patient number 1, but another ranked the patient number 4, ask each group why one considered the patient to be a high priority while another felt the patient was medium priority.

3. Use the ranking to promote a discussion on reasons for prioritizing interviews. 

4. Write down your answers and explain that the exact numbers do not have to be the same, but an approximate priority should be consistent.  For example, patients 1-3 should be about the same in a varying order, 4-6 can vary, and 7 and 8 can be another grouping.  The first grouping is the highest priority, the second is medium, and the third is the lowest.  However, all of these patient interviews need to eventually be initiated within the state’s designated timeframe for interviews.

 

Tips Since the purpose of this exercise is to prioritize interviews, participants need to understand the principles of infectiousness and apply them to the interviewing process.  Therefore, page 39 has suggested answers and page 40 gives the rationale for why the cases are prioritized as indicated.  Note that the answers may vary slightly.  However, there should be no major discrepancies such as low-priority and high-priority cases being interchanged.

 

Activity 3:  Prioritization Exercise

You are the only staff member available to visit patients in the field.  In addition to your regularly scheduled field assignments, your supervisor places eight new assignments on your desk for TB interviews for contact and source case investigations.  Your supervisor’s advice: “Prioritize these new patients for interviewing.”  Please prioritize the following assignments for interviews with ‘1’ being the highest priority and ‘8’ being the lowest priority.  Note that all of the following patients must be interviewed.

A. 25 y/o male___

TST 27 mm

CXR: abnormal/noncavitary disease

Sputum smear: positive (4+)

Culture: ID pending

Cough x3 months

Currently hospitalized

On TB treatment

E. 36 y/o female____

TST 12 mm

Initial CXR: infiltrates/noncavitary disease

Repeat CXR improving

Sputum smear/culture: negative

Verified by skin test result & improving CXR Asymptomatic
Outpatient TB treatment

B. 3 y/o child___

TST 17 mm

CXR: negative

Private patient
On treatment for latent TB infection

F.  29 y/o female____

Lymph node smear: negative

Drainage aerosolized while dressing changed at home by family member (without mask), prior to culture ID & treatment

Culture: M. tuberculosis

 

C. 17 y/o male___

TST 22 mm

CXR: abnormal/cavitary disease

Sputum smear: negative

Culture: identification pending

Cough, night sweats, weight loss x2 weeks

Currently hospitalized
On TB treatment

G. 51 y/o female___

HIV positive

TST 0 mm

CXR: abnormal/noncavitary disease

Sputum smear: negative

Culture: AFB positive; final ID pending

Productive cough, night sweats, weight loss x 3 weeks

Recent history of atypical mycobacterial disease
Currently hospitalized
On TB treatment

D. 21 y/o female___

TST 0 mm

CXR: abnormal/noncavitary disease

BAL smear: negative

Culture: M. tuberculosis

On TB treatment

H. 62 y/o female___

TST 12 mm

Larynx smear: negative

Biopsy results pending

CXR: infiltrates/noncavitary disease

Hoarseness

Currently hospitalized

On TB treatment

Key: y/o=years old; CXR=chest X-ray; ID=identification; TST=tuberculin skin test; BAL=bronchoalveolar lavage; AFB=acid fast bacilli

 

Activity 3:  Prioritization Exercise Answer Sheet

 

A. 25 y/o male_1__

TST 27 mm

CXR: abnormal/noncavitary disease

Sputum smear: positive (4+)

Culture: ID pending

Cough x3 months

Currently hospitalized

On TB treatment

E. 36 y/o female__7__

TST 12 mm

Initial CXR: infiltrates/noncavitary disease

Repeat CXR improving

Sputum smear/culture: negative

Verified by skin test result & improving CXR Asymptomatic
Outpatient TB treatment
 

B. 3 y/o child__5_

TST 17 mm

CXR: negative

Private patient
On treatment for latent TB infection treatment

F.  29 y/o female__4__

Lymph node smear: negative

Drainage aerosolized while dressing changed at home by family member (without mask), prior to culture ID & treatment

Culture M. tuberculosis

C. 17 y/o male__3_

TST 22 mm

CXR: abnormal/cavitary disease

Sputum smear: negative

Culture: identification pending

Cough, night sweats, weight loss x2 weeks

Currently hospitalized
On TB treatment

 

G. 51 y/o female__8_

HIV positive

TST 0 mm

CXR: abnormal/noncavitary disease

Sputum smear: negative

Culture: AFB positive; final ID pending

Productive cough, night sweats, weight loss x 3 weeks

Recent history of atypical mycobacterial disease
Currently hospitalized
On TB Treatment
 

D. 21 y/o female__6_

TST 0 mm

CXR: abnormal/noncavitary disease

BAL smear: negative

Culture: recently identified as M. tuberculosis

On TB treatment

H. 62 y/o female__2_

TST 12 mm

Larynx smear: negative

Biopsy results pending

CXR: infiltrates/noncavitary disease

Hoarseness

Currently hospitalized

On TB treatment

Activity 3:  Prioritization Exercise

The rationale for the ratings is as follows (see answer sheet):

1

Patient A:  Highly infectious due to 4+ smear status and cough
 

2 Patient H:  Laryngeal TB is highly infectious; hoarseness is a symptom of TB disease in that site.  The larynx can also be a secondary site for pulmonary TB, indicating need for a TB interview.  In addition, even though the laryngeal smear is acid-fast bacillus (AFB) negative, this does not give an indication of decreased infectiousness. Laryngeal smears often are AFB negative.
 

3 Patient C:  Infectious due to cavitary disease, TB symptoms, particularly cough
4 Patient F:  While lymph node TB is extrapulmonary and not infectious in itself, the fact that bacilli were aerosolized, which is the route in which TB is transmitted, makes this patient medium priority.
5 Patient B:  This patient is not infectious.  However, since the patient is a 3-year-old child, this indicates that the child is recent infected and that the infectious source case may be easily located.
6 Patient D:  This patient is not highly infectious because of lack of symptoms, noncavitary disease, and negative smear status.  The patient was just diagnosed with pulmonary TB disease and should now be interviewed for that reason.
7 Patient E:  This patient is not very infectious due to having noncavitary disease, having negative smears and cultures, and being asymptomatic.  The patient does have indications of pulmonary TB due to initially having infiltrates and a positive response to TB treatment; therefore, she should be interviewed.
8 Patient G:  While this patient has TB symptoms, the recent history of atypical mycobacterial disease makes the final diagnosis more likely to be non-TB disease.  The patient should still be interviewed due to having a positive culture, symptoms, and abnormal chest X-ray.  Eventually, however, if the culture results in nontuberculosis mycobacteria, the contact investigation process should end.

 
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