Effective TB Interviewing for Contact Investigation: Self-Study Modules
The TB interview
The infectiousness or potential infectiousness of a patient should be taken into consideration by the interviewer, not only for the purpose of eliciting contacts, but also for assessing the need for respiratory protection. Appropriate respiratory protection should be used when interviewing an infectious or potentially infectious patient. However, the use of respiratory protection may cause difficulty in establishing rapport with a patient, as some patients may be offended. If respiratory protection is used, the interviewer should explain to the patient why its use is necessary. For additional information regarding the infectiousness of patients, please consult the CDC resource, Self-Study Module on Tuberculosis #5: Infectiousness and Infection Control.
There are two basic types of respiratory protection that may be utilized during contact investigation:
- Personal Respirators – There are a variety of personal respirators available. The most commonly used personal respirator in a healthcare setting is the disposable N-95 respirator. Research has shown that use of a surgical mask is not adequate in capturing all TB bacteria. Some surgical masks fit poorly and, therefore, provide very little protection from any airborne hazards. Personal respirators should be used by the interviewer around an infectious patient. Different varieties of personal respirators are available. Staff should be trained on the appropriate method of wearing respirators and be fit tested according to their institutional policy. A personal respirator should not be worn by a patient, since it may result in increased difficulty in breathing for the patient and is generally moreexpensive than a surgical mask.
- Surgical Mask – These masks should be used by the infectious patient and may prevent
M. tuberculosis bacteria from spreading. However, surgical masks can be loose fitting and, depending on the proximity of an individual to the patient, may not be an adequate barrier for all M. tuberculosis bacilli.
In situations involving infectious or potentially infectious patients, personal respirators should always be worn by interviewers and surgical masks should only be worn by patients. There are a number of different factors that affect the use of respiratory protection by the interviewer and patient. Detailed below are several common contact investigation scenarios with infectious patients, and the correct use of respiratory protection for each scenario:
- Interview in an infectious patient’s home – While many infectious patients are hospitalized, this is not always the case. The patient should be wearing a surgical mask at home if he or she is living with others. In this situation, after entering the home, the interviewer should wear a personal respirator. The interviewer should not put on a respirator outside the patient’s home because it may draw attention from outsiders. Even though the patient’s mouth and nose are to be covered by a mask at all times, the interviewer cannot assume that the patient is always masked and should take adequate precautions.
- Interview in an airborne infection isolation (negative pressure) room (AIIR) in a hospital – In this case, the patient is considered infectious. The patient should not be asked to wear a mask in this situation, but should be instructed to cover his or her mouth with disposable tissue while coughing. Any person entering the room should wear a personal respirator (e.g., N-95).
- Interview in a clinic setting in both AIIR and non-AIIR– A patient can arrive at a clinic setting and be deemed infectious or potentially infectious based on symptoms, particularly a productive cough. In this case, the patient should be immediately triaged into an isolation room, that is, away from other patients. A surgical mask should be given to the patient for use as he or she proceeds through the clinic, and the patient should be instructed to cover his or her mouth with disposable tissue while coughing.
- In an AIIR – As above, the patient may remove the surgical mask, but the interviewer should wear a personal respirator.
- In a non-AIIR – The patient should wear a surgical mask and the interviewer should wear a personal respirator.
As noted above, the use of a surgical mask or a personal respirator may affect the rapport between interviewer and patient. Explaining the need for protection and acknowledging that surgical masks or respirators may be uncomfortable can help in re-establishing rapport. Out of respect to the infectious patient at home, an interviewer should not put on a respirator prior to entering the home, in sight of neighbors or passers-by. The respirator should be worn upon entering the home. The interviewer can say to the patient, “I hope you don’t mind, but I need to wear my respirator while I am here visiting you today.” If the patient questions the reasons, particularly if he or she is already wearing a surgical mask, the interviewer can explain, “I am glad that you are wearing your mask. However, it may not prevent all TB germs from spreading. That is why I need to take precautions. If, in a few weeks, you are no longer spreading germs, I will not need to wear this respirator.”