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Effective TB Interviewing for Contact Investigation: Self-Study Modules

Return to Module 4 Table of Contents

Case Presentations

The following case presentations demonstrate concepts from this module. You may review them with your supervisor if you have questions.

Case 1

Part 1 – Barbara is a 41-year-old woman who was diagnosed with TB while in jail. You need to interview her in the hospital to which she was transferred. The medical record review indicates that Barbara has a history of crack and cocaine use. The interview is difficult to conduct as Barbara appears tired and has little eye contact with you. Also, as indicated in her record, she is experiencing withdrawal symptoms. While Barbara does not have many questions about TB, she verifies most of the medical and personal information you provide. When you try to elicit contacts, Barbara becomes defensive and asks why you need to know all of this information.

How do you deal with Barbara’s concern about contact identification?

Explanation: Even though Barbara has been cooperative thus far, you have come to a critical and difficult point in the interview. Although the explanation of the purpose of the TB interview for identifying contacts should come at the beginning of the interview, this purpose should be reiterated once again prior to asking about contacts. You should also acknowledge to Barbara, through the use of reflection, that she seems tired and worried about her confidentiality. You should also acknowledge that the interview has been a long process for her.

Part 2 – Once you explain to Barbara again about the reason for identifying contacts, she states that she is willing to continue with the interview. As you ask questions, Barbara offers very little information about her contacts. She provides no names or just first names and little or no address information. She fidgets in her chair and has not mentioned where exposure has occurred.

Is the contact information you have received enough to work with? If not, how can you obtain more detailed information?

Explanation: Barbara appears nervous. She has not given enough information to allow you to end the contact identification process. At this point, you should mention to Barbara that while it is difficult to name people she may have exposed to TB, you need their names and where to find them so that they can be tested for TB and be evaluated by a doctor. Barbara may also be fearful of you finding out about illicit activities she was involved in during the infectious period. Even though she may not have stated her fear directly, you should reassure her that you are only concerned about the well-being of those individuals that may have been exposed to TB and not the nature of the activities in which they are involved.

Part 3 – After you explain the process and importance of contact identification again to Barbara, she agrees to give you some more contact information. However, she still claims to only know first names or nicknames of many of her contacts, and states that she has no mailing addresses. The contacts Barbara names outside of her household are individuals she has been involved with during drug use or transactions.

How should you proceed with the contact elicitation process from here? What other information may help you?

Explanation: Asking as much information as possible about the contacts will assist the healthcare worker who will go into the field to locate them. You should ask Barbara for physical descriptions and distinguishing characteristics of her contacts and descriptions of the locations in which she meets them, including times when she meets them.

Case 2

Part 1 – Joey is a 3-year-old boy who was diagnosed with pulmonary TB. You were asked to interview his mother, Ms. Jones, as part of a source case investigation. Joey is under the care of a private doctor who referred him to the health department. Ms. Jones is confused about why you are only looking for who transmitted TB to her son. She also wants to know why Joey should not be isolated so that he will not infect others. The doctor seemed unconcerned about this and she is worried, as there is another child at home.

What should you say to Ms. Jones regarding her concerns?

Explanation: Part of the interview process is to educate the patient on the reasons for the TB interview and answer any TB-related questions the patient may have. Ms. Jones should be told why a source case investigation is being conducted and why you are trying to find out who may have transmitted TB to her son. It is important that Ms. Jones understand that young children with TB are not usually able to spread infection and, therefore, do not need to be isolated. Also, she should understand that evidence of TB disease in a young child suggests that he has been infected recently and that you can potentially find the source of her son’s disease, who needs to be treated as well. Reassure Ms. Jones that you are conducting this investigation not to lay blame on anyone, but to provide medical attention to the source case so that he or she can get well and not infect others, including anyone else close to her or to Joey.

Part 2 – After Ms. Jones has understood the purpose of the interview and its outcomes, she is willing to provide you with information that you need. Your review of the patient’s record shows that Ms. Jones and her other child have negative tuberculin skin test results and are asymptomatic.

In order to assess where exposure to TB disease may have occurred, what types of locations and people would you want to ask Joey’s mother about?

Explanation: You should ask Ms. Jones where Joey spends time. To assist her with thinking of places, ask her about daycare centers, play or activity groups, and relatives’ and friends’ homes. You should ask about people Joey spends time with, including parents or guardians and relatives or friends who come to the house. Also, ask who has come to the house and stayed for prolonged periods of time in the past few months. In addition to regular visitors, this should also include those who have had extended contact with Joey. Finally, ask Ms. Jones about any people she knows who have had TB or TB symptoms, particularly cough. Giving Ms. Jones a time frame would provide a reference to guide her in answering this question. Consult your health department guidelines for a time frame used to elicit contacts for source case investigations.

Case 3

Part 1 – A small local hospital has contacted your health department. Four nurses, who undergo annual tuberculin skin testing, have tested positive this year. This is a highly unusual number of skin test conversions in this facility. The hospital reports that none of the nurses have TB disease. There have also not been any known TB cases in the hospital in the past several years.

What should you do as the TB interviewer in this situation?

Explanation: Even though these nurses are not infectious, the fact of their recent skin test conversions in a high-risk setting makes it important to do an interview with each of them. You also need to ask two questions: 1) Have the skin testing protocols and methods in the hospital changed recently? 2) Has there been a change in the hospital staff who are regularly tested?

Part 2 – After finding out that the skin testing procedures and staff have not changed, you decide to interview each of the nurses separately. You have confirmed that they have indeed recently tested positive for latent TB infection (LTBI) and do not have TB disease. You have also obtained documentation of the nurses’ previously negative skin test results.

Since these are healthcare workers, what kind of information should you provide regarding TB and this interview?

Explanation: Even though the nurses are healthcare workers, you should still determine their level of TB knowledge. If needed, you should explain the difference between latent TB infection and TB disease and why completing treatment is important. Each nurse should also understand why these interviews are being conducted. The reason is that the hospital had observed an unusually high rate of new skin test conversions, indicative of TB transmission, and wants to 1) find the probable source case, 2) see if all of the people being interviewed are linked in some way, and 3) prevent further TB transmission.

Part 3 – After the nurses receive the education, you are ready to identify associates and exposure settings.

What questions should you ask to gather contact information?

Explanation: You should ask about anyone that they know who has TB or may have been ill with symptoms consistent with TB. You should also ask about with whom and where they spend time frequently, including home, work, school, social, and congregate settings

Part 4 – After all of the interviews are completed, you analyze your interview data. You see that none of the nurses name the same associates nor know anyone likely to have TB. All four nurses do “moonlighting” work at the same nursing home. However, they all work different shifts and on different days.

What should be done with this information, what additional questions should be asked, and should further interviews be done?

Explanation: Since a substantial amount of information was collected from the nurses, you may not want to re-interview them at this time, but may need to do so later. You should conduct an investigation in the commonly named nursing home, since it may be the place of common exposure to a source case, who remains untreated. Further interviews may arise from this setting, if a case of infectious TB is discovered. In the congregate setting you should find out 1) what the nurses’ routines are, 2) which patients they care for, and 3) the locations in which they work.

 
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