Contact investigations
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Contact Investigations. WHO ?. WHERE ?. WHEN ?. HOW LONG ?. WHY ?. HOW ?. WHO ? IS RESPONSIBLE FOR CONTACT INVESTIGATION?. YOU ARE!!!!!!. ROLE OF HEALTH DEPARTMENT.

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Contact investigations

Contact Investigations

WHO ?

WHERE ?

WHEN ?

HOW

LONG ?

WHY ?

HOW ?


Who is responsible for contact investigation

WHO ?IS RESPONSIBLE FORCONTACT INVESTIGATION?

YOU ARE!!!!!!


Role of health department

ROLE OF HEALTH DEPARTMENT

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

MMWR TREATMENT OF TB pg.15


Contact investigations

  • Health departments are responsible for ensuring contact investigations

  • Public health officials must decide which

    • Contact investigations should be assigned a higher priority

    • Contacts to evaluation first

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


Contact investigations

WHY?

  • IDENTIFY TB EXPOSURE

  • IDENTIFY TRANSMISSION

  • PREVENT TB DISEASE


Purpose of contact investigation

Purpose of Contact Investigation

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

  • Detect additional cases of active TB

  • Identify and treat contacts with LTBI to prevent TB disease


Virginia s standard of care

VIRGINIA’S STANDARD OF CARE

TBCASES/TBSUSPECTS - the initial interview will be conducted within 3 days

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


Contact investigations

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

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


Contact investigations

HOW?

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


Case management skills

CASE MANAGEMENT SKILLS

  • EFFECTIVE COMMUNICATION

  • CONFIDENTIALITY

  • THOROUGHNESS

  • PERSISTANCE


Evaluation of the index patient

Evaluation of the Index Patient

  • Comprehensive information regarding the index patient is the foundation of a contact investigation

    • Requires review of medical records and patient interview(s)

    • Requires systematic collection and management of data


Guidelines for the investigation of contacts of persons with infectious tuberculosis 2005

Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis2005


Guidelines for investigation of contacts

Guidelines for Investigation of Contacts

  • Identification, evaluation and treatment of contacts is element of case management

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

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


Probability of tb transmission

Probability of TB Transmission

  • Transmission dependent on three factors

    • Infectiousness of the person with TB

    • Environment in which the transmission occurs

    • Duration of the exposure to TB bacteria


Contact investigations

  • Infectiousness of patient

    Pulmonary, laryngeal, or pleural

    AFB on sputum smear (1+ or 4+)

    Cavitation on x-ray,

    Adolescent or adult

    Period of infectiousness

  • Environment – activities leading to aerosolization

    Inspect home, work and social environment

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


Decisions to initiate a contact investigation

Decisions to Initiate a Contact Investigation


Contact investigations

NOT EVERY TB CASE REQUIRES A CONTACT INVESTIGATION


Additional considerations

Additional considerations….

Pulmonary, laryngeal or pleural TB

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

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


Additional considerations1

Additional considerations….

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


Additional considerations2

Additional considerations….

  • If original specimens were from

    bronchoscopy/bronchial washings:

    • Guidelines recommend equating results of AFB microscopy on bronch washings to sputum

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

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


Additional considerations3

Additional considerations….

  • Available resources should be focused on identifying, evaluating and treating exposed persons who are more likely to be infected or to become ill with TB disease if they are infected

    • Persons with longest, closest contact

    • Infants, young children , immunocompromised, persons with serious underlying medical conditions


Concentric circle

Concentric Circle

Work/School

Household

Social/

Community


Additional considerations4

Additional considerations

  • Do we suspect the base case to be MDR?

  • Contacts of MDR need to be continually re-assessted

  • Potential for prolonged periods of infectiousness


Index case

INDEX CASE

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


Source case

SOURCE CASE

  • THE PERSON OR CASE THAT WAS THE ORIGINAL SOURCE OF THE INFECTION

    • TWO CIRCUMSTANCES FOR SOURCE INVESTIGATION

      • WHEN CONGREGATE LIVING SETTING DETECTS AN UNEXPLAINED CLUSTER OF TST CONVERSIONS

      • WHEN LTBI OR TB DISEASE IS DIAGNOSED IN A YOUNG CHILD


Evaluation of the index patient and possible sites of transmission

Evaluation of the Index Patient and Possible Sites of Transmission

  • Elements of the patient investigation

    • Pre-interview phase

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

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

    • Determination of infectious period (preliminary)


Determining the infectious period

Determining the Infectious Period

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 patient

Interviewing the Patient

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

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

  • Second interview 1-2 weeks later

  • Interview process continues throughout course of treatment


Interviewing the patient1

Interviewing the Patient

  • Language of patient’s choice; interpreter if required

  • Assurance of confidentiality and privacy

  • Review and verify information gathered from other sources

    • Infectious period

  • Potential transmission settings – patient’s ADL

    • Day, night, work, school, social, health care, travel

    • Refer to calendar, use holidays as reminders

  • List of contacts

    • Names, including street names,types, frequencies and duration of exposure,

    • Use a standard form to record information

    • If no names, ask about “groups”, social network


Where

WHERE ?

  • WHERE ARE WE GOING TO LOOK FOR PEOPLE WHO HAVE SHARED AIRSPACE WITH OUR TB CASE?

  • REMEMBER, YOUR CONTACT LIST WILL CHANGE, CI IS AN ONGOING PROCESS

  • USE YOU ORW AS A SOURCE OF INFORMATION FOR CONTACTS


Field investigation

Field Investigation

  • Site visits

    • First visit to site should be to gather information; second and subsequent visits should be done after specific investigation plan is in place

    • Each site will have it’s own culture

    • Should be made within 3 days of initial interview

    • Media concerns


Field investigation site visits

Field Investigation/Site Visits

  • Complimentary/supplementary to interviews

  • All possible sites of transmission should be evaluated

  • May identify additional contacts

  • May identify high-risk contacts (children)

  • Size, ventilation characteristics may help estimate level of exposure

  • May raise additional questions for re-interview of patient

  • Likely to attract attention, raise questions

  • Requires planning, anticipation of questions


Specific investigation plan

“Specific Investigation Plan”

  • The final step in the evaluation of the index patient and possible sites of transmission

    • Summarize information from interviews, site visits

    • Make a decision on need for/extent of contact investigation

    • If a contact investigation is indicated

      • List contacts and assign priorities

      • Establish time line

      • Develop list of resource requirements and staffing plan

    • If a contact investigation is not required

      • Summary of available information and reason for decision

  • Include investigation plan in permanent record


Priorities

“Priorities”

  • Is the contact investigation high priority?

  • Is the contact high risk and therefore high priority?


Assigning priorities to contacts

Assigning Priorities to Contacts

  • Occurs after contact investigation decisions

    • Characteristics of the index patient

    • Availability of resources

  • Priority/order for investigation of contacts

    • Characteristics of contacts

      • Age, immune status, underlying medical conditions

    • Estimated level of exposure

      • Proximity, duration, volume of space (small room vs. large), ventilation


Priority for evaluation evaluation of contacts afb smear positive laryngeal pulmonary pleural tb

Priority for evaluation evaluation of contacts: AFB smear positive laryngeal/pulmonary/pleural TB

  • High

    • Under age 5

    • Medical risk factors

      • HIV

      • Immunosuppressive agents (steroids, cancer chemotherapy, anti-rejection drugs for organ transplants, tumor necrosis factor alpha agents)

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

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

    • Exposure in congregate setting


Priority for evaluation evaluation of contacts afb smear positive laryngeal pulmonary pleural tb1

Priority for evaluation evaluation of contacts: AFB smear positive laryngeal/pulmonary/pleural TB

  • Medium

    • Aged 5-15

    • Exposure exceeds time/space/ventilation limits recommended by state or local TB program

      • Estimate of exposure by setting

        • Time at location

        • Size/volume of shared airspace

        • Ventilation – windows, fans

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


Priority for evaluation evaluation of contacts afb smear negative laryngeal pulmonary pleural tb

Priority for evaluation evaluation of contacts: AFB smear negative laryngeal/pulmonary/pleural TB

  • High

    • Contacts < age 5

    • Medical risk factor

    • Exposure during medical procedure

  • Medium

    • Household

    • Exposure in congregate setting

    • Exceeds duration/environmental limits


  • Contact investigations

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

    • High

      • None

    • Medium

      • Household

      • Age < 5 years

      • Medical risk factor

      • Exposure during medical procedure


    Timeline for contacting evaluation of contacts

    Timeline for Contacting/Evaluation of Contacts

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

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

      • Symptomatic contacts should be evaluated immediately


    Diagnostic and public health evaluation of contacts

    Diagnostic and Public Health Evaluation of Contacts

    • Remember priority assignment

      • Highest risk = highest priority = major effort to contact and complete evaluation

    • Initial assessment for all high and medium priority contacts

      • Screen for symptoms of active disease; proceed immediately to x-ray and sputum collection if symptomatic; do not wait for results of TST

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


    Diagnostic and public health evaluation of contacts1

    Diagnostic and Public Health Evaluation of Contacts

    • Others (high and medium priority contacts) should receive TST ASAP if not already TST positive

      • Two step TST procedure should not typically be used for testing contacts

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

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

      • Individuals with positive TST require further evaluation

        • Chest x-ray

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

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


    Tuberculin skin testing of contacts

    Tuberculin Skin Testing of Contacts

    • Repeat testing

      • Estimated interval between infection and detectible skin test reactivity is 2-12 weeks

      • Reinterpretation of data previously collected indicates that 8 week is outer limits of window period.

      • CDC & NTCA recommendation that window period be decreased to 8-10 weeks

      • VIRGINIA – WINDOW PERIOD DEFINED AS 10 WEEKS FOR VIRGINIA CONTACT INVESTIGATIONS


    How long

    HOW LONG?

    • EXPANDING THE CONTACT INVESTIGATION

    • FINDING NEW CONTACTS NOT IDENTIFIED IN THE BEGINNING


    Contact investigations

    • Should be considered only after results of investigation of high and medium priority contacts is complete and results have been evaluated

      • Infection rates are higher than expected

      • Evidence of secondary transmission

      • TB disease is found ( source vs. secondary)

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

      • TST conversions occur between first and second TST


    Incident command

    INCIDENT COMMAND

    • VDH DDP-TB ENCOURAGES THIS MODEL IN ALL LARGE CONTACT INVESTIGATIONS

    • WE ARE AVAILABLE TO ANSWER YOUR QUESTIONS AND TO PROVIDE ASSISTANCE


    Does anyone have an unusual contact investigation to share

    DOES ANYONE HAVE AN UNUSUALCONTACT INVESTIGATION TO SHARE???


    Required documents

    Required Documents

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

      December 16, 2005; Volume 54, # RR-15.

    • Treatment of Tuberculosis, June 20, 2003;

      Volume 52, # RR-11.

    • Controlling Tuberculosis in the United States, March 2005.

    • Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, 2005.

    • Virginia’s CI Nursing Directive/Guideline http://vdhweb/nursing/documents.asp


    Questions

    Questions?


    Happy contact investigations

    HAPPY CONTACT INVESTIGATIONS !


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