Transcript Investigation of Contacts of Persons with Infectious

Medical Management of
Contacts to Infectious
Pulmonary Tuberculosis
Alfred Lardizabal, MD
New Jersey Medical School
Global Tuberculosis Institute
Continuing Education Statement
• The University of Medicine and Dentistry of New
Jersey –Center for Continuing and Outreach Education
(UMDNJ-CCOE) designates this educational activity
for a maximum of 1.5 AMA PRA Category 1
Credits. Physicians should only claim credit
commensurate with the extent of their participation in
the activity.
• UMDNJ-CCOE certifies that this continuing education
offering meets the criteria for up to .15 Continuing
Education Units, as defined by the National Task Force
on the Continuing Education Unit (CEU), provided the
activity is completed as designed. One CEU is
awarded for 10 contact hours of instruction.
Faculty Disclosure
• Alfred Lardizabal has expressed that his
presentation does not include discussion of
commercial products or services, or an
unapproved or uninvestigated use of a commercial
product. He has no significant financial
relationships to disclose.
• Lillian Pirog has expressed that her presentation
does not include discussion of commercial
products or services, or an unapproved or
uninvestigated use of a commercial product. She
has no significant financial relationships to
disclose.
Background (1)
• 1962: Isoniazid (INH) demonstrated to be effective in
preventing tuberculosis (TB) among household contacts
of persons with TB disease
– Investigation and treatment of contacts with latent TB infection
(LTBI) quickly becomes strategy in TB control and elimination
in the U.S.
• 1976: American Thoracic Society (ATS) published
guidelines for investigation, diagnostic evaluation, and
medical treatment of TB contacts
Background (2)
• 2005: National TB Controllers Association (NTCA) and
CDC release guidelines on the investigation of contacts of
persons with infectious TB
– Expanded guidelines on investigation of TB exposure and
transmission, and prevention of future TB cases through contact
investigations
– Standard framework for assembling information and using
findings to inform decisions
Contact Investigations – A Crucial
Prevention Strategy
• On average, 10 contacts are identified for each
person with infectious TB in the U.S.
• 20%–30% of all contacts have LTBI
• 1% of contacts have TB disease
• Of contacts who will ultimately have TB
disease, approximately one-half develop
disease in the first year after exposure
Decisions to Initiate a
Contact Investigation
• Public health officials must decide which
– Contact investigations should be assigned a higher
priority
– Contacts to evaluate first
• Decision to investigate an index patient depends
on presence of factors used to predict likelihood of
transmission
– Site of disease
– Positive sputum bacteriology
– Radiographic findings
Determining the Infectious
Period
• Focuses investigation on contacts most likely
to be at risk for infection
• Sets time frame for testing contacts
• Information to assist with determining
infectious period
– Approximate dates TB symptoms were noticed
– Bacteriologic results
– Extent of disease
Start of Infectious Period
• Cannot be determined with precision;
estimation is necessary
• Start is 3 months before TB diagnosis
(recommended)
• Earlier start should be used in certain
circumstances (e.g., patient aware of illness
for longer period of time)
Closing the Infectious Period
Infectious period closed when all the
following criteria are met
• Effective treatment for ≥ 2 weeks,
• Diminished symptoms, and
• Bacteriologic response
Assigning Priorities to Contacts
Prioritization of Contacts (1)
Patient has pulmonary, laryngeal, or pleural TB with cavitary lesion on
chest radiograph or is AFB sputum smear positive
Household contact
Contact <5 years of age
Contact with medical risk factor (HIV or other medical risk
factor)
Contact with exposure during medical procedure
(bronchoscopy, sputum induction, or autopsy)
Contact in a congregate setting
Contact exceeds duration/environment limits (limits per unit
time established by the health department for high-priority
contacts)
High
High
High
Contact is ≥ 5 years and ≤ 15 years of age
Contact exceeds duration/environment limits (limits per unit
time established by the health department for medium-priority
contacts)
Medium
Medium
Any contact not classified as high or medium priority is assigned a low priority.
High
High
High
Prioritization of Contacts (2)
Patient is a suspect or has confirmed pulmonary/pleural TB –
AFB smear negative, abnormal chest radiograph consistent
with TB disease, may be NAA and/or culture positive
Contact <5 years of age
High
Contact with medical risk factor (e.g., HIV)
High
Contact with exposure during medical procedure
(bronchoscopy, sputum induction, or autopsy)
Household contact
High
Contact exposed in congregate setting
Medium
Medium
Contact exceeds duration/environment limits (limits Medium
per unit time established by the local TB control
program)
Any contact not classified as high or medium priority is assigned a low priority.
Diagnostic Evaluation of
Contacts
Information to Collect During Initial
Assessment (1)
• Previous M. tuberculosis infection or disease
and related treatment
• Contact’s verbal report and documentation of
previous TST results
• Current symptoms of TB illness
Information to Collect During Initial
Assessment (2)
• Medical conditions making TB disease more likely
• Mental health disorders
• Type, duration, and intensity of TB exposure
• Sociodemographic factors
Information to Collect During Initial
Assessment (3)
• HIV status; contacts should be offered HIV
counseling and testing if status unknown
• Information regarding social, emotional, and
practical matters that might hinder participation
Reassess Strategy After Initial
Information Collected
After initial information collected
– Priority assignments should be reassessed
– Medical plan for diagnostic tests and possible treatment
can be formulated for high- and medium-priority
contacts
Tuberculin Skin Testing
• All high or medium priority contacts who do not have
a documented previous positive tuberculin skin test
(TST) or previous TB disease should receive a TST at
the initial encounter.
• If not possible, TST should be administered
– ≤7 working days of listing high-priority contacts
– ≤14 days of listing medium-priority contacts
Interpreting Skin Test Reaction
• ≥ 5 mm induration is positive for any contact
• Two-step procedure should not be used for testing
contacts
• A contact whose second TST is positive after initial
negative result should be classified as recently
infected
Postexposure Tuberculin
Skin Testing
• Window period is 8–10 weeks after exposure ends
• Contacts who have a positive result after a
previous negative result are said to have had a
change in tuberculin status from negative to
positive
Evaluation and Follow-up of
Children <5 Years of Age
• Always assigned a high priority as contacts
• Should receive full diagnostic medical evaluation,
including a chest radiograph
• If TST ≤5 mm of induration and last exposure <8 weeks,
LTBI treatment recommended (after TB disease excluded)
• Second TST 8–10 weeks after exposure; decision to treat
is reconsidered
– Negative TST – treatment discontinued
– Positive TST – treatment continued
Evaluation and Follow-up of
Immunosuppressed Contacts
• Should receive full diagnostic medical
evaluation, including a chest radiograph
• If TST negative ≥ 8 weeks after end of
exposure, full course of treatment for LTBI
recommended (after TB disease is excluded)
Window-Period Prophylaxis
Decision to treat contacts with a negative
skin test result should take the following
factors into consideration
• The frequency, duration, and intensity of
exposure
• Corroborative evidence of transmission from
the index patient
Prophylactic Treatment
Prophylactic treatment (after TB disease is
excluded) of presumed M. tuberculosis
infection recommended for persons
• With HIV infection
• Taking immunosuppressive therapy for organ
transplant
• Taking anti-tumor necrosis factor alpha (TNFα) agents
Treatment After Exposure to
Drug-Resistant TB
• Consultation with physician with MDR expertise
recommended for selecting a LTBI regimen
• Contacts should be monitored for 2 years after
exposure
Selecting Contacts for Directly
Observed Therapy
• Contacts aged <5 years
• Contacts who are HIV infected or otherwise
substantially immunocompromised
• Contacts with a change in their tuberculin skin test
status from negative to positive
• Contacts who might not complete treatment because
of social or behavior impediments
Source-Case Investigations
Source-Case Investigations
• Seeks the source of recent M.tuberculosis
infection
• In the absence of cavitary disease, young
children usually do not transmit M.tuberculosis
to others
• Recommended only when TB control program is
achieving its objectives when investigating
infectious cases
Child with LTBI
• Search for source of infection for child is unlikely
to be productive
• Recommended only with infected children <2 years
of age, and only if data are monitored to determine
the value of the investigation
Procedures for
Source-Case Investigation
• Same procedure as standard contact investigation
• Patient or guardians best informants (associates)
• Focus on associates who have symptoms of TB
disease
• Should begin with closest associates
Contact Investigations
Background – 1
• 6/14/04 39 year-old female admitted to the hospital with
complaints for approximately one month of cough, fever,
decreased appetite, night sweats and 23 lb weight loss
• 6/17 Chest x-ray cavitary disease consistent with TB
• 6/17 Bronchial wash AFB smear positive (3+)
Background - 2
• 6/19 Treatment (RIPE) initiated
• 6/21 Suspected case of tuberculosis verbally
reported by hospital infection control to the local
health department
Background – 3
• 6/21 LHD informed TB Control of suspected case
adding the following information
– Presenting patient was a volunteer at a daycare center
– Director of center is the sister of patient
– Name, address and telephone of daycare center
provided
Background – 4
• 6/21 Telephone call to director of daycare center
from TB controller
– Purpose to set up a meeting to discuss potential
exposure to children and staff
• Conduct on-site exposure assessment of center
• Provide TB education to the director
• Identify high-priority contacts during infectious period
established at 2/14–6/14/04
Background - 5
• During telephone conversation, the following was
indicated by the director:
– Index patient was a part-time volunteer
a “couple of hours” (2-5) per week
– Secretary with little or no exposure to children
Background - 6
• Near the conclusion of telephone call the following
exchange occurred
– Director: So, should my daughter be tested?
– TB Control: Tell me about your daughter and how much
exposure she had to your sister
– Director: Not too much. She doesn’t attend the daycare
but we do spend some time socially (maybe 5 hours)
together on the weekends going to the mall
Background - 7
– TB Control: How old is your daughter?
– Director: 6 months
– TB Control: I’ll make arrangements for your daughter to
be tested tomorrow morning
– TB Control: By the way, how is your daughter feeling?
– Director: Well, she was diagnosed with bronchitis a few
weeks ago and is still coughing
• Final culture result MTB
Contact Investigation
• 6/22: First of 4 TB interviews with the patient
conducted by HCW in hospital revealed
– Infectious period confirmed at 2/14-6/14/04
– Patient may have spent more time in daycare than originally
described
– Patient indicates not much contact with children at daycare
– 8 high priority contacts identified
• 2 household
• 6 social
• 6/23 Initiation of on-site assessment of daycare center
Contact Investigation
• As a result of on-site assessment 35 high priority
contacts identified
– 30 children ages 3-4 years
– 5 staff members
• Notification process begins for testing
• Education sessions provided to parents of daycare
children
• During these sessions it is learned that the 6 month old
infant, director’s daughter, was at daycare center on
regular basis
Contact Investigation
• 6/23 6 month old infant (director’s daughter)
evaluated at clinic
– TST 15 mm
– CXR hilar adenopathy with suspected miliary TB
– Admitted to hospital with diagnosis of suspected miliary
TB
Contact Investigation
• 6/25 Field visit to social contact residence by
HCW identifies a second 6 mo. old infant not
named on initial interview
– 70 hours exposure per week during infectious period
– Diagnosed with pneumonia 3 weeks ago
• HCW & TB Controller consult with pediatric nurse
practitioner at Lattimore and infant is referred to ED
and is admitted with a diagnosis of suspected
pulmonary TB
Medical Evaluation
• 6/29 - 6/30 Tuberculin skin tests administered on
all 35 daycare contacts and chest x-rays taken on
all 30 children from daycare
• Extra clinic sessions scheduled in addition to 3
evening clinics at local health department where
most contacts reside to accommodate the medical
evaluations of the 30 children
Contact Investigation Initial Infection & Disease
Results: Household and Social Contacts
• Total 9 high priority contacts identified
– 4 children/5 adults
 TST (+) 5/9 (56%)
• TB disease 2/9 (22%)
– 2 infants
 TST (-) 4/9 (44%)
Contact Investigation Infection & Disease Results:
Daycare
Children
30 (3-4 years of age)
TST (+)
TST (+) w/ disease
11/30 (37%)
5/11 (45%)
TST (-)
TST (-) w/ disease
19/30 (63%)
2/19 (11%)
Staff
5
TST (+)
TST (-)
3/5 (60%) - 2 adolescents
2/5 (40%)
No disease
Contact Investigation Results:
Totals After Initial Testing
Investigation Totals
44
TST (+)
19/44 (43%)
TST (-)
25/44 (57%)
TB disease
9/44 (20%)
32 ≤ 4 yrs old
All ≤ 4 yrs old
Prevention of Tuberculosis in Children:
Missed Opportunities
• Failure to find and appropriately manage adult source cases
(Case finding)
• Delay in reporting the initial diagnosis of TB
• Contact investigation interview failure
• Delay in evaluation of exposed children
• Failure to completely evaluate exposed children
• Failure to maintain a contact under surveillance
• LTBI diagnosed; treatment not prescribed
• Failure to complete treatment for LTBI (Adherence)
Contact Investigations: Lessons Learned
• Importance of on-site assessment
• Re-interviews of presenting patients strongly recommended to
allow a complete and accurate assessment of exposure
– Different interviewers if no contacts, rapport issue
• Despite the rapidity of the CI process 9 cases of disease occurred
– Children develop disease soon after infection so it is imperative to move
quickly
• Local pediatricians are generally not familiar with the evaluation
recommended for and the prophylactic treatment of children
exposed to tuberculosis
Medical Management of
TB Contacts from a
Nursing Perspective
Lillian Pirog, RN, PNP
Nurse Manager-Lattimore Practice
NJMS Global Tuberculosis Institute
The Role of the Nurse Case Manager
with Respect to TB Contacts
• Interview the index case for contacts
• Administer and read the TST
• Educate the contacts
• Monitor contacts at monthly interval
• Ensure treatment adherence
Note: Not all duties discussed today will apply to all nurses, and
some duties performed by TB nurse case managers may not be
discussed
Interviewing the Index Case
• Interviewing the index case for contacts should be
done on more than one occasion
– On the initial visit
– On subsequent visits until you are satisfied all the
contacts have been identified
– A visit to the site of exposure will help provide important
information regarding possible transmission and
contacts
Past Medical History
• Obtain contact’s past medical history
– Ask the contact
• Have you ever been diagnosed with tuberculosis?
• Have you ever had a TB skin test?
– If yes why, when, where, and what was the result
• Ask about medical conditions that may elevate the
contact’s status to high risk
• Ask about behaviors that may elevate the contact’s
status to high risk
• Ask about TB symptoms
• Ask about previous HIV testing
Contact Education
• Explain the following:
–
–
–
–
Transmission and Pathogenesis
TST (how it is performed)
TST results and what they mean
Retesting (if necessary)
Always give the contact an opportunity to ask questions
And ask them to tell you in their own words what they’ve
learned
Contact Education cont.
• The evaluation process
– TST
• If you are tested you must be available for the reading
in 48-72 hours
• X-ray
– Medical examination
– Treatment if necessary
• Importance of adherence with treatment
– Provide literature
TST
• Administer the TST
– Explain the procedure
– Explain that PPD is not a live bacteria. It can not give
you TB
– Explain how to care for the site
• Do not place a bandage on the site
• Do not scratch
– Pat it with cold cloth
– Can rub it with ice
• It’s okay to bathe and wash the site
TST cont.
• Results
– Explain a positive result
• It only tell us that the germ is in your body nothing
more. Further medical evaluation is needed
– Explain a negative result
– Explain the need for retesting (if necessary)
– Explain window prophylaxis (if necessary)
Monthly Follow up Visits
• First visit
– Review test results
• Blood
• Sputum
– Explain how medications are taken
– Explain possible adverse reactions to medication
– Provide clinic telephone number and an emergency
telephone numbers for after clinic hours and weekends.
Monthly Follow up Visits
• First visit cont.
– Reiterate the importance of medication adherence and
follow up appointments
– Offer HIV test (if HIV status is unknown)
• HIV testing should be offered to all contacts
Subsequent Follow up Visits
• Ask about medication side effects
• Observe for possible adverse reactions
• Reiterate importance of compliance with treatment
and follow up visits
• Review medication regimen
• Give follow up appointment (in a month)
High Risk Contacts
• HIV +
• Children <5 years old
• Those with Other medical conditions
Window Period
• The window period is the eight to ten week period
after last exposure
Window Prophylaxis
• Treatment doing the window period has been
recommended for susceptible and vulnerable
contacts to prevent rapidly emerging of TB disease
Signs of Adherence Problems
• Missed follow up appointments
• Not picking up medication refill from pharmacy
• Finding too many pills when conducting a pill
count
• Unaddressed adverse reactions
Addressing Adherence Problems
• Identify adherence problems and try to resolve
them
• Reeducate
• Free medication (Gratis Medication Program)
• DOT for contacts (If funding permits)
Don’t Underestimate the Power of a
Smile
• Build a rapport
• Show you care
Any Questions?