Contact Investigation San Antonio, Texas January 14-15, 2013

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1 Contact Investigation San Antonio, Texas January 14-15, 2013 Assigning Priorities to Contacts Patrick Moonan, PhD, MPH January 14, 2013 Patrick Moonan, PhD, MPH has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Assigning priority to persons exposed to M. tuberculosis Dr Patrick K. Moonan International Research and Programs Branch Program Strengthening and Epidemiology Division of TB Elimination National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis Elimination Objectives Define the information needed to PRIORITIZE contacts for TB investigation: Characteristics of the index patient Characteristics of contacts Identify factors that increase the likelihood of TB transmission and progression of latent TB infection (LTBI) to active TB disease 2

3 Why prioritize contacts? Distinguish all recently infected contacts from those who are not infected, and Prevent TB disease by treating those with infection (both active or latent) Why prioritize contacts? 3

4 Why prioritize contacts? Why prioritize contacts? Ricks PM, Cain KP, Oeltmann JE, Kammerer JS, Moonan PK. Estimating the burden of tuberculosis among foreign-born persons acquired prior to entering the U.S., PLoS One. 2011;6(11):e

5 Reality is merely an illusion, albeit a very persistent one. Albert Einstein First dose of reality Not all contacts with substantial exposure are identified during the contact investigation 5

6 First dose of reality Not all contacts with substantial exposure are identified during the contact investigation Although brief exposure can lead to TB tuberculosis infection and disease, certain contacts never become infected even after long periods of intensive exposure Second dose of reality Available tools to detect LTBI infection lack sensitivity and specificity and do not differentiate between persons recently or remotely infected 6

7 More is not always better Over testing of contacts is not productive Unfocused testing encourages false fears of epidemic of TB Contact follow up efforts should be directed at those truly at risk Priorities are based on the likelihood of infection and the risk of progression to active tuberculosis disease. 7

8 Exposure (LTBI) Progression to TB disease ~0.1% per year thereafter 2-3% Second Year 5% First Year No Disease (90%) Factors for Assigning Contact Priorities Characteristics of the index patient (how infectious were they?) Characteristics of contacts- how vulnerable are they? Age Immune status Other medical conditions Exposure -intensity, frequency, duration 16 8

9 Decision to Initiate a TB Contact Investigation 18 *Acid-fast bacilli Nucleic acid assay Approved indication for NAA Chest radiograph Contact Most Important Characteristics age <5 years immune status Other medical conditions also might affect the probability of TB disease after infection 9

10 Age After infection, TB disease is more likely to occur in younger children. o The incubation or latency period is briefer; o And lethal, invasive forms of the disease are more common. Age-specific incidence of disease for children who have positive skin test results declines through age 4 years. Children aged <5 years who are contacts are assigned high priority for investigation 10

11 Immune Status HIV infection results in the progression of TB infection to TB disease more frequently and more rapidly than any other known factor, and a greater likelihood of disseminated and extrapulmonary disease. HIV infected contacts are assigned high priority, and starting at the time of the initial encounter, extra vigilance for TB disease is recommended. Other immunosuppression Contacts receiving >15mg of prednisone or its equivalent for >4 weeks also should be assigned high priority. Other immunosuppressive agents, including: multiple cancer chemotherapy agents, anti-rejection drugs for organ transplant and tumor necrosis factor alpha (TNF alpha) antagonists, increase the likelihood of TB disease after infection; their contacts also are assigned a high priority. 11

12 TNF alpha antagonists Remicade (infliximab) Enbrel (etanercept) Humira (adalimumab) Cimzia (certolizumab pegol) Simponi (golimumab) Kineret (anakinra) Other medical conditions Being underweight for their height has been reported as a weakly predictive factor promoting progression to TB disease; however, assessing weight is not a practical approach for assigning priorities. 12

13 Other medical conditions to consider Silicosis: 3,600-7,300 cases per year in the United States from 1987 to Diabetes Mellitus: affects 25.8 million people of all ages (8.3 percent of the U.S. population) Diagnosed: 18.8 million people Undiagnosed: 7.0 million people stats Gastrectomy or jejunoileal bypass surgery: over 200,000 performed annually in the US. For optimal efficiency, Priorities should be assigned to contacts, and resources should be allocated to complete all investigative steps for high and medium priority contacts. Any contact not classified as high or medium priority is assigned a low priority. 13

14 Priority Scheme High: household, under age 5, medical risk factor (HIV), exposure during medical procedure (bronch, sputum induction or autopsy), congregate setting, exceeds duration/environmental limit Medium: age 5-15, exceeds duration/environmental limits Low priority: all other identified contacts Congregate Settings correctional facilities, workplaces, hospitals or other health care settings, schools, shelters, transportation modes, (airplanes, ships) drug or alcohol usage sites 14

15 CDC Prioritization Prioritization of Contacts (1) 41 Patient has pulmonary, laryngeal, or pleural TB with cavitary lesion on chest radiograph or is AFB sputum smear positive Household contact High Contact <5 years of age High Contact with medical risk factor (HIV or other medical risk High factor) Contact with exposure during medical procedure High (bronchoscopy, sputum induction, or autopsy) Contact in a congregate setting High Contact exceeds duration/environment limits (limits per unit High time established by the health department for high-priority contacts) 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) Any contact not classified as high or medium priority is assigned a low priority. Medium Medium 15

16 Also see Figure 2 on page 12 of Contact Investigation Guideline 16

17 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 Contact with medical risk factor (e.g., HIV) Contact with exposure during medical procedure (bronchoscopy, sputum induction, or autopsy) Household contact Contact exposed in congregate setting Contact exceeds duration/environment limits (limits per unit time established by the local TB control program) High High High Medium Medium Medium Any contact not classified as high or medium priority is assigned a low priority. 42 See Figure 3 on page 13 of Contact Investigation Guideline 17

18 Prioritization of Contacts (3) 43 Patient is a suspect pulmonary TB case AFB smear negative, NAA negative/culture negative, abnormal chest radiograph not consistent with TB disease Household contact Medium Contact <5 years of age Medium Contact with medical risk factor (e.g., HIV Medium infection or other immunocompromising condition) Contact with exposure during medical procedure (bronchoscopy, sputum induction, or autopsy) Any contact not classified as high or medium priority is assigned a low priority. Medium See Figure 4 on page 14 of the Contact Investigation Guideline 18

19 Environment Air volume, exhaust rate, and circulation predict the likelihood of transmission in an enclosed space. Environment In large indoor settings, because of diffusion and local circulation patterns, the degree of proximity between contacts and the index patient can influence the likelihood of transmission. Other subtle environmental factors (eg humidity and light) are impractical to incorporate into decision making. 19

20 The volume of air shared between an infectious TB patient and contacts dilutes the infectious particles, although this relationship has not been validated entirely by epidemiologic results. Circulation of Air Local circulation and overall room ventilation also dilute infectious particles, but both factors can redirect exposure into spaces that were not visited by the index patient. These factors have to be considered. 20

21 Contact Terminology The terms close and casual, which are frequently used to describe exposures and contacts, have not been defined uniformly and therefore are not useful for these guidelines. Depends on the intensity, frequency and duration of exposure. 21

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