Contact Investigation Overview PETER DAVIDSON, PH.D. MDCH TB NURSE CERTIFICATION COURSE JULY 23, 2014 Learning Objectives Explain purpose and principles of a TB contact investigation Determine when to initiate a TB contact investigation Describe core concepts and skills that are required to conduct a TB contact investigation Learning Objectives Explain purpose and principles of a TB contact investigation Determine when to initiate a TB contact investigation Describe core concepts and skills that are required to conduct a TB contact investigation 1
Purpose of Contact Investigation Identify persons exposed to TB through contact to a patient with infectious TB disease Evaluate as many contacts as possible and assess for TB infection or disease Provide treatment for TB infection or disease as appropriate Contact Investigations: A High-Priority TB Control Activity Conducting contact investigations (CIs) is one of the highest priorities for TB programs in the United States Second in importance only to detection and treatment of TB disease Who are TB Contacts? Contacts are persons who have shared airspace with a patient with infectious TB disease. Contacts can include: o Household members o Friends o Co-workers o Others (e.g., cellmates, shelter residents) 2
Why Contact Investigations Are Important (1) Contact Investigations help to: Interrupt spread of TB Ensure appropriate treatment for LTBI or TB disease Prevent outbreaks of TB Prevent future cases of TB Why Contact Investigations Are Important (2) In Michigan from 2008 2012, an average of 25 contacts were identified for each case 3% - 6% of total active cases each year are identified through contact investigations CDC estimates that 20% to 30% of household contacts have LTBI Who is Responsible for TB Contact Investigations in Michigan? Local health departments have legal responsibility to: Investigate TB cases reported in their jurisdiction Identify, evaluate and treat contacts as appropriate Although the health department maintains legal responsibility, some contact investigation steps may involve other partners and/or be delegated In worksite exposures, occupational health officials should be involved 3
Every TB case Began as a TB contact TB case TB Contacts TB case TB Contacts TB cases What Factors Influence TB Transmission? Remember that TB is airborne! The probability that TB will be transmitted depends on the following factors: 1. Infectiousness of person with TB disease 2. Duration and frequency of exposure 3. Environment in which exposure occurred Infectiousness of Person with TB Disease Characteristics associated with infectiousness: TB of the lungs, airway, or larynx Presence of cough Positive sputum smear Cavity on chest x-ray Positive cultures Not covering mouth when coughing Not receiving adequate treatment Undergoing cough inducing procedures 4
Duration and Frequency of Exposure Contacts at higher risk for TB infection are those who: Frequently spend a lot of time* with the case Have been physically close to the case * A lot of time is difficult to define, but may be determined locally based on experience Environment in Which Exposure Occurred Environmental characteristics that increase chances of TB transmission: Small or crowded rooms Areas that are poorly ventilated Rooms without air-filtering systems Learning Objectives Explain purpose and principles of a TB contact investigation Determine when to initiate a TB contact investigation Describe core concepts and skills that are required to conduct a TB contact investigation 5
When is a TB Contact Investigation Necessary? Yes: Pulmonary, infectious (positive AFB sputum smear or bronchoscopy and cavitary CXR) Positive Nucleic Acid Amplification or Culture-confirmed TB Cases Suspect cases pending confirmation No: Pulmonary, positive AFB sputum smear or bronchoscopy Negative Nucleic Acid Amplification or Culture Extrapulmonary So Should I Do a Contact Investigation If: Culture or NAA positive MTB complex Proceed AFB positive sputum smear or Bronchoscopy Cavitary CXR Culture or NAA negative MTB complex STOP Suspect case pending confirmation Proceed with High Priority contacts pending confirmation Pulmonary Disease Culture or NAA positive MTB complex Proceed with High Priority contacts AFB negative sputum smears or Bronchoscopy Culture or NAA negative MTB complex STOP Suspect case pending confirmation Seek medical guidance Prioritizing Among Contact Investigations If faced with multiple TB cases, health departments may have to decide which cases should be a higher priority for conducting CIs Decision will be influenced by: Likelihood of transmission (e.g., sputum smear positive*, cavitary chest x-ray, cough, and exposure environment) Risk of contacts rapidly progressing to TB disease (e.g., contacts in daycare, HIV care-settings, and dialysis centers) Resources available * Transmission is still possible for cases with negative sputum smears 6
Why is it Important to Promptly Start a Contact Investigation? Some contacts may develop TB disease soon after exposure and infection, especially: Infants and children younger than 5 years of age HIV-infected or other persons with weakened immune systems All contacts need to be found and evaluated promptly As time increases, some contacts might be more difficult to locate (e.g., homeless or transient persons) There could be ongoing transmission of M. tuberculosis Learning Objectives Explain purpose and principles of a TB contact investigation Determine when to initiate a TB contact investigation Describe core concepts and skills that are required to conduct a TB contact investigation Core Concepts and Skills For a TB Contact Investigation Determining the patient s infectious period Effective Interviewing Prioritizing Contacts 7
What is the Infectious Period? An estimate of the time period during which a patient is able to transmit M. tuberculosis Estimating infectious period is important because: It focuses the investigation on contacts most at risk for exposure Sets the time frame for contact assessment Contacts with initial negative TB test will need 2 nd TB test 8-10 weeks after date of last exposure Estimating the Start of the Infectious Period TB symptoms Characteristic of Case AFB sputum smear positive Cavitary chest x-ray Yes No No Yes Yes Yes No No No No Yes Yes Likely Period of Infectiousness 3 months before symptom onset or first finding consistent with TB disease, whichever is longer 3 months before symptom onset or first finding consistent with TB disease, whichever is longer 1 month (4 weeks) before date of suspected diagnosis 3 months before finding consistent with TB disease Ending the Infectious Period Biologically, a patient s infectious period ends when all of the following are met: 1) Effective treatment for 2 weeks or more 2) Diminished symptoms 3) Three consecutive negative sputum smears For contact investigation purposes, effective isolation can also end the infectious period since the case is not likely to be in contact with additional persons. 8
Infectious Period in Review For TB cases/suspects with symptoms, positive smears and /or cavitary disease Date of beginning of infectious period 3 months back Date of symptom onset or first finding consistent with TB, whichever longer Date of end of infectious period for CI is 2 weeks after treatment is started, diminished symptoms, AND mycobacteriologic response, and/or effective isolation For TB cases/suspects with no symptoms, negative smears and non-cavitary disease Date of beginning of infectious period 1 month (4 weeks) back Date of symptom onset or first finding consistent with TB, whichever longer Date of end of infectious period for CI is 2 weeks after treatment is started, diminished symptoms, and/or effective isolation Practice Scenarios Scenario 1 John is a 42 year-old man who was hospitalized on Dec. 4 th with symptoms of fever, night sweats and cough. As a result he was placed in Airborne infection isolation for two weeks. On the same date (Dec 4th), AFB sputum smears were collected and reported as positive with final cultures pending. Chest x-rays were taken on Dec 4 th and reported as abnormal with cavitary disease. John was diagnosed with suspected pulmonary TB with appropriate treatment started on Dec 5 th. John states that he started coughing around Nov 6 th. His symptoms resolved on Dec 24 th. Three consecutive sputum AFB smears were not negative until Feb. 10 th. 9
Determine Date of symptom onset or first finding consistent with TB, whichever longer Date of beginning of infectious period Date of end of infectious period Scenario 2 George, a 25 year-old man, was admitted to the hospital on March 10 th as a result of a cough of unknown duration. CXRs taken on March 10 th were reported as abnormal with noncavitary disease. Sputum samples collected on March 11 th were reported as AFB positive with final cultures pending. George was diagnosed with suspected pulmonary TB and was placed in airborne infection isolation on March 12 th when appropriate TB treatment was initiates. George reported that he had been experiencing a cough and night sweats for the past several months, but he doesn t remember exactly when his symptoms began. He reports he definitely remembers not feeling well around the Christmas and New Year holidays. He had three consecutive negative AFB smears, the last on April 2 nd. Determine Date of symptom onset or first finding consistent with TB, whichever longer Date of beginning of infectious period Date of end of infectious period 10
Assigning Priority to Contacts Once a list of contacts is obtained, the contacts should be prioritized to determine which contacts are of highest priority to locate and assess for TB disease or infection. The contacts priority should be assigned based on both of the following: Contact s risk for development of TB disease Likelihood of transmission from the case Which Contacts Should be Given Priority for TB Assessment? Priority should be given to contacts who Have symptoms of TB disease Are at risk for rapid development of TB disease Children <5; immune suppressed Had repeated or extended exposure to the case Were exposed to a case in an environment where transmission was likely (small, crowded, or poorly ventilated room or vehicle) Were exposed to a case undergoing medical procedures that can release substantial numbers of M. tuberculosis into the air (e.g., bronchoscopy) Concentric Circle Tool The concentric circle should only be used as a secondary tool to help further prioritize contacts based on exposure (duration, frequency, and distance) High Risk Contacts spend a lot of time and with case Medium Risk Contacts spend some amount of time with case Low Medium High CASE Low Risk Contacts spend little amount of time with case 11
Later (Re)Prioritization of Contacts Re-examine priority level assigned to contacts throughout the investigation If evidence of significant transmission has occurred in priority contacts, CI may need to be expanded to additional contacts However, investigation should not expand to additional contacts if doing so would compromise TB program s ability to assess and treat the known priority contacts Effective Interviewing Effective interviewing skills are essential for eliciting information from cases and their contacts Interview skills can be taught Interview skills improve with practice Shout out: What skills or attributes do you think contribute to effective interviewing? Components of Effective Interviewing for Contact Investigation Building rapport with patient Effective communication skills Recognize and balance between assertive, passive and aggressive behavior Ask the right type of questions at the right time 12
Building Rapport Building rapport is the key to a successful case/health care worker relationship Rapport: 1: relation of trust between people 2: a feeling of sympathetic understanding 3: in accord, harmony 4: having a mutual understanding How Do You Build Rapport? Methods to build rapport: Use effective communication skills Find common ground Display respect and empathy Effective Communication Skills 1. Active listening 2. Using appropriate nonverbal communication 3. Using appropriate voice and tone 4. Communicating at the case s level of understanding 5. Giving factual information 6. Using reinforcement 7. Summarizing important points from the conversation 13
Interpreting Body Language Nonverbal Cues Faltering eye contact Intense eye contact Rocking Stiff posture Elevated voice Prolonged and frequent periods of silence Fidgeting Possible Meaning Boredom or fatigue Fear, confrontation, or anger Fear or nervousness Discomfort or nervousness Confrontation or anger Disinterest, loss of train of thought, or fatigue Discomfort, disinterest, nervousness, possible drug use Communicate at Patient s Level Avoid technical terms and jargon Limit the amount of information shared Need to Know vs. Nice to Know Clearly explain necessary medical and technical terms and concepts Repeat important information Give Factual Information Correct misconceptions Provide comprehensive TB information Avoid irrelevant information Be genuine Maximize chances to build trust by giving facts 14
Use Honest Reinforcement Sincerely compliment or acknowledge the patient after they share information Do not appear to reward them for ratting out their friends, family, etc! Use smiles and affirmative nods and words Be genuine! This is the time to show the patient that you appreciate their position and their willingness to help you help others. Summarize Conversation Throughout the conversation, periodically summarize what has been said Summarizing gives the patient an opportunity to correct information that you may have misunderstood Examples We have covered a lot today. In your own words, review for me what we have discussed. Please tell me what you heard me say. This will help me provide you with any additional information you need. Avoid: Do you have any questions? Do you understand? Assertive, Passive, or Aggressive Behavior Passive: When you have an opportunity, it would be helpful to get the names of people you spent time with. Assertive: It s important to identify your contacts. Let s start making a list of the people you spend the most time with. Aggressive: You must give me all the names of your contacts. NOW! 15
Examples of Interview Question Types Closed-ended question Do you have symptoms of TB? Have you ever been tested for TB? Open-ended question What symptoms do you have? Who lives with you? Probing question Who are some of the people you ve visited during the past 3 months? You mentioned that your aunt came to visit three weeks ago. Please tell me more about that. Checking question What are some of the reasons we ve discussed for needing to test your family members for TB? Shout out: Suggest other examples for each type of question. Questions? Active Listening Hearing what is said and paying attention to how it is said so the conversation can be adjusted to elicit the needed response Utilizing various verbal and nonverbal techniques Paraphrasing and summarizing: rewording or rephrasing a statement It sounds like you are <action/problem/event> Reflecting: putting words to a patient s emotions I understand you are <emotion/reaction/experience> Being silent Allows the patient (or you!) to process information and respond. Shows respect, that one person is willing to wait for the other person to speak. 16
Active Listening Example: Paraphrasing and Summarizing Patient: I can t tell you the names of all my contacts. I just hang out at the pool hall; there is a guy we call Slim, another one named JD. How would you paraphrase this statement? Active Listening Example: Reflection Patient: I m feeling tired and this whole interview is making me nervous. YOU are asking me too many questions. How would you reflect this statement? Using Appropriate Nonverbal Communication Nonverbal communication (body language) Is an important aspect of building rapport Can be what the interviewer or patient conveys with his/her body language Interviewer should Be observant of the patient s body language Display appropriate body language Eye contact Facial expressions (be attentive) Posture (lean slightly forward) Gestures (nodding head politely indicates attention) Movement and mirroring (act in proportion to the patient) 17
Using Appropriate Voice and Tone Voice and tone Use natural volume and tone If voice is too loud, the case may be intimidated If too soft, the message may be inaudible or sound hesitant Pace Use regular pace If too fast, it can indicate a feeling of being rushed If too slow, it can sound tentative Assertive, Passive or Aggressive Behavior or Tone Assertive: maintaining one s rights without compromising the rights of others Passive: relinquishing one s rights in deference of others Aggressive: demanding one s rights at the expense of others Being assertive protects everyone s rights, including those of the contacts you hope to help Believe in what you re doing, and that it s right! Interview Question Types Closed-ended questions Short, finite answers (yes/no); minimal discussion Open-ended questions Descriptive answers; encourage discussion Probing questions A question (or statement) used to gain more information Can be open-ended or closed-ended Checking questions Specific and targeted question to check patient s understanding of information being shared with them 18