Instructions for Completing the MDH Tuberculosis Contact Investigation Report Form Please provide as much information as possible. Each field represents information that is important to the contact investigation. Index Case Information The top row of the contact investigation (CI) form will be partially completed by MDH staff and sent to the local agency via fax. The MDH TB Contact Investigation Coordinator will notify the local public health agency of the need for the CI. If you are completing the form yourself, please complete all of these fields. [Note: the index case information in the shaded bar at the top of the form (i.e., MDH Case Number, County, Date Counted by MDH, and Status) is for MDH use only and does not need to be filled out by local health department staff.] INDEX CASE INFORMATION Demographic Field Name Name Birth Date Country of Birth Living Arrangement Jobs/Schools/ Activities Clinical Site of Disease Description Name of index case (last, first, middle initial) Birth date of index case (mm/dd/yy) Index case s country of birth Describe the living arrangement of index case (e.g., lives with husband and 2 children in a small 2 bedroom apartment, lives with 3 roommates in large house, etc.) Describe the activities of index case (e.g., works from home; plays poker 1x/week with a steady group, works at ACME factory; attends ESL classes at Blue University on weeknights, etc.) Pulmonary: TB diagnosis includes pulmonary disease Extrapulmonary/respiratory: non-pulmonary TB disease that involves the respiratory system (e.g., laryngeal, nasopharyngeal) Bacteriology Extrapulmonary/not respiratory: non-pulmonary TB disease that does not include a respiratory site (e.g., pleural, lymph, bone, etc.); this selection will be used infrequently Sputum smear positive: positive AFB smear from any sputum 1
Sputum smear negative or unknown, sputum culture positive: no positive AFB smear from sputum and positive culture of M. tuberculosis from sputum No positive smear or culture from sputum: no positive AFB smear from sputum and no positive culture of M. tuberculosis from sputum. May have positive smear and/or positive culture from other specimens such as bronchoscopy, gastric aspirate, etc. Symptoms Onset: enter onset date of symptoms (mm/dd/yy) Cough?: check yes or no (based on patient s report or observation) Chest X-ray Negative for active TB: CXR is normal or shows some abnormalities not consistent with active TB (e.g. calcified granulomas, fibrotic changes) Abnormal, cavitary: CXR shows cavitary lesions Abnormal, non-cavitary: CXR is consistent with active TB and shows no cavitary lesions (e.g., infiltrates, nodules, consolidation, etc.) Estimated Level of Infectiousness Determined based upon the above information. High: case meets several (or all) criteria for high risk of infectiousness (e.g., positive sputum smear, cough, cavitary CXR) Low: case meets few (if any) criteria for high risk of infectiousness Treatment started Estimated Infectious Period INH Susceptibility Date case started taking 2 or more TB medications consistently (mm/dd/yy) Determine the beginning date and end date of the index case s estimated infectious period (per current contact investigation guidelines) Susceptible: Index case s M. tuberculosis isolate is susceptible (sensitive) to isonaizid (INH), per drug susceptibility results Resistant: Index case s M. tuberculosis isolate is resistant to INH, per drug susceptibility results Unknown: INH susceptibility results unknown CONTACT INFORMATION For each contact, provide the following information: 2
Demographic/Exposure Data Name Birth Date Sex County Address Phone Number(s) Country of Birth Name of contact (last, first, middle initial) Contact s date of birth (mm/dd/yy) Sex of contact (M = male, F = female) County of residence of contact Home address of contact Telephone number(s) of contact U.S.: contact was born in the United States Foreign-born: contact was born outside the United States Arrival in U.S. Exposure Setting Date contact first arrived in U.S. (if foreign-born) (mm/yy) Household: contact lives in the same household as index case Work/school: contact works/goes to school with index case Leisure: contact spends time with the index case outside of the home or work/school (e.g., friend, neighbor, sports team, club, etc.) Other: contact was exposed to index case in a setting other than those listed above Exposure Risk Close: a person who had prolonged, frequent, or intense contact with index case during the infectious period Other than close: contacts with less intense, less frequent, or shorter durations of contact with index case 3
Relationship to Index Case Date of Last Exposure 8-week Follow-up TST Due Follow-up Priority Briefly describe contact s relationship to index case. (e.g. husband, friend, co-worker, choir member, classmate, bar patron, etc.) Date when contact was last exposed to index case during infectious period (mm/dd/yy) 8 weeks after the Date of Last Exposure (mm/dd/yy) High: age <5 years, medical risk (HIV-infected, immunocompromised, etc.), intense exposure Medium: other than those reasons listed above Prior History BCG Yes: contact reports and/or has documentation or physical evidence of prior BCG vaccination No/unknown: contact has not had BCG vaccine, or vaccination history is unknown Previous TST (Tuberculin Skin Test) Yes: contact has documentation of a previous TST result or reports a reliable history No: contact denies having a TST administered in the past Date: date previous TST, if any, was administered (mm/dd/yy) Result: result of previous TST (in mm of induration). If induration not known, write Positive or Negative. Prior TB Disease Yes: contact has documentation of previous TB disease, previous TB diagnosis has been confirmed by the health department, or contact reports a reliable history of prior TB disease (if yes, Year: year of most recent diagnosis of TB disease) No: contact has no history of prior TB disease 4
Completed Treatment Check the appropriate box if contact has documentation or reports a reliable history of having completed treatment for one of the following: TB disease: contact has completed adequate multi-drug therapy for previous TB disease (try to confirm with their clinic or health department) Latent TB infection: contact has completed adequate prophylactic therapy for previous LTBI (try to confirm with their clinic or health department) No/unknown: contact has not been treated previously for TB disease or LTBI, did not complete treatment for previous TB disease or LTBI, or treatment history is unknown Relevant Medical Condition Relevant medical conditions are those that increase the risk of progression from latent TB infection to active TB disease. Yes: if yes, list the medical condition(s) (i.e., HIV infection, intravenous drug use, diabetes mellitus, silicosis, prolonged corticosteroid therapy, other immunosuppressive therapy, head or neck cancer, hematologic and reticuloendothelial dieases, end-stage renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndrome, or low body weight) No: contact does not have any relevant medical conditions Current Evaluation and Treatment for LTBI TB Symptoms Yes: contact has symptoms consistent with TB (prolonged cough, night sweats, weight loss, fever, etc.); if yes, list the symptom(s) No: contact does not have symptoms consistent with TB TST (Tuberculin Skin Test) Initial Date: date contact s initial TST was administered (mm/dd/yy) --Result: result of contact s initial TST (mm of induration) Re-test Required? --Yes: initial TST was negative, and the TST was administered <8-10 weeks since contact s last exposure to index case during his/her infectious period --No: Initial TST was positive and/or administered 8-10 weeks after 5
contact s last exposure to index case during his/her infectious period Final Date: date contact s final TST was administered --Result: result of contact s final TST (mm of induration) Chest X-ray Date: date of contact s current CXR, if indicated (following positive TST) (mm/dd/yy) Result: --Abnormal, consistent with active TB: CXR consistent with active TB (e.g., infiltrates, nodules, consolidation, cavities, etc.) --Negative for active TB: CXR is normal or shows some abnormalities not consistent with active TB (e.g. calcified granulomas, fibrotic changes) TB Disease Yes: contact has been diagnosed with current active TB disease (REPORT TO MDH) No: contact does not have active TB disease Unknown: contact was not fully evaluated for TB disease Started Therapy for LTBI Yes: contact has started therapy for LTBI Date: date contact started therapy for LTBI (mm/dd/yy) No: contact has not started therapy for LTBI LTBI Meds Circle the medication(s) that the contact is receiving as treatment for LTBI: INH = isoniazid RIF = rifampin Other = TB medication other than INH or RIF Physician/Clinic Comments Name of physician and clinic treating contact for LTBI Any comments regarding the contact Last Updated May 2007 6