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EXCELLENCE EXPERTISE INNOVATION
Initiating and Prioritizing Contact InvestigationsTabitha Gibbs, RN
May 4, 2016
TB Contact Investigation 101
May 4, 2016
Little Rock, AR
• No conflict of interests
• No relevant financial relationships with any
commercial companies pertaining to this
educational activity
Tabitha Gibbs, RN has the following
disclosures to make:
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SPECIAL CONSIDERATIONS
Presentation adapted from:
Jessica Quintero, M.E.d
Director of Education
Heartland National TB Center
• Competing demands
restrict the resources that
can be allocated to
contact investigations.
• Identify those most likely
to transmit infection.
Why Do We Need to Prioritize Patients With TB
Disease ?
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• The index patient has
confirmed or suspected
pulmonary, laryngeal or
pleural TB.
• An investigation is
recommended if the
sputum smear is positive.
A Contact Investigation Should be Considered
if…
What Characteristics Should We Consider in Our Decision
to Initiate an Investigation?
+AFB sputum, Pulmonary Cavities, Anatomical site of disease
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• Site of disease
• Sputum Smear results
• Nucleic acid assay results
(other rapid)
• Chest X-Ray results
• Index patient factors
• Resources
Prioritization Factors
Sputum smear positive
• Pulmonary
• Laryngeal
• Pleural
• Extrapulmonary
Site of Disease
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• Smear Positive
• Smear Negative
• Non sputum smears
Sputum Smear Results
Sputum smear negative
Not Generally Indicated If…
Sputum smear has AFB on microscopy and nucleic
acid amplification (NAA) tests for M.tuberculosis
are negative.
Amplified M. tb Direct Test® (MTD): Gen-Probe, Inc.
Amplicor® M. tuberculosis
(MTB): Roche Diagnostics
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• Normal
• Abnormal
Chest X-Ray Results
• Age
• HIV Status
• Other Medical Conditions
• Symptoms
Index Patient Factors
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• Patients with TB disease
management
• Contact investigators
• Fiscal constraints
• Seasonal implications
• Other investigations
Resources
• Gather data
• Evaluate
• Organize plan
• Act on plan
• Monitor and evaluate
So Who Goes First?
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They all They all They all They all qualify qualify qualify qualify as high as high as high as high
risk, top risk, top risk, top risk, top priority!priority!priority!priority!
• Often times the greatest
challenges of a TB contact
investigation are the result
of failure to ask for help
when it is needed.
• Even the Lone Ranger had
Tonto by his side…
Ask for Help
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– Disease
Intervention Staff
– STD Staff
– Preparedness Staff
– Immunization Staff
– Administration
Look elsewhere in the local
health department…
• State Tuberculosis people are nice people, they enjoy helping others, they want to be your friend, part of their mission is to be there for you, asking them for help will make them happy people.
• You have not failed by asking for assistance.
Other Resources
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• Centers for Disease
Control and Prevention
(CDC)
• Available with many
resources at the request
of the state.
• Technical assistance
• Epi-Aid
• Financial assistance
Ask for Help
• How infectious is the patient
with TB disease?
• How long was the patient with
TB disease likely infecting?
• What are the characteristics of
the likely contacts?
• What additional information is
needed?
• How complex is the
investigation likely to be?
Questions to ask
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• What resources will likely be
required?
• What resources do I have
available?
• What resources could be
reallocated?
• Who else could assist?
• Who do we need to inform?
• What are the likely obstacles?
• How do I encourage the team?
Questions to ask
• Once the priorities have
been set, move on, take
action.
• Plans can change.
• Be flexible but not wishy
washy.
• Be thorough and
complete.
Take Action
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Initiation of Other Investigations
Depends On
• Availability of resources to
be allocated.
• Achievement of
objectives for higher
priority contact
investigations.
In many cases, prioritizing multiple
contact Investigations at one time is
not required. In most cases of
medium and low incident states,
multiple patients with TB disease are
not being diagnosed in the same area
at the same time, however, having a
plan and policies in place for how to
address this challenge is critical and
the one time that it is needed you will
be happy you prepared for it.
Summary
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Questions
You are clinical TB case manager at a busy clinic in Brown County, Wisconsin
(home of Lambeau Field and the Green Bay Packers). Three new TB cases have
been assigned to you. You need to review their charts and assign them to
contact investigators.
A. Mr. Garcia is a 35 yr. old agricultural worker diagnosed by a local private physician with extrapulmonary TB of the kidneys. He lives with his wife and 3 children (5yrs, 3 yrs., and 9 months old) in a small, rented house in a rural part of the country. He rides to work every day in a van with 7 other agricultural workers.
B. Mr. James is a 72 yr. old widower who lives alone on the south side of town. He drives himself to the local retirement center 2 miles from his house for bingo and poker four times a week. He was recently evaluated by the retirement center physician because he complained of a productive cough, shortness of breath, fatigue and weight loss. He is AFB sputum smear positive and his culture is pending. His chest x-ray shows a cavity in the right upper lobe. He started a four drug regimen.
C. Mrs. Osaka is a 25 yr. old woman who recently arrived from Japan. She was seen in the Brown County Clinic complaining of shortness of breath, a weak nonproductive cough, fatigue and weight loss. Her AFB sputum smear was negative and her culture is pending. She lives with her husband and parents in a large apartment off Lombardi Avenue. She is currently
unemployed. She started 4 drug therapy.
• Questions:
• 1. For which case(s) should a contact investigation be conducted?
• 2. How should the case(s) be prioritized in terms of conducting a contact
investigation?
Prioritization of Contacts Exercise