TB Contact Investigation Interviewing Skills Course

After this session, participants will be able to:

Priority TB Control Activities

1. Identify and treat persons who have active TB disease
2. Find and evaluate persons who have been in contact with TB cases and provide appropriate latent TB infection (LTBI) or TB disease treatment as needed
3. Use targeted testing strategies to identify and treat persons with LTBI at risk for developing TB disease
4. Identify settings at high risk for transmission of M. tuberculosis and apply effective infection-control measures

Contact Investigations: A 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

[IMAGE:  A man and a woman having a discussion while sitting in chairs facing each other.]

What is a Contact Investigation?

A systematic process to:

• Identify persons (contacts) exposed to cases of infectious TB disease
• Assess contacts for infection with M. tuberculosis and TB disease
• Provide appropriate treatment for contacts with LTBI or TB disease

[IMAGE: Ten black spokes radiating from a pink circle.]

Who are TB Contacts?

Contacts are persons who have shared airspace with a person with infectious TB disease. This might include

• Household members
• Friends
• Co-workers
• Others (e.g., cellmates, shelter residents)

[IMAGE: A circle with a TB case in the middle showing people the case might encounter at work, home, and/or leisure activities around the circle.]

Why is it Important to Conduct TB Contact Investigations? (1)

CIs help to:

• Interrupt spread of TB
• Prevent outbreaks of TB
• Ensure appropriate treatment for LTBI or TB disease

Why is it Important to Conduct TB Contact Investigations? (2)

•       On average, 10 contacts are identified for each case
  • 20% to 30% of household contacts have LTBI
  • 1% of contacts have TB disease

Who is Responsible for TB Contact Investigations?

• State and local health departments have legal responsibility to
  • Investigate TB cases reported in their jurisdiction
  • Evaluate effectiveness of TB investigations
• Although the health department maintains legal responsibility, some CI steps may be delegated
  • For example, with worksite exposures,  occupational health offices are often involved

Group Discussion

• Share a few examples from your CI experience when you successfully identified active TB cases.
• What are some barriers to conducting CIs in your area?

What Core Concepts and Skills are Required to Conduct TB Contact Investigations?

• Knowledge of TB transmission
• Knowledge of TB pathogenesis

Difference between LTBI  and TB disease
Risk factors for progressing to TB disease
Effective interviewing skills

• Data management and analysis skills

Contact Investigation Core Concepts

TB Transmission

Remember: TB is Transmitted
Person to Person!

Every TB case Began as a TB contact

[IMAGE: Stick people showing how TB can be transmitted.]

TB Transmission

• When a person with infectious TB disease coughs, sneezes, speaks, or sings, tiny particles containing M. tuberculosis (droplet nuclei) may be expelled into the air.
• If another person inhales droplet nuclei, transmission may occur; however, not everyone who is exposed to TB becomes infected with TB.

What Factors Influence TB Transmission? 

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

1. Infectiousness of Person with TB Disease

Characteristics associated with  infectiousness:

[IMAGE: A woman coughing into her cupped hands.]

[IMAGE: An x-ray of lungs with an arrow pointed at the diseased area of the lungs.]

1. Duration and Frequency of Exposure

Contacts at higher risk for TB
infection are those who:

* “A lot of time” is difficult to define, but may be determined locally based on experience

[IMAGE: A smiling man and woman sitting close and drinking a beverage.]

1. 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

[IMAGE: A House.]

STOP the Chain of Transmission

The BEST way to stop transmission is to
Identify and isolate infectious persons
Start infectious persons on effective treatment for TB disease

[IMAGE: Male and female stick people handing hands.]

Contact Investigation Core Concepts
TB Pathogenesis

What Happens Once Someone is Exposed To TB?

Not every person who is exposed to TB becomes infected
Persons who become infected will generally have a positive
Tuberculin skin test (TST)
Or
Blood test (interferon gamma release assay [IGRA])
Persons who become infected can have either:
LTBI
Active TB disease

Latent TB Infection (LTBI)

LTBI - immune system keepstubercle bacilli under control
LTBI characteristics
Usually positive TST or IGRA
Not infectious
No symptoms
Normal chest x-ray
Sputum smears and cultures are negative
Not a “case” of TB

[IMAGE: A granuloma surrounding tubercle bacilli.]

Active TB Disease

TB disease - immune system cannot stop tubercle bacilli from multiplying leading to active TB disease
Usually affects lungs, but can affect other areas of the body
Characteristics usually include:
Positive TST or IGRA
Infectious (before treatment)
Symptoms
Abnormal chest x-ray
Positive sputum smear and culture
Considered a “case” of TB

[IMAGE: A granuloma opened up and releasing tubercle bacilli.]

4. Importance of Contact Investigation

• Stress the importance and urgency of identification of all contacts
• Emphasize the role of the case in helping to protect family and friends from TB

What is Effective Education?

• Listening carefully
• Asking questions
• Understanding the case’s needs and concerns
• Demonstrating a caring attitude
• Helping to solve problems
• Clarifying misinformation

Tips for Providing Effective Education (1)

Use visuals

• Visuals can complement verbal and written information
  • Pictures
  • Calendars
  • Flipbooks
  • Real-life examples
  • Pills

[Image: A health care worker providing education to a TB case using a flipbook.]

Tips for Providing Effective Education (2)

Use culturally appropriate materials

[Image: A collage of culturally appropriate TB educational materials available from the CDC. There is a brochure specifically for TB contact investigations.]

Tips for Providing Effective Education (3)

• Speak clearly and simply
• Use simple non-medical terms
• Use familiar words the case will understand
  • Simple: “These pills will help you get better” 

vs.

Medical Terminology Exercise

Appendix P

The TB Interview: Video

[Image: A health care worker interviewing a TB case in an office.]

Information Collection and Confirmation

During the interview, information previously collected during the pre-interview phase should be reviewed and confirmed

• Personal information
• Medical information
• Infectious period

Confirm Personal Information

• Full name, aliases, and nicknames
• Date of birth
• Place of birth
• If born in another country, date arrived in United States
• Current address
• Telephone number
• Next of kin
• Emergency contact information
• Physical description
• Other locating information

[Image: A clipboard with pen and paper.]

Confirm Medical Information (1)

Obtain and/or confirm:

• Known exposure to TB (who, where, when)
• Recent hospitalization for TB (name of hospital, admission date, discharge date)
• Other medical conditions
• HIV status
• Substance use (frequency, type, how long)
• Medical provider for TB (private or public clinic, name, telephone number, address)
• DOT plan (where, when, by whom)
• Any barriers to adherence

Confirm Medical Information (2)

Review the following symptoms, including onset dates and duration:

• Cough
• Coughing up blood
• Hoarseness
• Unexplained weight loss
• Night sweats
• Chest pain
• Loss of appetite
• Fever
• Chills
• Fatigue

[Image: A woman with TB disease coughing into a tissue.]

Confirm Medical Information (3)

Discuss the case’s current diagnosis

• TST or IGRA results
• Site of disease
• Symptom history
• Radiographic and bacteriologic results

[Image: A health care worker interviewing a TB case.]

Review the Infectious Period

• Refine the previously established infectious period based on a medical record review
• Review the significance of the infectious period with the case and discuss its role in the contact identification

(Title Slide). Interview Process: Contact Identification

Contact Identification (1)

• Contact identification is the most important part of the initial interview with the case
• Get as much information as possible about contacts from the case during the interview
  • Talk to the case as if it is the last time you will see them

Contact Identification (2)

To help identify contacts, interviewers should collect and confirm information regarding:

• Places WHERE they spent time
• Persons with WHOM they spent time
• Participation in activities and events (WHAT and WHEN)

Identify Places WHERE Case Spent Time (1)

Ask the case where they spent time during the infectious period

• Residence
• Work, school, or volunteer sites
• Social, leisure, religious, or recreation sites
• Sites where illicit activities might have occurred
• Homeless shelters or jails

[A diagram split into three sections showing common locations where TB cases may spend time. These include locations of work/school, leisure/recreation, and household/residential.]

Identify Places WHERE the Case Spent Time (2)

After getting the list of places, ask the case about

• Amount of time spent at each
• Environmental characteristics
  • Number of rooms
  • Room size/square footage
  • Crowding
  • Ventilation
  • –  Windows open or closed
  • –  HVAC systems

[Image: Cartoon image of a house.]

Identify Places WHERE the Case Spent Time (3) – Residence

• Residence can include:
  • House
  • Apartment
  • Congregate settings
  • –Nursing home
  • –Assisted living facilities
  • – Dormitory
  • –Correctional facility
  • –Shelters

[Image: Cartoon image of a house.]

Identify Places WHERE the Case Spent Time (4) – School

If attending school, collect information regarding:

• Name of school, address, telephone number
• Grade in school
• Hours per day/week
• Transportation type to and from school, length of commute

[Image: Students sitting on a staircase leading up to a high school.]

[Image: School buses.]

Identify Places WHERE the Case Spent Time (5) – Workplace

• If employed, collect information regarding:
  • Employer name, address, telephone number
  • Full or part-time, hours worked per day/week
  • How long employed
  • Transportation type to and from work, length of commute
  • Occupation/type of work
  • Indoor or outdoor work space, enclosed or open work space
• If unemployed
  • Source of income

Identify WHO the Case Spent Time With (1)

Ask the case who they spent time with during the infectious period, for example:

• Wife, husband, or partner
• Children
• Household members
• Other family members
• Friends
• Roommates
• Cellmates
• Coworkers

[Image: Stick figures.]

Identify WHO the Case Spent Time With (2)

• Ask for names and aliases of contacts
• Ask if contacts
  • Have TB symptoms
  • Have weakened immune systems
  • Are children younger than 5 years of age

[Image: Two women talking to each other.]

Identify WHEN and WHAT Activities or Events the Case Participated In (1)

• Ask about activities during  infectious period
  • Travel, vacations
  • Social events
  • Holidays
  • Ask the case to review calendar or appointment book
• Review cell phone logs and social networking sites (e.g., Facebook)

[Image: Cartoon image of an airplane.]

[Image: Cartoon image of a calendar.]

Identify WHEN and WHAT Activities or Events the Case Participated In (2)

• Examples of social/recreational places and activities
  • Hangouts, bars, clubs
  • Team sports
  • Community centers
  • Bands, choir
  • Places of worship
• Ask about the number of hours per day/week, and means of transportation

[Image: A glass of beer at a bar.]

[Image: Men playing basketball.]

What Information Should Be Collected About Contacts?

• Name/aliases/nicknames
• Relationship to the case
• Address, telephone number, and other locating information
• Hours of exposure per week and date of first and last exposure 
• Setting in which exposure took place
• Age, sex, race, and physical description

Process for Collecting Contact Information (1)

Contact and place information can be gathered using the following format:

1. Name
2. Relationship
3. Locating
4. Exposure time
5. Setting size
6. Description

Process for Collecting Contact Information (2)

1. Name

• Get a name and/or alias
• Ask the case to list as many contact names as possible before moving on

Process for Collecting Contact Information (3)

2. Relationship

• Ask the case what their relationship is to the contact
  • Spouse      
  • Boyfriend/Girlfriend
  • Child
  • Friend
  • Co-worker
  • Classmate
  • Roommate
  • Teammate
  • Any other “mate”

Process for Collecting Contact Information (4)

3. Locating Information

• Collect information on how to get in touch with the contact:
  • Address or map to home/living space
  • Phone number
  • Best time to contact
  • Email address

Process for Collecting Contact Information (4)

4. Exposure Time

• Collect information on how to get in touch with the contact:
  • Address or map to home/living space
  • Phone number
  • Best time to contact
  • Email address

Process for Collecting Contact Information (6)

5. Setting Size

• Determine the size of the setting in which exposure took place:
  • Size of a bedroom?
  • Size of a car/van?
  • Size of a house?

Process for Collecting Contact Information (7)

6. Description

• Obtain a detailed physical description for each contact
  • Age
  • Hair color and length
  • Height
  • Weight
  • Complexion
  • Identifying features (e.g., tattoos, piercings)

Contact Identification Exercise

Refer to Appendix Q

[Image: A cartoon image of two people talking.]

Conclusion of the Interview (1)

1. Answer the case’s questions.
2. Review and reinforce all components of the adherence plan.
3. Evaluate the case’s remaining needs or potential adherence problems.
4. Confirm the date of the next medical appointment, if known.

Conclusion of the Interview (2)

5. Arrange for both a re-interview and home visit, if not already completed.
6. Confirm referral procedure of each contact.
7. Leave information on how the case can contact you.
8. If appropriate, shake the case’s hand, express appreciation, and close the interview.

Potential Interview Problems

The case:

• Does not believe or trust the health care worker
• Will not talk
• Is distracted or not paying attention
• Is hostile, abusive, or aggressive

Methods to Confront and Solve Problems

1. Provide Information
2. Direct Challenge
3. Self-Involvement
4. Withdrawal of Reinforcement

1. Provide Information

Use a factual statement to challenge what a case has told you.

For example:

• If the case says: “I knew I shouldn’t have shaken my neighbor’s hand when he offered it.”

How would you confront this statement by providing information?

2. Direct Challenge

A direct challenge is confronting a statement that is false. Use when the case says something which can lead to greater problems if not addressed.

For example:

• A case denies any contact with children. However, there are toys in the front yard and a picture of the case and a baby hanging on the wall.

How would you directly challenge this statement?

3. Self Involvement

Used to challenge information or commitments a case has made in interviewer’s presence.

For example:

• A case states that they don’t have a phone number for a contact. When looking through their cell phone address book, with permission, you notice a number for that contact.

How would you use self-involvement to address this statement?

4. Withdrawal of Reinforcement

Designed to appeal to a case’s need for positive reinforcement: the interviewer expresses disappointment with the case’s present behavior and/or withdraws positive feedback previously given. 

For example: 

• “You know, I thought you acted responsibly by coming into the clinic so quickly; however, by saying that you don’t care if your co-workers get examined for TB, that’s demonstrating little concern for their health.”

If You Continue to Have Challenges…

• Recognize the need to stop and reschedule a stalled interview.
• Assign another team member to conduct the interview at a later time if you are unable to gather necessary information.

The TB Interview: Video

[Image: A health care worker interviewing a TB case in an office.]

Review

1. What are the objectives of the initial case interview?
2. What are the steps of a TB interview?
3. What are some ways in which to confront and solve problems that may arise during the interview?