TB Contact Investigation Interviewing Skills Course

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(Title Slide).  Special Circumstances

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Learning Objectives

After this session, participants will be able to:

1. Decide when to use a proxy for an interview
2. Explain how to work with the management of congregate settings
3. List two strategies for working with the media during a contact investigation

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(Title Slide). Conducting Interviews with Persons Other than the Case

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(Title Slide). Proxy Interviews

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What is a Proxy Interview?

• A proxy interview is when a person is interviewed in place of the case.

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When to Use Proxy?

• Proxies are used when a case cannot be interviewed because they are
  • A child
  • Physically or mentally unable to communicate
  • Deceased
  • Unable to be located

[Image: A woman holding a young child.]

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Who is an Appropriate Proxy? (1)

• An appropriate proxy is someone who
  • Knows the case’s practices, habits, and behaviors
  • Is able to identify persons whom the case has been in contact with

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Who is an Appropriate Proxy? (2)

• An appropriate proxy can be:
  • A family member
  • A close friend
  • Someone else who knows the case well

7. In congregate settings, the proxy may not have personal knowledge of the case, but may have access to documentation about the case.

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What Information Should be Gathered from a Proxy?

• Where the case spent time
• Who the case spent time with
• What activities the case participated in

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Maintaining Confidentiality

• Proxies should be educated about
  • His or her responsibility to keep the case’s information confidential
  • The health department’s confidentiality policy

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When NOT to Use a Proxy Interview

• Proxies should not be used simply because the case
  • Is unwilling to be interviewed
  • Speaks a different language than the interviewer

[Image: A health care worker talking to a TB case and her husband at a dining table.]

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(Title Slide.) Source Case Investigations

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What is a Source Case?

• A source case is a person with TB disease who is responsible for transmitting M. tuberculosis to another person or persons.

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What is a Source Case Investigation?

• A source case investigation is a method of identifying source cases of TB disease.

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When to Conduct a Source Case Investigation

• Source-case investigations should be considered for
  • Children younger than 5 years of age who have TB disease
  • Children younger than 2 years of age who have LTBI
  • Health care workers whose serial testing indicates recent transmission

[Image: A grandfather sitting with his grandson outside.]

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Procedures for a Source Case Investigation

• Use the same procedures as a standard contact investigation, but in the opposite direction.
• The case or guardians are the best informants.
• Focus on associates who have symptoms of TB disease.
• Begin with the closest associates such as household members.

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(Title Slide) Social Networks

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What is a Social Network?

• A social network is a group of people connected by common behavior/activities
  • Drug use
  • Gathering places (e.g., church, work, bars)
  • Other connections that promote disease transmission
• Focuses on groups and places rather than individuals

[Image: Dots with arrows pointing to other dots. In this image, three pink dots represent three TB cases. There are 16 black dots representing contacts. The arrows show the connections between the cases and contacts.]

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Why Use a Social Network Strategy for a TB Contact Investigation?

• Complements the traditional CI approach by interviewing contacts for more information related to potential TB transmission
• Helps narrow or expand CI activities by
  • Identifying groups of contacts that might be infected because of common activities and/or locations
  • Identifying possible places of transmission (exposure settings)
• Helps to detect and stop outbreaks

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When to Use Social Network Strategies?

• There are gaps in information provided by case
  • Epidemiology indicates transmission is ongoing
• There is insufficient locating information for contacts
  • Homeless populations, drug partners, full name of contact not known, etc.
• There are gaps in exposure dates

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How is the Social Networking Strategy Implemented for CI?

• Interview the case and contacts to increase an understanding of who is part of the “social network”
• Use the information from various interviews to identify commonly named
  • Locations of exposure
  • Contacts
• Conduct a field visit at commonly named sites and assess commonly named contacts

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What Types of Questions to ask in Social Network Interview?

• What kind of activities are you involved in?
• Who do you know who has been coughing or may have TB?
• Where do you like to spend your time/hangout?
• Who are your closest friends?

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(Title Slide) Congregate Settings

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What is a Congregate Setting?

• A congregate setting is a setting in which a group of usually unrelated persons reside, meet, or gather either for a limited or extended period of time in close physical proximity.

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Examples of Congregate Settings (1)

• Schools
• Nursing homes
• Correctional facilities
• Places of worship
• Hospitals
• Shelters
• Social settings
• Workplace settings

[Image: Prison cells.]

[Image: Bunk beds in a homeless shelter.]

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Examples of Congregate Settings (2)

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What Are Some Challenges for Contact Investigations in Congregate Settings?

• Collaboration with officials and administrators unfamiliar with TB
• Legal implications
• Media coverage
• Substantial number of contacts
• Incomplete information regarding contact names and location
• Incomplete data for determining priorities
• Difficulty in maintaining confidentiality

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Working with Congregate Setting Management

• When a CI is needed in a congregate setting, it is important to communicate effectively and immediately begin to build trust and rapport with the management.
  • Initial notification of the need for a CI can occur by telephone

7. Do not provide specific case information and risk violating medical privacy

• • An in-person meeting to discuss CI process should be scheduled

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What Should Occur at the Initial Meeting? (1)

• Agenda items to discuss:
  • Provide basic TB education
  • Discuss potential media interest
  • Discuss confidentiality issues

7. In some situations, the case’s identity may be released to management. If so, obtain signed confidentiality agreement

• • Discuss case information (e.g., medical status, infectiousness)

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What Should Occur at the Initial Meeting? (2)

• Agenda items to discuss (continued)
  • Explain infectious period
  • Conduct site tour
  • Determine total number of individuals in setting
  • Explain process of identifying and testing contacts

7. Provision of TB education
8. Explanation of testing
9. Who will be administering tests
10. Where testing will take place
11. Follow-up testing

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What are the Steps for Conducting the CI for a Congregate Setting?

• Identify and prioritize contacts to be assessed
  •  Can be challenging to limit to high priority contacts
• Assess contacts
  • Most convenient approach: on-site
  • Alternative approach: at the health dept. with additional personnel and extended hours
  • Last resort: notify contacts to seek TB evaluation with own healthcare provider

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Working with Congregate Settings: Correctional Facilities

• Establish collaboration between the correctional facility and the health department
• Identify priority contacts who have been transferred, released, or paroled
• Unless follow-up supervision can be arranged, there is a possibility of low completion rate

[Image: Inmate resting his hands on the bars to his prison cell.]

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Working with Congregate Settings: Workplaces

• Duration and proximity of exposure can be greater than in other settings
• Details to gather from the case during the initial interview include
  • Employment hours
  • Working conditions
  • Workplace contacts
• Occasional customers are not a priority

[Image: Woman working in a factory.]

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Working with Congregate Settings: Health Care Settings

• Majority of hospitals and other health care settings test employees for TB infection on regular basis
• Plan CI jointly with health care settings
  • Responsibilities should be divided between occupational health and TB program

[Image: Health care worker examining a patient in a hospital.]

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Working with Congregate Settings: Schools

• Early collaboration with school officials and community members is recommended
• Issues of consent and disclosure of information more complex for minors
• Establish and focus on priority contacts rather than testing the whole school
  • Be aware of possible political pressure

[Image: Classroom with students and a teacher.]

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Working with Congregate Settings: Homeless Shelters

• Challenges include
  • Locating cases and contacts
  • Mental illness
  • Periodic incarceration
  • Migration between jurisdictions
• Site visits and interviews are crucial
• Work with administrators to offer onsite treatment

[Image: Homeless man underneath a bridge.]

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(Title Slide) Working with the Media

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Possible Situations for News Coverage

• Certain CIs have potential for sensational news coverage
• Examples include CIs that
  • Involve numerous contacts (especially children)
  • Occur in public settings
  • Occur in workplaces
  • Are associated with TB fatalities
  • Are associated with drug-resistant TB

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Reasons for Participating in News Media Coverage (1)

• Educates the public about TB
• Reminds the public of the continued presence of TB and the importance of public health efforts
• Provides another method to alert exposed contacts for the need to seek a medical evaluation
• Relieves public fears regarding TB

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Reasons for Participating in News Media Coverage (2)

• Illustrates health department leadership in communicable disease control
• Guides public inquiries to the health department
• Validates the need for public resources to be directed to disease control

[Image: Cartoon image of a person being interviewed by the media.]

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Potential Drawbacks to News Coverage

• May increase public anxiety
• Persons may seek unnecessary medical care
• Could contribute to unfavorable views of the health department
• Could contribute to the spread of misinformation
• Unintended disclosure of confidential information

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Strategy for News Coverage

• Prepare media messages
• Develop communication objectives
• Issue news release in advance of any other media coverage
• Collaborate with partners outside the health department

[Image: Image for a resource available from the CDC called “Crisis Emergency Risk Communication by Leaders for Leaders.” This resource is available online at: http://emergency.cdc.gov/cerc/pdf/leaders.pdf]

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(Title Slide) Review

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Review

1. What is a proxy interview?
2. Who is considered an appropriate proxy?
3. What should be discussed with the management of a congregate setting if one of their clients has been diagnosed with TB disease?

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Role Plays

• Refer to Appendix V