Download Improving risk assessment among contacts exposed to a person with infectious tuberculosis in Maryland

Improving risk assessment among contacts
exposed to a person with infectious tuberculosis
in Maryland
Cristina Stoyanov and Wendy Cronin
Center for TB Control and Prevention
Maryland Department of Health and Mental Hygiene
May 11, 2012
MISSION
• To improve the health of Marylanders by reducing the
transmission of infectious diseases, helping impacted
persons live longer, healthier lives, and protecting
individuals and communities from environmental
health hazards
• We work in partnership with local health departments,
providers, community based organizations, and public
and private sector agencies to provide public health
leadership in the prevention, control, monitoring, and
treatment of infectious diseases and environmental
health hazards.
Outline
• Project Overview
– Background information
– Objectives
• Methods/Findings
• Lessons learned
– Limitations and Challenges
– Policy and Practice Implications
• Questions & Answers
Background Information1-3
• CDC Guidelines for TB programs:
• Identify, treat, and report of all persons with infectious TB
• Conduct contact investigations to find persons who were exposed to a TB
infectious patient
– Extent investigations to second- and third tier contacts outside the
household
• Determine contacts TB status and risk of progression to TB disease
• Provide care and TB treatment to contacts if needed
• Of contacts with latent TB infection, ~55-65% complete
treatment
• Screening for infection is not often based on health status of individual
contacts
• Genotyping data has helped to identify weaknesses in
contact investigations
• Locations outside the household are not commonly identified by
investigators
Objectives
• To continue to improve contact investigations
by creating/implementing forms that
standardize collection of information that has
been missed historically
• To use our increasingly limited resources in the
very best way possible by ensuring that
disease is prevented in those at greatest risk
• To aid in the prioritization process of contacts
Methods
• Assemble a comprehensive list of factors that may
accelerate progression to active TB in latently infected
contacts
• Establish a working group to:
• Review the status quo of risk assessment in Maryland
• Brainstorm possible ways to improve the TB Contact Record and the
Location-based Contact Investigation forms
• Revise Forms
• field-tested Location-based Contact investigation form
• TB Contact Record form
• Encourage implementation of both forms into contact
investigations
Findings: Medical Risks4-15
– Well-known: HIV, diabetes, lung-disease, kidney
disease, immunosuppressants (e.g.
corticosteroids), age<5, malnourishment
– Recently identified: Smoking, excess alcohol, TNFalpha inhibitors, malignancies (e.g. head/neck
cancer)
Risk Factors Associated with the Development of Tuberculosisa
0.1
HIV CD4 low *
Antonucci G., et al. 1995
HIV CD4 high*
Antonucci G., et al. 1995
Diabetes
Jeon DY., and Murray MB. 2008
Alcohol#
Coetzee N. et al. 1988
Alcohol
Lonnroth K. et al. 2008
Silicosis
Hnizdo E. and Murray J. 1998
Kidney failure
Chia S. et al. 1998
anti-TNFs
Brassard P. et al. 2006
Infliximab
Brassard P. et al. 2006
Nutrition
Downes J. 1950
Smoking
Bates M. 2007
Cancer^
Kim H-R. 2008
Malignancies*
Moran-Mendoza O. 2010
0-10 years age*
Moran-Mendoza O. 2010
Coricosteroids*
Moran-Mendoza O. 2010
1
10
a Relative Risks unless indicated, * Hazard Ratios, # Odds Ratio, ^ Incidence Risk Ratio
100
Findings: Forms Content and Format
TB Contact Form
• Medical risks
• Multiple contacts per page
• Index Case infectious period and case ID
• Added Interferon gamma release assay (IGRA)
• Contact priority level based on CDC guidelines
Location-based Contact Investigation Form
• Types of exposure settings in which the contact
could have taken place
TUBERCULOSIS CONTACT RECORD
Page ___ of _______
INDEX CASE: ___________________________ COUNTY: ____________ STATE/LOCAL CASE #:____________
CASE INFECTIOUS PERIOD:_Start:_________ End: ________
FORM COMPLETED BY: __________________________ DATE:_____________
TYPE OF CASE/SUSPECT:____Pulmonary Smear Pos.
____Pulmonary Smear Neg.
_____ Other (describe)__________________________________
Last Name
First
Address
City
Phone
PRIORITY
Middle
State
Country-of-origin
EXPOSURE
SETTING
W
O
Date contact ended:__/____/_____
Comments:
Last Name
Address
Phone
First
______
Hrs/wk
PRIORITY
State
Country-of-origin
Date contact ended:__/____/_____
Comments:
DHMH 659
Rev. 02/2012
High
Medium
Low
EXPOSURE
SETTING
Age
Sex F M
Hispanic
Y
N
Race AA
A/PI NA
Relation to case:
Household
Work
School
Leisure
Congregate
Middle
City
Y
N
X-Ray: __/___/__
Normal
Abnormal
Active TB
PRIOR HISTORY
Age
Sex F M
Y
N
Hispanic
Race AA
A/PI NA
Relation to case:
High
Medium
Low
TST
OTHER INFO
TB Sxs now:
W
O
Household
Work
School
Leisure
Congregate
______
Hrs/wk
Prior TB:
Y N
Year:______
Prior BCG:
Y N
Prior TST:
Y N
Year:_______
___mm;
Neg
Pos
Prior IGRA: Y N
Year:_______
Neg
Pos
Prior TLTBI: Y N
Year:______
OTHER INFO
TB Sxs now:
Y
8-10 week f/u
Placed:___/___/___
Read:___/___/__
____ mm
IGRA
Date: ____/_____/___
QFT
T-SPOT
Result:_______
Neg
Pos
Y N HIV
Y N Diabetes
PRIOR HISTORY
Y N
Year:______
Prior BCG:
Y N
Prior TST:
Y N
Year:_______
___mm;
Neg
Pos
Prior IGRA: Y N
Year:_______
Neg
Pos
Prior TLTBI: Y N
Year:______
8-10 week f/u
Placed:___/___/___
Read:___/___/__
____ mm
IGRA
Date: ____/_____/___
QFT
T-SPOT
Result:_______
Neg
Pos
Y
Y
Y N Smoking
N TB disease
N LTBI
TLTBI
Y N Lung disease
PMD evaluation
Y N Alcohol abuse
LHD evaluation
Y N Kidney failure
Not Recommended
Recommended
Accepted
Refused
Begun: ___/___/__
Y N Steroids
Y N TNFa inhibitors
Y N Other immunosuppressants
Y N Head/neck cancer
Y N Age<5 years
Y
Initial
Placed:___/___/___
Read:___/___/__
____ mm
OUTCOME
RISK FACTORS
N Underweight (<10% normal)
TST
N
X-Ray: __/___/__
Normal
Abnormal
Active TB
Prior TB:
Initial
Placed:___/___/___
Read:___/___/__
____ mm
RETURN APPT:
____/____/___
___/___ /___
RISK FACTORS
Y N HIV
Y N Diabetes
Y N Lung disease
Y N Smoking
Y N Alcohol abuse
Y N Kidney failure
Y N Steroids
Y N TNFa inhibitors
Y N Other immunosuppressants
Y N Head/neck cancer
Y N Age<5 years
Y
OUTCOME
Y
Y
N TB disease
N LTBI
TLBI
PMD evaluation
LHD evaluation
Not Recommended
Recommended
Accepted
Refused
Begun: ___/___/__
RETURN APPT:
____/____/___
___/___ /___
N Underweight (<10% normal)
Please complete every box carefully
Box 1
TUBERCULOSIS CONTACT RECORD INSTRUCTIONS
Page ___ of _______
INDEX CASE: ___________________________ COUNTY: ____________ STATE/LOCAL CASE#:____________
CASE INFECTIOUS PERIOD:_Start:_________ End: ________
FORM COMPLETED BY: ___________________________ DATE:______________
TYPE OF CASE/SUSPECT:_____Pulmonary Smear Pos.
_____Pulmonary Smear Neg.
_____Other (describe)_____________________________
Last Name
First
Address
Phone
City
Box 2
PRIORITY
Middle
State
Country-of-origin
EXPOSURE
SETTING
Date contact ended:__/____/_____
Comments:
W
O
Household
Work
School
Leisure
Congregate
______
Hrs/wk
Box 4
DHMH 659
TB Sxs now:
Y
TST
N
X-Ray: __/___/__
Normal
Box
Abnormal
Active TB
5
PRIOR HISTORY
Age
Sex F M
Hispanic
Y
N
Race AA
A/PI NA
Relation to case:
Box 3
High
Medium
Low
OTHER INFO
Prior TB:
Y N
Year:______
Box 6
Prior BCG:
Y N
Prior TST:
Y N
Year:_______
___mm;
Neg
Pos
Prior IGRA: Y N
Year:_______
Neg
Pos
Prior TLTBI: Y N
Year:______
Initial
Placed:___/___/___
Read:___/___/__
____ mm Box 7a
8-10 week f/u
Placed:___/___/___
Read:___/___/__
____ mm
IGRA
Date: ____/_____/___
QFT
T-SPOT Box 7b
Result:_______
Neg
Pos
RISK FACTORS
Box 2: Name- Indicate the complete name of the contact
Address- Indicate the complete address of the contact
Phone- Indicate the contact’s phone number
Country-of-origin- Indicate the contact’s nationality
Age- Indicate the contact’s age
Sex and Race- Indicate the contact’s sex and race
Relation to case- Describe the relationship of the
contact to the index case. i.e. spouse, co-worker,
housemate, friend, in same homeless shelter, etc. and
provide the date that the relationship ended.
Comments- Document the place of exposure or any
other applicable information such as signs/symptoms,
etc. Be specific.
Box 8
Y N Lung disease
Y N Smoking
Box 9
N TB disease
N LTBI
TLTBI
PMD evaluation
Y N Alcohol abuse
LHD evaluation
Y N Kidney failure
Not Recommended
Recommended
Accepted
Refused
Begun: ___/___/__
Box 10
Y N Steroids
Y N TNFa inhibitors
Y N Other immunosuppressants
Y N Head/neck cancer
Y N Age<5 years
Y
Rev. 02/2012
Box 1: Index Case- Local identification of index case.
Case Infectious Period- Indicate the beginning and
ending dates of the infectious period for the index case.
County- Case’s county of residence
Case #- Indicate state or local case number
Form Completed By and Date- Indicate clearly who is
completing the form and the date that the form was
completed
Y
Y
Y N HIV
Y N Diabetes
OUTCOME
N Underweight (<10% normal)
RETURN APPT:
____/____/___
___/___ /___
Please complete every box carefully
Box 3: Priority- Indicate the priority level of the contact based
on state and CDC guidelines.
Box 4: Exposure Setting- Check if the contact lived in the
same household, worked at the same place, attended
the same school, spent leisure time, or attended the
same congregate settings (i.e. church, prison, homeless
shelter, etc.). Indicate the number of hours per week that
the contact took place.
Box 7a/7b: TST- Specify if TST was used to test this contact.
Indicate the date a TST was placed and read, and
indicate the mm reading. Indicate the dates and the
results of the follow up test.
IGRA- Specify which type of IGRA test was used,
and indicate the date, the actual result of the test,
and the interpretation (Neg./Pos.).
Box 8: Risk Factors- Check all known medical risk factors.
Box 5: Other Info- Check if the contact has any common TB
symptoms (cough, night sweats, fever, hemptyisis, etc.).
Specify the date and the results of the chest X-ray.
Box 9: Outcome- Check the final outcome of the test. Specify if
the contact has TB disease or latent TB infection.
Box 6: Prior History- Check if there is knowledge of prior TB
disease or BCG vaccination. Indicate the specific dates
when known. Check and date if there are prior
tuberculin skin test (TST) results or prior interferon
gamma release assay (IGRA) results. Check if there
was prior treatment of latent TB infection (TLTBI) and
provide the year if known.
Box 10: TLTBI- Specify if the evaluation was conducted by a
personal medical doctor or by the local health
department. Specify if treatment for LTBI was (or was
not) recommended. If recommended, specify whether
or not the contact accepted or refused treatment. If
accepted, specify when the treatment began and
provide the dates of follow-up appointments. Complete
an 851 form for this contact.
Contact Investigation Form for Locations
STATE/LOCAL CASE# :_____________________
1. Most days, how do you spend your day during the daytime? (ask generally about : 6 am – 5 pm, but specific time not essential)
Place name
Location (address/ zipcode)
Activity
Transportation to and from
_____________________________
________________________________________
___________________________________ ___________________________
_____________________________
________________________________________
___________________________________ ___________________________
2. Most days, how do you spend your time during the early evening hours? (ask generally about 5 pm – 10 pm, but specific time not essential)
Place name
Location (address/ zipcode)
Activity
Transportation to and from
_____________________________
________________________________________
___________________________________ ___________________________
_____________________________
________________________________________
___________________________________ ___________________________
3. Most days, how do you spend your time during the overnight hours? (ask generally about 10 pm- 6 am), but specific time not essential)
Place name
Location (address/ zipcode)
Activity
Transportation to and from
_____________________________
________________________________________
___________________________________ ___________________________
_____________________________
________________________________________
___________________________________ ___________________________
4. Tell me about other regular weekly or monthly activities where you usually spend time with other people? What do you like to do on the weekends?
Place name
Location (address/ zipcode)
Activity
Transportation to and from
_____________________________
________________________________________
___________________________________ ___________________________
_____________________________
________________________________________
___________________________________ ___________________________
5. Can you think of any other place or special indoor event where you spent time with people? (specify a specific date range according to patient’s infectious period)
(i.e. music concerts, weddings, birthdays, reunions, night clubs, weekend trips, etc.)
Place name
Location (address/zipcode)
Activity
Transportation to and from
_____________________________
________________________________________
___________________________________ ___________________________
_____________________________
________________________________________
___________________________________ ___________________________
Lessons-learned
• Need to develop additional interventions to
improve contact investigations
• Database for electronic documenting of contact’s risk factors
• Fostering of collaboration across TB program staff is
essential to develop the best policies regarding contact
investigations
• Continual review and revision as needed of
available tools is needed for improving contact
investigations and for coordinating efforts
through training
Policy & Practice Implications
Improved TB Contact and Location-based
Contact Investigation Form:
• Provide new training tools for TB staff
• Provide a new system for identifying additional contacts
and for documenting contacts’ risks
• Aid in screening prioritization following a contact
investigation, so most high risks are fully screened and
treated for latent TB infection
Acknowledgements
•
•
•
•
•
•
•
Nancy Baruch
Maureen Donovan
Cathy Goldsborough
Mark Hodge
Jan Markowitz
Andrea Raid
Judy Thomas
Questions & Answers
References
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Marks, S.M., et al., Am. J. Respir. Crit. Care Med. 2000
Reichler, M. R., . et al., JAMA. 2002
CDC. Tuberculosis. 2011 [cited 2012; April 29]. Available from:
http://www.cdc.gov/niosh/topics/tb/
Antonucci G, et. al. JAMA. 1995
Bates MN, et al. Arch Intern Med. 2007
Brassard P, et al. Clin Infect Dis. 2006
Chia S, et al. Int J Tuberc Lung Dis. 1998
Cliffton EE. and Irani BB. N Y State J Med. 1970
Coetzee N, et al. 1988
Hnizdo E. and Murray J. Occup Environ Med. 1998
Jeon CY. And Murray MB. PLoS Med. 2008
Kim HR, et al. Respirology. 2008
Lonnroth K, et al. BMC Public Health. 2008
Moran-Mendoza O, et al. Int J Tuberc Lung Dis. 2010
Selwyn PA. et al. N Engl J Med. 1989