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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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 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