Download Clinical Pathway for managing Tuberculosis Suspects/Cases in

NAME
ID #
DOB
Clinical Pathway
TB Contact Investigation for Corrections
Name of Corrections person(s) completing this form:
Title:
Name of Health Department Staff Assist:
Title:
Instructions: Initial and Date after each task. Observe Respiratory Precautions when speaking with infectious
tuberculosis (TB) suspects/cases. Assure proper isolation and treatment of suspect/case.
INITIAL
WHEN
DONE
DATE
COMPLETED
Identify the Infectious Period of the Suspect/Case (Determine “infectious period” based upon symptom history. If no
symptoms or poor historian, use three months prior):
From Date
To Date
TIP: Contact the health department TB program staff for assistance in determining the infectious period.
Report the suspect/case to the Corrections Facility Administration (as per protocol)
Report the suspect/case to the Corrections Infection Control Nurse/designee for reporting to the Health
Department (as per protocol).
Document name and title of contact at local health department who took the report:
Name: _________________________ Title: _______________ Date: ________________
Was the inmate identified as a suspect/case previously?
 Yes
 No
 Unknown
If yes, obtain prior incarceration medical record (document date of request and date obtained)
Request Date:_____________
Date Obtained:_____________
Comments:________________________
Obtain a list from Classifications of all areas where suspect/case was located (Movement List) within the
confines of the correctional facility within three (3) months prior to symptom onset or during infectious period.
List areas:
History of Inmate (medical and movement)
WITHIN THREE WORKING DAYS
Conduct a thorough chart review to obtain the following:

History of TB symptoms (cough, fever, night sweats, etc.)

History of sick call visits to medical

Weight history

Chest radiographs

Tuberculin Skin Test (TST)

HIV status

Bacteriology

Other medical conditions
Interview inmate about TB symptom history while incarcerated and for contacts in community (relevance
determined by the infectious period).
Create Lists
Identify locations where the inmate was housed during the infectious period.
Create a separate list for each area (and indicate length of time in each area):

Housing or cells

Work areas (i.e. 2 hours, 8 hours)

Recreation areas

Transfers to/from the facility (include addresses)
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Instructions: Initial and Date after each task. Observe Respiratory Precautions when speaking with infectious
tuberculosis (TB) suspects/cases. Assure proper isolation and treatment of suspect/case.
INITIAL
WHEN
DONE
DATE
COMPLETED
Identify any inmates who are symptomatic (refer them for evaluation immediately)
Identify staff that was in the same area with the index case for prolonged or repeated duration
TIP: Notify employee health of staff that needs screening. (Staff screening should be conducted per facility
protocol).
Best Practices: Assure Classifications provides lists only during the specified infectious period and explain there is a need to correlate
length of time with names on lists.
Release Planning (begins early)
Plan for the inmate’s eventual release from the facility (as well as those high and medium priority inmates who
are identified as contacts) using the Release Planning form, if needed.
Include a Treatment Plan with the release information, if on medications.
If not already done, review and assess lists
Verify movement list/history of inmate housing (include dates/locations of housing and work)
Identify high and medium contacts and their location
Note: Highest priority based on risk includes:

HIV positive

Other immune suppressed

IV Drug Users

Diabetics
Tour locations where Index case was housed during infectious period to obtain the following information:
WITHIN FIVE WORKING DAYS
Location / Housing
# of
Inmates
Duration of
Exposure
Grade
(1 – 4)*
Airflow
Absence or Presence
of UVGI
**Grade 1 – Size of a car (For Corrections – this would be a single cell)
**Grade 2 – Size of a bedroom (For Corrections – a two or four-person cell)
Grade 3 – Size of a house (For Corrections – an open dorm)
Grade 4 – Bigger than a house (For Corrections, the size of a recreation yard)
**Indicates higher priority if prolonged contact with infectious inmate
Environmental Control
Note airflow patterns in all areas and document (ie, directly to outside, no air, fans, etc.)
Assess ventilation/heating/air conditioning system
TIP: Check if air is re-circulated or if it flows to other cells prior to exhaust to the outside
Consider checking other locations, e.g. the cafeteria, general areas, common dayroom, control room, chapel,
school or classroom, etc.
Is there an absence/presence of UV light (windows, UVGI)?
TIP: Confer with public health regarding airflow patterns and UVGI
WITHIN EIGHT
WORKING DAYS
Identify contacts at high and medium locations for first round of screening/testing
TIP: Cross check clinic logs with contact list for high priority inmates
Identify current locations of high and medium priority contacts
Conduct medical record review for each high and medium priority contact to determine:

Exposure time

Prior TST/Chest X-ray (CXR) results/dates

History of TB/Latent TB Infection (LTBI) treatment
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Instructions: Initial and Date after each task. Observe Respiratory Precautions when speaking with infectious
tuberculosis (TB) suspects/cases. Assure proper isolation and treatment of suspect/case.

HIV status

Other medical conditions and risk factors
INITIAL
WHEN
DONE
DATE
COMPLETED
Prioritize and refer immediately those with sick calls complaining of potential TB symptoms (weight loss,
respiratory symptoms, feeling very tired, requesting antibiotics for cold signs/symptoms, etc.) Refer to clinic.
Initiate screening of contacts
Screen/test all priority contacts
TIP: Use Risk Assessment for Tuberculosis tool
For all those contacts who are TST/IGRA positive prior to the infectious period:

Evaluate for symptoms and refer inmates to clinic immediately for medical evaluation
For contacts who are TST/IGRA positive and HIV negative or unknown HIV status prior to infectious period

Conduct a symptom review

Offer HIV counseling/testing (if applicable)

No new testing is required if mm or IGRA results are available
WITHIN TEN WORKING DAYS
For contacts who are HIV positive (and TST/IGRA positive at baseline)
o
Conduct a symptom review/ CXR and compare with previous CXR
o
Initiate treatment for LTBI once active TB disease is ruled out (regardless of history of prior
treatment for LTBI)
For all those contacts who are Baseline TST/IGRA negative prior to infectious period and 8-10 weeks after
break in exposure

If contact is HIV negative or unknown HIV status

Conduct a symptom review

Administer TST/IGRA

Offer HIV counseling and testing


CXR if TST/IGRA positive (and prior to beginning medications – rule out active disease)
If contact is HIV positive
 Conduct a symptom review
 Administer a TST/IGRA
 CXR regardless of TST/IGRA result and compare with previous CXR
 Initiate treatment for LTBI regardless of TST/IGRA results if high/medium priority contact
Inform health department TB staff/other correctional facility of released inmates in need of follow-up screening
testing.
Identify exposed employees and conduct screening/testing with employee health per facility protocols
Identify exposed volunteers/other staff exposed to infectious case and conduct screening/testing as appropriate
per facility protocol.
Expand to other priority contacts if evidence of transmission is present as directed by health department.
Follow-up TST/IGRA for contacts should be placed and read 8 - 10 weeks after exposure ends
For ease in organizing second round of TSTs or IGRAs, do the following:
WITHIN SIXTY DAYS (2 MONTHS)
Staff:

Remind appropriate staff one week before testing is to be initiated

Conduct follow-up screening and testing of employees/other staff volunteers
TIP: Use the Tuberculin Skin Test Log STAFF and the Risk Assessment for TB

Conduct follow-up screening and testing of employees/other staff/volunteers
Inmates:

Conduct search to determine current location of inmates (either Classifications or Medical Records)

Conduct follow-up screening and testing for inmate contacts who remain incarcerated
TIP: Use the Tuberculin Skin Test Log INMATES and the Risk Assessment for TB

Initiate referrals for any additional released inmates in need of follow-up (second) TST or IGRA
Determine infection rate on second round of TST testing according to area (if more than one)
TIP: Collaborate with the health department to identify the infection rate of each location
Discuss/review findings with health department TB staff to determine the need to expand the contact
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Instructions: Initial and Date after each task. Observe Respiratory Precautions when speaking with infectious
tuberculosis (TB) suspects/cases. Assure proper isolation and treatment of suspect/case.
INITIAL
WHEN
DONE
DATE
COMPLETED
Initials
Date
investigation
Document on the progress notes or the comment section the decision to expand contact investigation or not.
Inform appropriate staff involved in decision-making.
WITHIN 180 WORKING DAYS
Complete a preliminary summary report for local health department TB program staff that includes the following
for each round of testing. TIP: use the Aggregate Evaluation Form – Contact Investigation in Corrections

# of inmates/staff/volunteers screened/evaluated

# of TSTs administered

# of TSTs read

# of positive TSTs

# of follow-up CXRs

# of suspects/cases identified and isolated

# of inmates/staff/volunteers placed on treatment for LTBI

# of IGRA’s drawn (if applicable)

# of inmates/staff/volunteers who were released/transferred/did not show
Note: Determine with the Health Department the conclusion of the contact investigation
Prepare a Final Summary Report with the information noted above.
COMPLETION OF THE CONTACT INVESTIGATION
Include all of the above information as in the preliminary summary, as well as the following:
For those not completing testing/treatment for LTBI; document the following information (TIP: use the
Evaluation of Contact Investigation in Corrections):

Transferred to other facility

Released to community

Refusing treatment

On work-release

Lost to follow-up

Active TB developed

Adverse effect of medications

Died

Provider decision to discontinue medications

Other (please specify)
TIP: Use the Aggregate Evaluation Form – Contact Investigation in Corrections
Once the documentation summary is complete, maintain the original documentation in the correctional facility
records and provide a completed copy for health department records.
ADDITIONAL COMMENTS:
Signature
Title
NAME
NOTE: AT ANY POINT, IF THE INMATE IS RELEASED OR
TRANSFERRED TO ANOTHER FACILITY, COMPLETE
INFORMATION MUST BE SENT ALONG WITH THE INMATE
ID #
DATE OF BIRTH
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Clinical Pathway – TB Contact Investigation for
Corrections
Various areas within correctional facilities have different levels of risk for TB transmission.
According to CDC guidelines for Prevention and Control of Tuberculosis in Correctional and
Detention Facilities, 2006, each facility should assess all levels of TB risk at least annually. This
can be accomplished using information from contact investigations. By using the Clinical Pathway
for TB Contact Investigations for Corrections, the Health Service Administrator or the Infection
Control Nurse can identify the steps needed when doing a contact investigation around an
infectious case of tuberculosis, and if needed, increase the need for testing and screening.
Use this form to identify and prioritize steps of a contact investigation (CI) in a correctional facility.
Timelines and tips for task completion are provided throughout the form for ease in implementing
each step along the way.
Terminology and Definitions
Although these terms are not inclusive of everything that may be discussed during a contact
investigation, we have included the most pertinent. Some terms may not be included on the
Clinical Pathway CI form, although you may hear them throughout the contact investigation, and
therefore, are included in this section.
Airborne Infection Isolation Room – Formerly, negative pressure isolation room, an AIIR is a singleoccupancy patient-care room used to isolate persons with a suspected or confirmed airborne infectious
disease. Environmental factors are controlled in AIIRs to minimize the transmission of infectious agents
that are usually transmitted from person to person by droplet nuclei associated with coughing or
aerosolization of contaminated fluids. AIIRs should provide negative pressure in the room (so that air
flows under the door gap into the room); and an air flow rate of 6-12 Air Changes per Hour (ACH) (6
ACH for existing structures, 12 ACH for new construction or renovation); and direct exhaust of air from
the room to the outside of the building or recirculation of air through a HEPA filter before returning to
circulation (MMWR 2005; 54 [RR-17])
Conversion – A tuberculin skin test increase of 10mm or more within a 2-year period, regardless of age
(i.e., 5/10/05 – TST = 4mm, tested again 3/17/07 – TST = 16mm.)
Conversion Rate – calculation is identified by dividing the number of conversions among workers by the
number of workers who were tested and had prior negative results during a certain period.
NOTE: If the population served by the correctional facility is not representative of the
community in which the facility is located, an alternate comparison population might be
appropriate.
Contacts – contacts are categorized and assessed according to priority, and include high-priority and
medium priority. A contact is a person who has shared the same air space with a person who has TB
disease for a sufficient amount of time to allow possible transmission of M. tuberculosis.
High-priority - those persons most likely to become infected (were in close proximity of the
infectious case and for prolonged periods of time) and most likely to develop active TB disease
once infected (HIV+, other immune compromised, drug users, silicosis, etc.).
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Medium-priority – those persons who spent time with or was physically close to the patient and,
once infected, may develop active TB disease (low body weight, diabetes, organ transplant,
cancers, renal disease, etc.
Low-priority – those persons with short duration of exposure (includes officers and staff who do
not have prolonged exposure).
Exposure – the length of time spent with a person with active infectious TB disease during his/her
infectious period.
Index Case – the first patient that comes to your attention as a TB case
Infectious Period – the period during which a person with TB disease might have transmitted M.
tuberculosis organisms to others. For patients with positive AFB sputum smear results, the
infectious period begins 3 months before the collection date of the first positive smear result or the
date of collection for the first consistently negative smear results. For patients with negative AFB
sputum smear results, the infectious period extends from 1 month before the symptom onset date
and ends when the patient is placed into airborne infection isolation (AII), whichever is earlier.
Latent TB Infection – a person infected with the bacteria Mycobacterium tuberculosis. The person
with LTBI shows no signs or symptoms of active TB, and has a negative chest x-ray and negative
symptom screen, but will test positive with an IGRA or TST.
Suspect – a person in whom the diagnosis of TB disease is being considered, regardless of
whether anti-TB therapy has been started. Suspects should always be isolated in a negative AII
room.
BEST PRACTICE: Begin and complete the contact investigation in conjunction with the local health
department whenever possible.
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