Self-Study Modules for Effective TB Interviewing
The following case presentations demonstrate concepts from this
module. You may review them with your supervisor if you have questions.
Part 1 – Barbara is a 41-year-old woman who was diagnosed
with TB while in jail. You need to interview her in the hospital
to which she was transferred. The medical record review indicates
that Barbara has a history of crack and cocaine use. The interview
is difficult to conduct as Barbara appears tired and has little
eye contact with you. Also, as indicated in her record, she is
experiencing withdrawal symptoms. While Barbara does not have many
questions about TB, she verifies most of the medical and personal
information you provide. When you try to elicit contacts, Barbara
becomes defensive and asks why you need to know all of this information.
How do you deal with Barbara’s concern about contact identification?
Explanation: Even though Barbara has been cooperative
thus far, you have come to a critical and difficult point in the
interview. Although the explanation of the purpose of the TB interview
for identifying contacts should come at the beginning of the interview,
this purpose should be reiterated once again prior to asking about
contacts. You should also acknowledge to Barbara, through the use
of reflection, that she seems tired and worried about her confidentiality.
You should also acknowledge that the interview has been a long process
Part 2 – Once you explain to Barbara again about the reason
for identifying contacts, she states that she is willing to continue
with the interview. As you ask questions, Barbara offers very little
information about her contacts. She provides no names or just first
names and little or no address information. She fidgets in her
chair and has not mentioned where exposure has occurred.
Is the contact information you have received enough to work
with? If not, how can you obtain more detailed information?
Explanation: Barbara appears nervous. She has not
given enough information to allow you to end the contact identification
process. At this point, you should mention to Barbara that while
it is difficult to name people she may have exposed to TB, you need
their names and where to find them so that they can be tested for
TB and be evaluated by a doctor. Barbara may also be fearful of
you finding out about illicit activities she was involved in during
the infectious period. Even though she may not have stated her
fear directly, you should reassure her that you are only concerned
about the well-being of those individuals that may have been exposed
to TB and not the nature of the activities in which they are involved.
Part 3 – After you explain the process and importance of
contact identification again to Barbara, she agrees to give you
some more contact information. However, she still claims to only
know first names or nicknames of many of her contacts, and states
that she has no mailing addresses. The contacts Barbara names outside
of her household are individuals she has been involved with during
drug use or transactions.
How should you proceed with the contact elicitation process
from here? What other information may help you?
Explanation: Asking as much information as possible
about the contacts will assist the healthcare worker who will go
into the field to locate them. You should ask Barbara for physical
descriptions and distinguishing characteristics of her contacts
and descriptions of the locations in which she meets them, including
times when she meets them.
Part 1 – Joey is a 3-year-old boy who was diagnosed with
pulmonary TB. You were asked to interview his mother, Ms. Jones,
as part of a source case investigation. Joey is under the care
of a private doctor who referred him to the health department.
Ms. Jones is confused about why you are only looking for who transmitted
TB to her son. She also wants to know why Joey should not be isolated
so that he will not infect others. The doctor seemed unconcerned
about this and she is worried, as there is another child at home.
What should you say to Ms. Jones regarding her concerns?
Explanation: Part of the interview process is to
educate the patient on the reasons for the TB interview and answer
any TB-related questions the patient may have. Ms. Jones should
be told why a source case investigation is being conducted and why
you are trying to find out who may have transmitted TB to her son.
It is important that Ms. Jones understand that young children with
TB are not usually able to spread infection and, therefore, do not
need to be isolated. Also, she should understand that evidence of
TB disease in a young child suggests that he has been infected recently
and that you can potentially find the source of her son’s disease,
who needs to be treated as well. Reassure Ms. Jones that you are
conducting this investigation not to lay blame on anyone, but to
provide medical attention to the source case so that he or she can
get well and not infect others, including anyone else close to her
or to Joey.
Part 2 – After Ms. Jones has understood the purpose of the
interview and its outcomes, she is willing to provide you with information
that you need. Your review of the patient’s record shows that Ms.
Jones and her other child have negative tuberculin skin test results
and are asymptomatic.
In order to assess where exposure to TB disease may have
occurred, what types of locations and people would you want to ask
Joey’s mother about?
Explanation: You should ask Ms. Jones where Joey
spends time. To assist her with thinking of places, ask her about
daycare centers, play or activity groups, and relatives’ and friends’
homes. You should ask about people Joey spends time with, including
parents or guardians and relatives or friends who come to the house.
Also, ask who has come to the house and stayed for prolonged periods
of time in the past few months. In addition to regular visitors,
this should also include those who have had extended contact with
Joey. Finally, ask Ms. Jones about any people she knows who have
had TB or TB symptoms, particularly cough. Giving Ms. Jones a time
frame would provide a reference to guide her in answering this question.
Consult your health department guidelines for a time frame used
to elicit contacts for source case investigations.
Part 1 – A small local hospital has contacted your health
department. Four nurses, who undergo annual tuberculin skin testing,
have tested positive this year. This is a highly unusual number
of skin test conversions in this facility. The hospital reports
that none of the nurses have TB disease. There have also not been
any known TB cases in the hospital in the past several years.
What should you do as the TB interviewer in this situation?
Explanation: Even though these nurses are not infectious,
the fact of their recent skin test conversions in a high-risk setting
makes it important to do an interview with each of them. You also
need to ask two questions: 1) Have the skin testing protocols and
methods in the hospital changed recently? 2) Has there been a change
in the hospital staff who are regularly tested?
Part 2 – After finding out that the skin testing procedures
and staff have not changed, you decide to interview each of the
nurses separately. You have confirmed that they have indeed recently
tested positive for latent TB infection (LTBI) and do not have TB
disease. You have also obtained documentation of the nurses’ previously
negative skin test results.
Since these are healthcare workers, what kind of information
should you provide regarding TB and this interview?
Explanation: Even though the nurses are healthcare
workers, you should still determine their level of TB knowledge.
If needed, you should explain the difference between latent TB infection
and TB disease and why completing treatment is important. Each
nurse should also understand why these interviews are being conducted.
The reason is that the hospital had observed an unusually high rate
of new skin test conversions, indicative of TB transmission, and
wants to 1) find the probable source case, 2) see if all of the
people being interviewed are linked in some way, and 3) prevent
further TB transmission.
Part 3 – After the nurses receive the education, you are
ready to identify associates and exposure settings.
What questions should you ask to gather contact information?
Explanation: You should ask about anyone that they
know who has TB or may have been ill with symptoms consistent with
TB. You should also ask about with whom and where they spend time
frequently, including home, work, school, social, and congregate
Part 4 – After all of the interviews are completed, you
analyze your interview data. You see that none of the nurses name
the same associates nor know anyone likely to have TB. All four
nurses do “moonlighting” work at the same nursing home. However,
they all work different shifts and on different days.
What should be done with this information, what additional
questions should be asked, and should further interviews be done?
Explanation: Since a substantial amount of information
was collected from the nurses, you may not want to re-interview
them at this time, but may need to do so later. You should conduct
an investigation in the commonly named nursing home, since it may
be the place of common exposure to a source case, who remains untreated.
Further interviews may arise from this setting, if a case of infectious
TB is discovered. In the congregate setting you should find out
1) what the nurses’ routines are, 2) which patients they care for,
and 3) the locations in which they work.