Self-Study Modules on Tuberculosis
Module 6: Contact Investigations for Tuberculosis
Medical Record Review
What Information Should Be Collected?
The first step in a contact investigation is to review the TB patient's
medical record and ask the clinician for information to determine
whether the patient has been infectious and, if so, when. Knowing
about the patient's infectiousness helps health care workers decide
which contacts are at risk. Sometimes this also requires talking
to the hospital's infection control nurse, reviewing the laboratory
record, or talking to the patient directly (see
Module 8, Tuberculosis Surveillance and Case Management in Hospitals
and Institutions, for more detailed information on medical record
The following information should be collected about the patient:
- Site of TB disease
- TB symptoms and approximate date symptoms began
- Sputum smear and culture results, including the dates of specimen
- Results of nucleic acid amplification testing (if available)
- Chest x-ray results and date
- TB treatment (medications, dosage, and date treatment was started)
- Method of treatment administration (DOT or self-administered)
For suspected TB cases the following information should also be
- Medical risk factors that may increase the risk for development
of TB disease (see Module 1, Transmission
and Pathogenesis of Tuberculosis)
- History of tuberculin skin test results
- History of previous treatment for TB disease or TB infection
Patients are more likely to be infectious if they
- Have pulmonary or laryngeal TB
- Are coughing (especially if they are producing
a lot of sputum)
- Have positive sputum AFB smear results and
a positive culture for M. tuberculosis
- Have chest x-ray results showing a cavity in
- Have had no treatment or have recently started
The Period of Infectiousness
The period of infectiousness is the time period
during which a person with TB disease is capable of transmitting
M. tuberculosis. Determining the period of infectiousness
can help focus the contact investigation efforts on those persons
who were exposed while the patient was infectious. There is no universal,
well-established method to determine the period of infectiousness.
The beginning of the infectious period is usually estimated by determining
the date of onset of the patient's symptoms (especially coughing).
Sometimes when it is difficult to obtain a reliable history from
the patient about the onset of symptoms, the beginning of the infectious
period is estimated to be earlier than the onset of symptoms. Estimating
the period of infectiousness should be done by clinical and supervisory
staff after a complete assessment of the information available.
The period of infectiousness ends when all the
following criteria are met:
- Symptoms have improved
- The patient has been receiving adequate treatment for at least
2 to 3 weeks
- The patient has had three consecutive negative sputum smears
from sputum collected on different days
The medical record review is summarized in Table 6.2 (see
Module 5, Infectiousness and Infection Control, for detailed
information on infectiousness; see Module
8, Tuberculosis Surveillance and Case Management in Hospitals
and Institutions, for more information on medical record reviews).
Medical Record Review
|Information Collected During the Review
||Conditions that Increase Likelihood of Infectiousness
and Relative Priority of Contact Investigation
|Site of TB disease
||Pulmonary or laryngeal TB disease
|TB symptoms and approximate date symptoms began
||Coughing, producing a lot of sputum
Hoarseness (may indicate laryngeal TB)
|Sputum smear and culture results, including the dates of
||Positive AFB smear results
identified in the culture
|Chest x-ray results
||Cavity in the lung
|TB treatment, date treatment started, and method of administration
||No treatment or recently started treatment
|Study Questions 6.10-6.12
seven types of information that should be collected during
the medical record review.
6.11. List five conditions that increase the likelihood
that a patient is infectious.
6.12. Define the period of infectiousness and discuss how
it is estimated.
The next step in the contact investigation is to interview the
TB patient (Figure 6.1). In this section, the purpose of the contact
investigation interview will be covered, as well as strategies to
conduct effective interviews.
The patient interview is one of the most critical parts of the
contact investigation, because the health care worker who interviews
the patient serves as the main link between the health department
and the contacts. If the health care worker does not communicate
well enough with the patient to get accurate information about symptoms,
places, and contacts, people who need evaluation and treatment may
Figure 6.1 This is a picture of a health care worker interviewing
a TB patient.
The initial interview should occur no more than 3 working
days after the case is reported to the health department
because it is possible that some contacts may have already developed
infectious TB disease. Also, as time goes by, some contacts may
be harder to locate. If TB is diagnosed in the hospital, the health
care worker should visit the patient in the hospital before the
patient is discharged. Health care workers should remember to follow
infection control precautions while visiting a potentially infectious
TB patient. These precautions may include wearing a personal respirator
(see Module 5, Infectiousness and
Purpose of Contact Investigation Interview
For a contact investigation, there are three main reasons to interview
the TB patient:
- To find out more about the patient's symptoms
to help determine the period of infectiousness
- To find out places where the patient spent
time while he or she was infectious
- To identify the patient's contacts, get locating
information for the contacts, and find out how often and how long
the contacts were exposed to the patient while he or she was infectious
Symptoms. The TB patient should be asked whether
he or she has had TB symptoms, especially coughing, and how long
those symptoms have been present. This will help determine how long
the patient was infectious. The patient might relate the onset of
symptoms to certain events such as birthdays, holidays, or major
news reports. The health care worker may be able to obtain information
from the patient by using these prompts. With the patient's approval,
family members or other persons who live with the patient may be
interviewed to help estimate when the symptoms began.
Places. The patient should be asked to identify
all of the places he or she has been since the symptoms began, especially
places where the patient spent the most time. The easiest way to
do this is to ask the patient to go over his or her daily routine.
Common places include the patient's home or shelter, workplace (including
car pools), school, places of worship, soup kitchens, and places
where the patient spends his or her free time, such as friends'
houses, restaurants, or bars. Some patients may live or work in
more than one place, and some may be homeless or may have spent
time in a correctional facility. In general, there are three different
types of places where patients may spend most of their time (Figure
- Household or residence
- Work or school
- Leisure or recreation environments
It is important that patients be asked questions about all three
types of places, not just questions regarding the household or other
After being asked to review his or her daily routine, the patient
should be asked about places he or she has gone less frequently,
even places that don't seem important enough for the patient to
mention (such as meetings, parties, vacations, or family gatherings)
or places that the patient may be reluctant to mention. Getting
a complete and accurate list of places should become easier for
interviewers as they gain experience in conducting contact investigations.
Figure 6.2 This is a figure with images of the three
different types of places where patients spend most of their time:(1)
household or residential; (2) work or school; (3) leisure or recreation.
In addition, the patient should also be asked about the characteristics
of each place, including the size of the place, time spent in the
place, and whether the windows were open or closed. This information
is important for assessing the risk that M. tuberculosis
was transmitted in each place. When it is possible, the health care
worker should visit each place after the interview to get an accurate
idea of the amount of risk, especially the extent of ventilation.
Contacts. The patient should be asked to give
the names of people he or she spent time with in each of the places,
especially people he or she sees every day or shares sleeping space
with. Nearly every TB patient has at least one contact; the number
of contacts can range from one to several hundred, depending on
living quarters, workplace, and other circumstances.
The interviewer should be aware that some patients may be reluctant
to identify some or all of their contacts. For example, a patient
may not want to identify people who use illegal drugs with him or
her, may not want to identify people who reside in the United States
illegally, or simply may not want his or her friends to know that
he or she has TB. The interviewer should be sensitive to the patient's
fears, explain the importance of testing the contacts, and assure
the patient that all information, including the patient's name,
will be kept confidential.
The patient should also be asked where each contact can be found,
so that the contacts can be notified about their possible exposure
to TB and asked to come to the health department for testing. The
patient may not give the names of all contacts, but usually the
health care worker can identify more contacts when he or she visits
each place. For example, homeless patients often do not know the
names of their contacts. If possible, the patient should be re-interviewed
later on to identify more contacts.
A patient interview checklist can assist the health care worker
with obtaining the right information on symptoms, places, and contacts.
A sample checklist of topics to cover in a patient interview is
shown in Figure 6.3.
A good contact investigation form can assist the health care worker
in obtaining important information on the TB patient, as well as
on the identified contacts. Forms used in contact investigations
will vary from setting to setting. Table 6.3 summarizes some important
information that should be collected during contact investigations.
Figure 6.4 is an example of a contact investigation form that contains
some of the elements listed in Table 6.3.
Figure 6.3 This is a sample checklist for a patient interview.
Example of Elements for Data Collection Forms for Contact Investigation
|Index patient identifying information
||Index patient medical information
- Date of birth
- Employment, school, or group living situation
- Site of disease
- Symptoms (date of onset)
- Chest x-ray
- Bacteriology (smear and culture) results
- Assessment of risk of transmitting M. tuberculosis
- TB medication
|Contact identifying information and risk
||Contact evaluation and follow-up information
- Date of birth (age)
- Relationship to contact
- Setting of exposure (home/ residence/ work/ school/
- Date of last contact with infectious case
- Hours of exposure
- Close/casual contact status
- Risk that transmission occurred (high, low)
- Living situation
- Country of origin
- HIV status
- Other immunosuppression (i.e., diabetes, cancer, etc.)
- Substance abuse
- Previous documented tuberculin skin test (TST) (date,
- Initial TST dates placed, read, mm results
- Follow up TST dates placed, read, mm results
- Chest x-ray, date, results (normal, abnormal, cavitary
- Treatment for LTBI recommended (date, regimen)
- Reason treatment for LTBI not recommended
- Start date for treatment for LTBI
- Stop date for treatment for LTBI
- Stop reason
- Completion status for treatment for LTBI
Figure 6.4. This is an example of a contact investigation form.
It was adapted for the County of Los Angeles.
Contact Investigation if Patient Dies or Cannot be Located
Occasionally, a contact investigation will need to be conducted
without an interview with an index patient. The patient may have
died, may be difficult to locate, or may be psychologically unfit
to participate in a contact investigation interview. In such cases,
it is still important that a contact investigation be conducted
to identify contacts who may have been exposed to TB. For example,
if the patient has died before the contact investigation interview
is initiated, a member of the patient's household (or another person
who is knowledgeable about the places where the patient may have
potentially exposed others) should be interviewed as a proxy for
Likewise, if a health care worker is unable to locate a known infectious
TB patient, but knows some of the places where the infectious patient
may have exposed others, the contact investigation should be initiated.
For example, if a homeless individual with untreated infectious
TB cannot be located but is known to frequent a particular shelter,
health department staff may decide it is necessary to inform the
shelter management about the index case's TB status in order to
initiate timely contact follow-up.
When information must be revealed about a case without prior permission
in order to protect public health, consultation should be made with
a supervisor or TB controller to obtain approval to breach confidentiality.
The approval should be documented in the patient record.
|Study Questions 6.13-6.15
should a patient interview be done?
6.14. List three reasons why the TB patient should be interviewed
for a contact investigation.
6.15. When conducting a contact investigation interview,
from what three types of places should TB patients be asked
to identify contacts?
Strategies for Conducting Effective Interviews
For the patient interview to be effective and successful, a health
care worker should
- Explain to the patient the importance of the contact investigation
for preventing and controlling TB
- Ensure that the interview takes place under conditions that
encourage effective communication
- Establish the foundation for a good relationship with the patient
based on mutual trust and understanding
- Begin an assessment of the patient's knowledge, feelings, and
beliefs about TB and educate the patient
- Ask open-ended questions
- Have a clear understanding of the interview's objectives
- Plan the interview so that each objective is given adequate
- Listen to the patient's concerns about TB and its treatment
- Share information freely with the patient
The initial interview provides a good opportunity for the health
care worker to gather information from the patient. However, the
health care worker should keep in mind that as patients first learn
of their new TB diagnosis, they may not be ready to give or receive
detailed information. The patient may be overwhelmed and may be
experiencing fear over the diagnosis of TB disease. Likewise, the
patient may still be very sick and unable or unwilling to participate
fully in a patient interview. The health care worker should be aware
of these factors that can affect the initial patient interview and
should plan accordingly to educate patients and schedule follow-up
Explain the importance of the contact investigation interview.
The health care worker should explain to the patient the goals of
the contact investigation and why it is important to identify all
possible contacts. For example, the health care worker should explain
to the patient that a contact investigation is important to find
contacts who may be family, friends, coworkers, etc., who may have
TB disease or TB infection and who may need treatment. Contacts
who have TB disease can begin treatment to get better as well as
prevent further transmission. Contacts who have LTBI can be given
treatment for LTBI to prevent them from getting TB disease. The
patient should be told about his or her right to privacy and the
measures that will be taken to maintain confidentiality (see
Module 7, Confidentiality in Tuberculosis Control, for further
Conditions that encourage effective communication. When
the health care worker first meets a patient, he or she should introduce
himself or herself, clearly stating his or her title and role with
the TB program and the purpose of the interview. If the patient
and the health care worker do not speak the same language, an interpreter
should be used (see Module 9, Patient
Adherence to Tuberculosis Treatment, for additional information
on working with interpretors). Because it is important to make the
patient as comfortable as possible, the health care worker should
ensure that the interview takes place under conditions that encourage
effective communication. These conditions include
- Arranging for privacy and maintaining confidentiality and assuring
the patient that all information will be kept private
- Creating an environment relatively free of distractions and
- Listening attentively and respectfully to the patient (for example,
sit down near the patient and use open, relaxed body language)
- Being objective and nonjudgmental (for example, be patient,
not accusatory, and never show frustration)
Understanding the patient's point of view is very important.
It is important to
- Maintain open, frank communication with the patient
- Listen and try to understand the patient's knowledge, beliefs,
and feelings about TB disease and treatment
- Be open minded about the patient's beliefs and cultural expectations
- Recognize and address the patient's fears about the illness
- Communicate clearly so that the patient can understand the messages
- Treat the patient with dignity and respect
- Provide needed information and education
- Maintain the patient's confidence
Establishing a trusting relationship. It is very
important to establish a trusting relationship with the patient.
Trust implies a firm reliance by the patient on the integrity, ability,
and character of the health care worker. If a patient trusts or
has confidence in his or her health care worker, he or she is more
likely to be willing and able to follow instructions and advice
and to cooperate in the contact investigation. The initial interview
is a good time to begin to develop trust. In all likelihood the
establishment of a true trusting relationship between the health
care worker and the patient will develop over time through various
interactions that will test the relationship. However, the foundation
from which a trusting relationship can be established begins at
the initial interview.
By bringing his or her health problem to the attention of a health
care worker, the patient is entrusting personal and private information
to the health care worker. As the health care worker interviews
the patient, the patient may divulge information about lifestyle
choices and risky, even illegal behaviors, such as injection drug
use. In addition, some patients may reveal that they reside in the
United States illegally and fear being reported to immigration authorities.
It is extremely important that the health care worker safeguard
patient information and assure the patient that this information
will not be shared with authorities or prevent the patient from
receiving health services (see Module
7, Confidentiality in Tuberculosis Control). The time and concern
taken with the patient at the initial interview serves to establish
rapport and mutual trust, critical factors in ensuring collaboration
and cooperation with contact investigation as well as adherence
to follow-up visits.
Educating the patient. The patient may have little
or no knowledge of TB or may have misconceptions about TB. It is
therefore critical during the interview for the health care worker
to first determine the patient's level of understanding about TB
and then work from this basis toward developing an accurate understanding.
To be certain that the patient has an accurate understanding, the
health care worker should ask the patient what he or she has understood.
At this time, it may be necessary to spend extra time addressing
any particular concerns the patient may have.
Open-ended questions. During the interview the
health care worker will ask the patient many questions. One way
that the health care worker can learn more about the patient's symptoms,
the places the patient has spent time while infectious, and the
contacts who may have been exposed to the patient is through the
use of open-ended questions.
An open-ended question is one that cannot be answered with a simple
"yes" or "no." Open-ended questions are designed to elicit the patient's
knowledge, feelings, and beliefs by beginning with words that demand
an explanation, like
In addition, phrases that begin with "Tell me about" or "Explain
to me" may be helpful in eliciting information. Such questions are
used when a health care worker needs to explore complex issues that
do not have a finite or predetermined set of responses.
The questions in Table 6.4 are examples of open-ended questions
that can be used in the contact investigation. These open-ended
questions may assist health care workers assessing the patients
understanding of TB, as well as in identifying contacts who may
have been exposed to an infectious TB patient.
Examples of Open-Ended Questions for Contact Investigation
- What symptoms do you have?
- When did your symptoms begin?
- How long have you had these symptoms?
- Who are the people who visit your home?
- What places do you go to on a daily basis?
- What is your daily routine?
- How do you get to work?
- Who do you ride to work with?
- What is the room like where you spend most of
your time at work?
- Who are the people you spend time with at work,
at church, etc.?
- Who are the people you see every day?
- What do you do in your free time?
- What are your hobbies?
- Who do you sleep with each night?
- Where else do you sleep?
- Where did you go on vacation?
Open-ended questions such as these are useful during the contact
investigation interview. They are a starting point only. The health
care worker should ask many more questions about the names and locations
of the possible contacts and ensure that all contacts are notified
and scheduled for testing.
Completing the Interview
Before completing the interview, the health care worker and the
patient should decide who will notify the contacts. Some TB patients
prefer to notify their contacts themselves, especially when the
contacts are family members or close friends. Others prefer that
the health care worker notify the contacts.
Again, the patient's confidentiality is very important. If the
health care worker is going to notify the contacts, he or she should
assure the patient that the contacts will not be told who identified
them as a contact. Either way, the health care worker should get
the names and locations of the contacts and ensure that all contacts
are notified and scheduled for testing.
Potential barriers of the contacts to complying with testing should
be identified through discussion with the patient. For example,
if it is determined that a contact is unlikely to appear at the
health department for testing, the health care worker may decide
to conduct testing in the field.
The health care worker should realize that the patient may not
be able to recall all of the names of possible contacts at the initial
interview, especially if the interview occurs around the same time
as the diagnosis. The health care worker should provide the patient
with an opportunity to provide other contacts as they are remembered.
The health care worker can encourage the patient to phone the health
department if he or she remembers other contacts. In addition, the
health care worker should schedule a follow-up interview with the
patient to identify more contacts.
|Study Questions 6.16-6.18
6.16. What are some strategies the health care
worker can use to conduct effective interviews?
6.17. What are four conditions that encourage effective
6.18. If the patient is not able to recall all
of his or her contacts at the initial interview, what can
the health care worker do to obtain more information about
|Case Study 6.3
Matilda Landers is a 73-year-old resident at the Washington
County Nursing Home who has been hospitalized for a serious
respiratory illness. She has been reported to the health department
as a suspected TB case, and you are the health care worker
assigned to conduct a contact investigation. You have conducted
a medical record review and found the following information:
- Site of TB disease: laryngeal TB suspected
- TB symptoms: hoarseness, cough, fatigue, weight
- Smear results: AFB positive (3+) on 5/23/99
- Culture results: pending
- Chest x-ray results: cavity in left upper lobe
- TB treatment: four-drug regimen begun on 5/24/99
- What additional information is needed to establish
the period of infectiousness? How will you get this information?
- What other information will you ask for when
you conduct a patient interview with Ms. Landers?