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TB CONTACT TRACING & NOTIFICATION

TB CONTACT TRACING & NOTIFICATION. Dr Elyna Turis LAT ST3 RUH Bath. Contact tracing. Close contacts – household contacts, boy/girlfriend, frequent visitor Household contacts – those sharing bed/bath/living room, kitchen

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TB CONTACT TRACING & NOTIFICATION

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  1. TB CONTACT TRACING & NOTIFICATION Dr Elyna Turis LAT ST3 RUH Bath

  2. Contact tracing • Close contacts – household contacts, boy/girlfriend, frequent visitor • Household contacts – those sharing bed/bath/living room, kitchen • Casual contacts – not normally assessed (unless there’s high transmission rate/really close/immunosuppresed) • Give ‘Inform And Advise’ info to all contacts of patients with smear +ve TB

  3. Contact tracing • Screening comprises • Mantoux • IGRA (6 wks after Mantoux) – if appropriate • CXR (for those >35 years) • Before initiating large contact tracing, be sure it’s MTB on microscopy/culture. If result inconclusive/delayed, use clinical judgement.

  4. HOUSEHOLDCONTACTS

  5. Household contact – No Previous BCG • If no BCG before, do Mantoux. • If Mantoux +ve (≥ 6mm), do IGRA. • If IGRA –ve, inform & advise, discharge. • If IGRA +ve, assess for TB. Treat as latent TB or investigate further. • If Mantoux –ve (<6mm), • offer BCG. But if index if smear +ve, do IGRA and share same pathway as above.

  6. Household contact - previous bcg • If >35 years, do CXR. • If normal, inform and advise, discharge. • If abnormal, investigate. • If ≤ 35, do Mantoux. • If –ve (<15mm), inform and advise, discharge. • If +ve (≥15mm), do IGRA. If –ve  inform and advise, discharge. If +ve, exclude active TB treat latent TB or investigate further.

  7. BABIES AND TODDLERS

  8. Close contact (neonate) • Treat with isoniazid 3 mo, then do Mantoux. • If Mantoux +ve (≥ 6mm), assess for active TB. • If this is negative, complete treatment for total 6 mo. • If Mantoux –ve, stop isoniazid, give BCG. • Offer Inform and Advise information to carer.

  9. Contacts >4 wks-2 yrs – no prior BCG • Start isoniazid, do Mantoux. • If –ve (<6mm), continue isonizide, repeat in 6 weeks. • If no size, stop treatment, offer BCG. • If +ve/size, do IGRA. If –ve, stop treatment, offer BCG. If +ve, assess for active TB and treat latent TB/active TB. • If +ve, assess for active TB. Then either treat latent TB/active TB.

  10. Contacts >4 wks-2 yrs – prior BCG • Do Mantoux. • If –ve (<15mm), repeat in 6 weeks. If no change, discharge. • If +ve/size  by 5mm, do IGRA. If –ve, discharge. If +ve, assess for active TB and treat for latent TB/active TB. • If Mantoux +ve, assess for active TB, treat for latent TB/active TB.

  11. AIRCRAFT TRAVELLER

  12. Aircraft traveller • Contact tracing of fellow travellers not routinely undertaken • CCDC should give I&A information to passengers who sat in the same part • Inform CCDC if flight was <3 months ago or > 8 hrs and index was smear +ve, coughing, or index has MDR-TB • If index is an air crew, no need to trace passengers, but contact tracing of other staff is as usual.

  13. SCHOOL

  14. School • If index is smear +ve, contact tracing for all classmate and those who share classes. • If teacher is smear +ve, contact tracing for all pupils in his/her class in the preceding 3 months • Consider children/teacher involved in extra-curricular activities if index is really infectious/spent lots of time together/contacts are immunocompromised

  15. School • CCDC should be prepared to give talk/advise to staff/parent/press • If index case not found, and child is not in high risk group, consider contact tracing and symptom enquiry or CXR in all relevant staff.

  16. PRISON AND REMAND CENTRES

  17. Prison/remand centres • On entry, all prisoners fill a questionnaire. Those with symptoms/signs will have CXR and 3 sputum samples sent within 24 hrs. • All on anti-TB treatment are under DOT. • People working with prisoners are screened like new NHS employees. • Early planning for follow up in case prisoner gets discharged early.

  18. HOSPITAL WARD

  19. Hospital in-patient • Do risk assessment first • Is index really infectious? • Was there significant delay in getting isolated? • Are other patients immunocompromised? • Was anyone working really closely to the index? • Do contact tracing and testing for those with significant high risk. Manage as household contact. • At risk if shares the same bay as index for > 8 hours if index is smear +ve and coughing. Document in their notes.

  20. Hospital in-patient • Ask microbiologist/regional/national HPA if in doubt. • Give Inform and Advise information. • Inform their GP. • If index has MDR TB and contact has HIV, contact tracing should be in-line with the Interdepartmental Working Group On TB Guidelines.

  21. Community childcare • Contact tracing is as per household/close contacts.

  22. TB diseased animals • Contacts of TB diseased animals should be given I&A info. • Offer BCG to those <16 years who have regularly drunk unpasteurised milk from TB infected udder.

  23. TB notification

  24. Tb notification - objectives • Detect outbreaks & other TB related incidents • Guide immediate action e.g. contact tracing • Measure the occurrence and trends of TB & anti-TB drug resistance • Identify population subgroups at higher risk • Inform planning, implementation and evaluation of programs and public policy on TB control

  25. Tb notification • Statutory requirement since 1913. Clinical suspicion is all that is required since 1968. • Cases are more vigorously checked through the Enhanced TB Surveillance (ETBS) and National Surveys. Their minimum requirements are: • Notification details • Demographic • Clinical info • Microbiological info

  26. Tb notification • Clinician notifies ‘proper officer’ by filling in official Formal Notification certificate. • The local officer (usually CCDC/ETBS) will inform HPACi every week. • IT dept of HPACi collate all weekly returns and publish analyses of local and national trends.

  27. Tb notification • NHS/HPA labs also report newly identified mycobacterium to CDSC LabBased II Pathology system. • ETBS • produces annual corrected analysis report • Does treatment outcome surveillance

  28. Summary • If you suspect TB, get all the relevant history, arrange immediate tests, alert relevant staff. • Inform respiratory dept and TB lead nurse, who will pilot contact tracing. • Neonates, toddlers and immunocompromised people are susceptible. • Don’t ignore index’s/contacts’ anxiety. Inform and advise.

  29. references • Health Protection Agency website – www.hpa.org.uk • NICE guideline – Clinical diagnosis and management of TB, and measures for its prevention and control, March 2006 (CG33) – www.nice.org.uk/CG033fullguideline • Information for the public – www.nice.org.uk/CG033publicinfo • TB outbreak hits 30 schoolgirls - http://news.bbc.co.uk/1hi/england/west_midlands/7375598.stm

  30. reference • Hospital alert after TB detected – http://news.bbc.co.uk/1/hi/england/bristol/7774734.stm • Hundreds of pupils to get TB blood tests after school outbreak – http://www.dailymail.co.uk/health/article-1067311 • Notification & data collection form for Enhanced Tuberculosis Surveillance – Health Protection Agency

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