TB Contact Investigation for Frontline Workers

TRANSCRIPT: MODULE 3 (Parts 1 & 2)

Part 1

Slide 1

Welcome to Module 3 of TB Contact Investigation for Frontline Workers. This module is divided into
two parts, with a quiz at the end of part 2.

This module will take approximately 50 minutes to complete, with each part taking about 25
minutes.

If you would like to review how to navigate the module, select the navigation button, or select
“Next” to get started with part one.

Slide 2 (Optional)

To the left, the menu shows you where you are in the presentation. You may go back to revisit slides
at any time, but you may not jump forward.

Click the notes tab if you want to read along with the narration. Click Glossary to find the definition
of acronyms and terms used in the module.

You can check your progress and the total time for the module by looking at the timer located next
to the Module title.

Click on Resources to access documents and practice exercises referenced in the module. Select Exit
to leave the session.

The module will advance automatically. You may pause, play, or replay a slide, using the control
buttons at the bottom center of the screen. Click on replay if a slide plays and you can’t hear the
narration.

You may also regulate the volume.

Use the Next and Previous buttons to move between slides when requested.

Now let’s get started!

Slide 3

After completing the module, you will be able to:

• Describe TB contact investigation, or TBCI
• Identify and describe key activities in a TBCI
• Identify and review quality components of a TBCI and
• Describe recording and reporting requirements for a TBCI.

Slide 4

As you learned in Module 2, contact investigation is a systematic process for identifying and
screening previously undiagnosed people with TB among the contacts of an index case.

Studies have shown that the prevalence of TB disease may reach up to 5% among household
contacts, particularly children, so it is important to screen these household and other close contacts
to stop the spread of the disease.

Furthermore, contact investigation can identify people who are exposed to prioritized index cases,
such as an index person with multidrug-resistant or extensively drug-resistant TB, who require
customized treatment as well as people who are more vulnerable to becoming infected with TB or
whose risk is high for developing TB disease once infected, such as people with HIV, young children,
and people with diabetes or who have other medical conditions.

Slide 5

Finding, screening, and eventually treating infected contacts through TBCI goes beyond a simple
intervention or a strategy and is a mandatory TB program activity. Quality TBCI is a journey, not a
one-time event and requires multiple steps. It is targeted, systematic screening and one of the most
cost-effective active case finding approaches. We must recognize that the index individual with TB
disease may not be the source of the infection but he or she will lead us to others exposed to TB
and at risk of infection or developing TB disease. When conducting TBCI we must remain flexible,
person-centered, and culturally sensitive to the person with TB disease and to their contacts.

Slide 6

In Module 2 you learned about the components of TBCI. In this module you will learn more about
the systematic activities you will conduct during TBCI.

Slide 7

These important activities include:

• Interviews with the index person with TB disease, or index case
 • Review of their medical records
• Household and field investigation, risk assessment, and prioritization of contacts
• Screening contacts for symptoms and using screening and diagnostic tools and technologies
• Referrals and linkage to treatment, and
• Treatment and follow-up for contacts

Let’s look at each activity, starting with interviewing an index person with TB disease.

Slide 8

TBCI starts with an initial interview with the index person with TB disease following TB diagnosis at
the clinic, hospital, or diagnostic center.

Only well-trained personnel should interview the index person with TB disease using approved tools
and questionnaires in order to conduct a quality-based interview.

The initial interview can be done by the clinical provider and/or the frontline worker in charge of
TBCI. Thus, it can be done by one or two healthcare workers, depending on a country’s context and
available human resources.

If possible, prepare for the interview by reviewing the person’s medical records. We will cover this
as a separate step in the next section of this module.

The World Health Organization recommends that masks be worn by anyone who has TB or
presumed to have TB to reduce probability of transmission to health workers, persons attending
health care facilities or other persons in settings with a high risk of transmission.

Slide 9

Health workers who are in contact with people with potentially infectious TB should take the
following precautions to protect themselves from exposure to TB bacteria:
• Always wear quality respirators such as N95 masks or higher filtering facepiece respirators
when visiting the home of a person with infectious TB disease or when transporting a person
with infectious TB disease in a vehicle
• Meet a person with TB disease or who is presumed to have TB disease outdoors when
possible
• Instruct people who are potentially infectious to wear a mask and cover their mouth and
nose with a tissue when coughing or sneezing.
• Collect specimens away from other people in a well-ventilated area or outdoors.
Slide 10

The objectives of the index case interview are the following:

• Learn about the extent and type of the person’s TB disease
• Assess the likely infectiousness of the person with TB disease and determine their infectious
period, which we will review on the next slide.
• Explain the importance of contact investigation, obtain consent for TBCI from the individual,
and identify their household and close contacts during the infectious period
• Evaluate the individual’s needs for medical, social, and psychological support and
• Assess infection prevention and control (IPC) measures needed for the individual with TB
disease based on what the person tells you about conditions in their home.

During the interview, assure the index person with TB disease that all information, including their
name, age, job, history of other diseases, etc., will be kept confidential. Remember, the initial
interview is an opportunity to build trust with the index person with TB disease.

Slide 11 (Interaction)
Do you remember from Module 2 how to calculate the infectious period of a person with TB disease? Which
of the following is the true about the infectious period of a person with TB disease?

• The infectious period begins 2 months prior to the person having TB symptoms and runs
until they have a negative sputum smear
• The infectious period begins 3 months prior to a person being diagnosed with TB disease
and usually runs for two weeks after he or she starts effective treatment.
• The infectious period begins 3 months prior to a person having TB symptoms and usually
runs for two weeks after he or she starts effective treatment
• None of the above

Let’s practice!
Raj was diagnosed with TB disease on July 10th and said he had started coughing around June 1st.
Raj began treatment on July 30th after all of his test results came back. What would the infectious
period be for Raj?

One more!
Blessing was diagnosed with TB disease on January 21st as part of her brother’s TBCI. She did not
have symptoms, but her tests and chest X-ray indicated TB disease. She began treatment the same
day. What would the infectious period be for Blessing?

Slide 12

During an interview with a person with TB disease, use open-ended questions to gather information
such as these.
You will learn more about asking questions and other communication skills in Module 4 of this
course. Ask your supervisor about the tools and questionnaires used in your setting for index
patient interviews. You will need to become very familiar with the tools to fill them in properly.

Select “Next” to continue.

Slide 13

Depending on the readiness of the index person with TB disease, who may be overwhelmed by a TB
diagnosis, you may also use the initial interview to educate the person about infection prevention
and control measures to reduce the risk of spread to others.

For example, explain cough hygiene or how to cover the mouth and nose when they cough or
sneeze to reduce the spread of the disease. You will find a poster from the US Centers for Disease
Control about cough hygiene you can use with TB patients and their contacts as Handout 3.1 in the
Resources tab.

Give other messages on how to prevent the spread of TB, including:

• Take your medicines as directed. This is very important!
• Sleep alone and not in a room with other household members until you are no longer infectious
(at least 2 to 3 weeks or longer after treatment starts).
• Do not go to work or school, or other public places and avoid having visitorsin the home until
you are non-infectious.
• Ensure air circulation and ventilation in your room, by using fans and open windows, if possible,
to create airflow. TB spreads in small, enclosed spaces where air doesn’t move.

Remind the individual that TB is spread through the air. People cannot become infected with TB by
shaking someone’s hand, touching bed linens or toilets, sharing food, drink, or utensils, or sharing
toothbrushes with someone who has TB.

Slide 14

Other topics to discuss during the interview may include:

Understanding their TB diagnosis, their treatment plan and how to adhere to their treatment, and
where and how to access support while receiving treatment.

As a frontline worker you should ask individuals you interview what questions they have about
these topics and feel confident in providing answers to their questions.
Slide 15

A critical conversation to have with the index person with TB disease during the initial contact
investigation interview is the importance of identifying anyone who they may have been near
during their infectious period and who were likely to have been exposed to TB.

No one wants to think they may have spread TB to another person. The index person may feel
shame or fear linked to her or his TB diagnosis.

Emphasize that TB is curable if a person takes their medicine as prescribed.

Not all contacts exposed to TB will be infected, but it is important to find those who are, in order to
get them the testing and treatment they may need.

TB is especially dangerous for children and persons infected with HIV. If infected with TB bacteria,
these people need medicine right away to keep them from developing TB disease.

Slide 16

Explain how contact investigation works to the index person with TB disease. Describe how you will
keep their information confidential.

Emphasize that contact investigation is voluntary and answer any questions they may have.

You will learn more about interviewing and obtaining informed consent in Module 4.

If the index person does not give his or her consent during the initial interview, you should ask again
at the next follow-up visit.

Slide 17
The first follow-up interview should be conducted 1 to 2 weeks after the initial interview depending
on results from the initial interview and assessments and your country’s guidelines. This typically
takes place back at the clinic, hospital, or diagnostic center.

Before the follow-up interview, review the person’s medical records, as additional test results may
have been added.

During follow-up interviews, evaluate the person’s symptoms to assess if they are improving.
Remember, with improvement, the infectious period usually lasts two weeks after the beginning of
treatment.

Ask how the person with TB disease is following treatment and encourage continued adherence.
Review the list of the person’s contacts with them, as they may have thought of more people they
may have exposed during their infectious period. Ask about consent for contact investigation. if the
patient declined during the initial interview.

Finally, answer the person’s questions and provide information about how they can access needed
support.

Additional interviews may be held, as needed.

Slide 18

You will record the results of all interviews with the index case on a TB case investigation form like
this one from Cambodia. The form in your country may have a different name.

You will also enter information about the index person with TB disease and their contacts on a TB
register, like this one from Nigeria. You should be familiar with all the forms you are required to fill
out for a TBCI. Discuss any questions you may have about them with your supervisor. Accurate
recording and reporting are very important for quality TBCI, to make sure we do not miss
opportunities to identify contacts and to stop the spread of the disease.

Slide 19

Now let’s look at a second important step of TBCI: reviewing the index person’s medical records at
the clinic, hospital, or diagnostic center. Medical records provide important information about an
index case that helps you prepare for case interviews and prioritize cases for contact investigation.
This information includes:

• The site and type of TB disease: if it is pulmonary TB in the lungs (bacteriological positive or
bacteriological negative), extra-pulmonary TB found in bones or organs outside the lungs, or
both.
• Symptom start date and infectious period. It is very important to check when symptoms
began, how they evolved, and medications taken to determine both the infectious period
and how infectious the person with TB has been. For example, a patient who is coughing is
more likely to infect a contact than a patient without cough. Further, in most cases, a person
with TB disease who has been adhering to treatment for two weeks should no longer be
infectious.
• Sputum smear and culture results, including the dates and types of test used. If drug
resistance testing is available, describe the drug resistance pattern of the index case.

For example, a case with a positive smear will take priority over a case with a negative
smear. Similarly, if a case has a negative smear after beginning treatment it signals that her
or his infectious period has ended.
 If a test such as Xpert MTB/RIF is used, the results will show whether the person’s TB is
sensitive to the anti-TB drug rifampicin, or RIF, or if it is resistant to RIF. If the case shows
drug resistance, it should be prioritized for contact investigation to stop the spread of this
more dangerous form of TB.

• Chest X-ray results and date. For example, the presence of cavities in the lungs indicates that
the case is highly infectious.
• Finally, you will gather information about TB treatment /medications, dosage, the date
treatment started, methods of treatment administration, side effects, etc. You will use this
information to answer the index person’s questions and promote adherence to treatment as
well as to determine the end of the infectious period.

You will want to review the index person’s medical records and speak with the treating clinician
before conducting interview or visits, whenever possible.

Slide 20

Let’s look at a case scenario to reinforce what you have learned about TBCI. You may download a
copy of this case scenario from the Resources tab.

In this scenario, you have just been given copies of the initial interview results and medical records
of a new contact investigation case. From the documentation you learn that the index person with
TB disease is a 25-year-old woman with a child under five years. She is HIV-negative, 32 weeks
pregnant, and had been experiencing a cough and night sweats for four weeks before coming to the
clinic today.

Her sputum was tested and indicates she is positive for TB that is sensitive to rifampicin.
The index person lives with her husband and a maid. She has two sisters who visit her almost every
day since her pregnancy.

Which elements are important when deciding how to prioritize this index case? Is there any
information missing or any details you need before moving forward? Take a moment to consider
these questions before advancing by selecting “Next.”

Slide 21

Upon initial reading of the case files, you should identify the following details to help prioritize the
case.

Information about this person that does not increase case priority is that she is HIV-negative and
does not have drug-resistant TB. However, she does have a household contact who is under age five
and she is pregnant.

Now, please answer a few questions about the case.

Slide 22 (Interaction)

How many household and close contacts can you identify from the documentation you have been
provided?

If the woman was diagnosed today and the date is May 1st, when did her infectious period start if
she began coughing four weeks ago?

Slide 23 (Interaction)

What additional information would be helpful for you to know? Click on each tab for ideas.

Chest X-ray results: A chest X-ray during pregnancy may present some risk for the unborn child and
although it would indicate whether the woman has lung cavities and is thus more infectious,
sputum smear test results can be used to assess infectiousness.

Employment: Yes! Although the woman may not be currently working because of her pregnancy,
her infectious period will extend back almost four months, so she may have contacts from her
workplace who may be considered close contacts.

Standard Operating Procedures for TB during pregnancy: Yes! You could consult a medical officer
for more information about TB and pregnancy management so that you can answer any questions
the woman may have.

Status of informed consent: Yes! You need to know if the woman has given her informed consent
for contact investigation.

Slide 24 (Interaction)

When should you schedule the first follow-up visit?

Slide 25

This is the end of Module 3 part 1. You may take a break or continue to part 2. Please select Exit and
return to the course webpage.

Part 2

Slide 1

Welcome to part 2 of Module 3: Steps in TB Contact Investigation. In part 1 you learned about
interviewing the index person with TB disease and reviewing the medical records. Now, you will
learn about activities conducted with prioritized contacts of the index case.
Slide 2

Household and field investigation, risk assessment and prioritization will lead you to the index case’s
contacts who should be screened and further investigated for TB.

You will plan and conduct TB contact investigations for all prioritized household and close contacts
of the index case. Household contacts who share living space with the index person with TB disease
are always prioritized. When resources allow, close contacts from the person’s school or workplace,
or any other location where TB transmission could occur may also be prioritized.

Slide 3

During household and field visits you will use what you’ve learned through interview(s) with the
index person with TB disease and his or her medical records to:
• Identify additional household contacts who share the index person’s home and additional close
contacts from the index person’s neighbors, workmates or classmates, and friends. You will do
this while keeping the index person’s name and personal information confidential.
• You will assess the environmental characteristics of each location where TB exposure could have
occurred. You will look for room sizes, ventilation, and the number of people in shared rooms or
spaces.
• You will be able to screen household and close contacts for TB symptoms and risks for
developing TB disease to determine which contacts to prioritize for further evaluation. This will
be done based on your country’s national guidelines and what you learned in Module 2 of this
course.
• When needed and indicated, you should refer contacts to nearby health facilities for additional
evaluation and diagnostic testing.
• When possible, you will collect and transport sputum or fecal, or stool, samples for diagnostic
testing per local protocol.
• You may provide information on TB transmission and how to prevent the spread of TB and
COVID-19. When an index case is HIV positive you may provide information on HIV, assess
contacts for risk, and refer for testing or offer in home rapid HIV testing, if available

Slide 4

Before conducting a household or field visit:

• Review what you know about the index person’s contacts and medical history.
• Schedule a date and time with the index person to visit their household.
• Gather contact investigation and TB education tools and materials, such as contact investigation
forms, sputum request forms, specimen shipment forms, sputum cups and boxes, and any forms
needed for referrals
• Depending on your setting, you may need to contact TB diagnostic and treatment providers and
facilities to share information.

Now let’s take a closer look at the activities you will undertake during household and field visits.

Slide 5

Before screening contacts educate them about TB. This includes describing how TB is transmitted,
and informing them that they may have been exposed to someone with TB disease. Use posters, job
aids, pamphlets, or any educational materials that may be available in your country.

Describe how TB is transmitted through the air, usually when a person with TB disease coughs or
sneezes.

Explain that if exposed to someone with TB disease, they may become infected with TB bacteria,
but they would not be able to spread the bacteria to others right away. Only people with TB disease
can spread TB bacteria to others.

Emphasize that TB is treatable and generally curable with medicine. Explain that this is why they are
being screened and possibly referred for a chest X-ray and other tests, to determine if they have TB
infection or TB disease and to get them treatment, if needed.

Conduct screening sessions with respect, confidentiality, and ethics. Empathy and listening skills are
very important at this stage to build trust for quality-based screening sessions. You will learn more
about these in Module 4.

Slide 6

Individually screen all household and close contacts for TB clinical signs and symptoms such as
cough, weight loss, and night sweats and ask about medical conditions that would put them at
greater risk for developing TB.

To ensure quality, use a standardized tool when screening contacts, such as this one to document TB
symptoms and risk factors for developing TB disease. You can also download it as Handout 3.3:
Sample Contact Screening Tool from the Resources tab. Check to see what screening tool is used in
your country or worksite.

Click “Next” when you are ready to continue.

Slide 7

Using information about the index person with TB disease and about their contacts that you gather
through screening, you will prioritize those contacts to refer for further evaluation.
The criteria you use will be determined by your country’s guidance.

Slide 8

During field visits, it is recommended to collect sputum from prioritized adult contacts and fecal, or
stool, samples from young children if local resources allow. Send collected samples to the nearest
laboratory facility for rapid molecular TB tests such as GeneXpert and Truenat.

For sputum samples:

• Collect in well-ventilated outdoor areas in the sunlight.

• Teach the contact how to produce enough sputum to fill the bottom of the sample container. A
good explanation of how to produce sputum for sampling can be found in the short video “Better
Sputum, Better Diagnosis” by In Tune For Life. Select the link on the screen to watch the video or
download and read a transcript of the English version of the video as Handout 3.4 Transcript for
Better Sputum, Better Diagnosis in the resources tab.

If a contact has TB, their sputum is very infectious. For your safety, coach the contact from behind
and watch that you are not downwind.

Ask the contact to close the lid of the container once they have produced enough sputum. Make
sure that it is firmly closed.

Take care to label the container correctly, then carefully wash your hands with soap and water.

Sputum is easiest to collect in the morning. If a contact cannot produce sputum during your visit,
ask them to try again in the morning and instruct them on what to do with the sample collected.

Select “Next” when you are ready to continue.

Slide 9

If children under ten-years-old are unable to provide a sputum sample, you can collect stool
samples in a clean wide-open container. Wear protective clothing (coat/apron and gloves) when
handling the specimens.

Stool samples must be processed on the day of collection. Fresh stool samples can be used within 3
hours if kept at room temperature. Treat all stool specimens as potentially infectious and follow
basic universal precautions.
Slide 10

Next, you should refer all contacts who are eligible for further investigations or who need to provide
specimens that could not be collected during the field visit, to an appropriate facility.

You may escort contacts to the clinic for appropriate further clinical evaluation. If you do not
accompany the contacts, make sure that they reach the relevant facility and are registered
accordingly, by following up with the referred contacts and/or the clinics within one week of
referral.

Slide 11
For example, chest X-rays can be requested in case of ‘’no clinical signs/symptoms’’ for household
and close TB contacts as well as for persons living with HIV who are on anti-retroviral therapy, or
ART, since the results will play a role in confirming or ruling-out TB disease when considering
treatment options.

Skin and blood tests may be used to rule out TB infections in household and close contacts older
than five years who are HIV-negative.

Deciding who to refer for further investigation should be based on national algorithms and official
guidance

Slide 12

Presented here is an algorithm used in Nigeria to manage children who are in close contact with a
TB case.

According to this algorithm, what should a healthcare worker in Nigeria do for a close contact who
is a four-year-old child with unknown HIV status and no TB symptoms?

Click “Next” when you have your answer.

Slide 13

According to the algorithm a four-year-old child is treated the same, no matter their HIV status.

The healthcare worker would not request any additional diagnostic testing, but would refer the
child for TB preventive treatment, or TPT.

Please note that all adults and adolescents living with HIV should also be screened for TB according
to a clinical algorithm.
Slide 14

During your visit, counsel people with TB disease and their contacts on how they can prevent the
spread of TB by using infection control practices such as cough hygiene. Offer them printed
materials, if available.

You may want to discuss voluntary HIV counseling and testing to contacts, in general, because of the
danger of TB for persons living with HIV. This is especially important if the case is HIV positive, as his
or her sexual partners and biological children may be at greater risk of being HIV positive, as well.

Remember, however, that medical information about the case, including their HIV status must be
kept confidential.

Slide 15

Before completing a field visit you should answer any questions the contact may have about TB.
These may include when they will receive the results from any specimens collected, future clinical
investigations you are requesting, and possible treatment, which we will discuss next. Reinforce that
their participation in this process will result in treatment for them, if needed, and will help stop the
spread of TB in their community.

Plan for how and when you will follow-up with contacts. If you will be conducting a follow-up visit,
make sure the contacts know the date and time so they will be at the designated location. Timing of
follow-up visits should be defined in your country’s guidelines, recommendations, or best practices.

Record all results from the visit on the appropriate reporting form.

Slide 16

The treatment offered to household and close contacts will depend on the results of TB screening
and other evaluations.

In general, those contacts found to have TB disease will be placed on anti-TB treatment. Note that
with a TB disease diagnosis, these contacts will become new TB index cases and will need their own
contact investigation.

Those contacts who test positive for TB infection, but not for TB disease will be offered TPT.

Those contacts who test negative for TB infection and who are not part of an at-risk population will
not need treatment. Remember, children under 5 and people living with HIV, or with other medical
conditions that are at higher risk, should be offered TPT, according to national guidelines. Let’s now
look at the World Health Organization’s, or WHO, recommendations
Slide 17
As you learned earlier, adults and adolescent household and close contacts living with HIV should be
screened for TB according to a clinical algorithm.

According to WHO recommendations:

HIV-positive adults and adolescents who do not report any TB symptoms, such as current cough,
fever, weight loss, or night sweats are unlikely to have TB disease. They should be offered TPT
regardless of their ART status.

HIV-positive adults and adolescents who report any TB symptoms including current cough, fever,
weight loss, or night sweats, may have TB disease. They should be evaluated for TB, and other
diseases that cause such symptoms, so appropriate treatment can be started. These treatments
include anti-TB therapy if they have TB disease, or TPT if they do not have TB disease.

Infant and child household contacts or close contacts living with HIV, with or without TB symptoms
should be evaluated for TB disease. If TB disease is excluded after an appropriate clinical evaluation
or according to national guidelines, these children should be offered TPT, regardless of their age. If
found to have TB disease, they should begin anti-TB treatment.

From the Resources tab, download Handout 3.5: Key Actions When Considering TB Preventive
Treatment. This table summarizes WHO guidance on screening and tests to rule out TB disease, as
well as TPT contraindications and important counseling messages for TPT recipients.

You will find a link to the WHO Consolidated Guidelines on Tuberculosis: Module 1: Tuberculosis
Preventive Treatment in the Resource Library on the TBDIAH eLearning webpage.

Click “Next” when you are ready to continue.

Slide 18

Let’s now look at a case scenario to help reinforce what you have learned about TBCI.

You may download a copy of this case from the Resources tab.

You are given responsibility for the contact investigation of a new index case. Your colleague
diagnosed the case and conducted the initial interview. You learn the following from reviewing the
report of the interview and the medical records: The case is a 35-year-old woman, who is a primary
school teacher. She lives with her three children: a 4-year-old girl on ART, who is HIV positive; an 8-
year-old boy who is HIV negative; and a13-year-old girl who is HIV negative.

The case is:

• HIV positive and taking ART
• For two months she has been suffering from lower back pain and numbness in her feet
 • She has had fever and feels fatigue
• She has no cough
• A paraspinal abscess, with pus around the spinal column, was discovered during clinical
examination. The pus was sampled and tested with GeneXpert, Results from the test came
back positive for TB with resistance to rifampicin.

What are the most important details of this case that will help you prepare for your scheduled
home visit to meet the woman and her children? Click “Next” when you have your answers.

Slide 19

Details about the index case that are very important include the following:

She is HIV positive and taking ART.

She has been diagnosed with drug-resistant TB. This makes her case a high priority.
Although she has no cough, she can still spread TB if she has TB disease that involves her lungs.
She has one child under 5 who is also HIV positive and thus at high risk of developing TB disease, if
infected.

Also important is her occupation. As a school teacher, she could be in close contact with children
and colleagues.

Finally, there is no mention of informed consent in the documentation.

When planning for the home visit, would you plan to begin with further case investigation or by
contact investigation? Click “Next” when you have your answer.

Slide 20

When conducting the home visit, you must start by continuing the case investigation, as the woman
has not yet given her consent for contact investigation.

Begin your conversation by explaining that you are there to support her and her family and to
provide her with answers to questions she may have about her diagnosis or her treatment.
Remember, this is a time to build trust and provide more information.

Explain how having drug-resistant TB is very serious for her health, and that she must adhere to her
treatment to be cured.

Confirm when she started having back pain and numbness in her feet. Request that she return to
the clinic for collection of a sputum sample for additional tests as well as a chest X-ray to help you
better understand whether she has TB in her lungs. You may give her the referral to the clinic or
accompany her to the health facility for further evaluation.
Ask the woman what she is currently doing to protect others from being exposed to TB while she
may still be infectious. Reinforce how she should isolate herself, use cough hygiene if she begins to
cough, and how to air-out the house. Remind her that the infectious period will end sooner if she
follows her treatment.

Explain the importance of contact investigation and how you will keep her information confidential.
Ask for her consent to screen her children and to contact the school to make sure those she may
have exposed to TB are screened.

Slide 21 (Interaction)

If the index person with TB disease refuses to give her consent for contact investigation, which of
the following would be an appropriate response?

• “My job is to conduct a contact investigation and I need to do it!”

• “Don’t you understand the danger you are putting your children and students in if you don’t
consent to contact investigation? They might be infected with TB and become sick with TB
disease if they don’t have timely screening and have access to preventive treatment, if
needed.”
• “I understand that this is scary and you are worried about your family and your job. I will do
my best to not give your name to anyone and you would be helping anyone who may have
gotten infected and the sooner we start contact investigation, the better. Please think about
this more and let me know if you change your mind. In the meantime, we will concentrate
on getting you well.”

Slide 22

Fortunately, the woman gives her consent, and you start the contact investigation immediately.

You begin by confirming that there are no additional household contacts. You then screen the
children for TB symptoms using your country’s standardized tool. You find the following:

• the 4-year-old has no symptoms

• the 8-year-old has been sneezing, coughing, and had nasal congestion for the last week
• the 13-year-old has no symptoms of TB.

Collect sputum or stool samples, if possible.

According to Handout 3.5: Key Actions When Considering TB Preventive Treatment, that you
downloaded earlier, would you refer the children for chest X-rays? What about other tests?
Note that when you perform a TBCI you will need to use the algorithms and guidelines of your
country.

Click “Next” when you have your answer.

Slide 23

According to the handout, chest X-rays are not mandatory, but they are desirable especially for
persons on ART and for asymptomatic adolescents and adults. If available, you should refer the 4-
year-old and the 13-year old, who meet these criteria, for chest X-rays.

If you cannot collect sputum or stool samples, you should refer the children for tests either for TB
infection or TB disease, as indicated in the table.

Slide 24

Explain to the index case that the infectious period began three months prior to her first symptoms,
in this case five months ago. Ask her about close contacts who may have been exposed to TB during
this period.

Ask about the school building where she works, the colleagues she was in frequent contact with,
and the students she teaches. Inform her that you will be contacting the school to begin the TB
screening process. Assure her that you will keep her name and personal information confidential.

Ask her for information about other close contacts during the infectious period.

When you have completed the visit, set up a time for a follow-up visit and make sure to document
your findings.

Slide 25

After the home visit you contact the school administration and explain that students and staff at the
school may have been exposed to TB. Without making the identity of the index case obvious,
request that faculty and students report all symptoms that correspond with TB. For example, rather
than asking that all students from the teacher’s classes be screened, you could ask that all students
who are in a certain grade level or any students who take classes in a particular part of the school
building be screened.

Confidentiality, ethics, and professionalism are key in this situation.

Provide the administration with a handout or other tool, if possible and offer your support for the
screening if no one is available to carry it out.
You will also reach out individually to adult close contacts identified by the index person to screen
for TB symptoms. You should ask about co-morbidities that may put them at higher risk for being
infected or developing TB.

Slide 26

Follow-up is an important part of contact investigation. On your next visit to the case’s home, you
will review the case’s medical records, as well as the test results of her children to provide updates
on her infectious period and to discuss treatment for her children.

Displayed on the screen are the test results for the children and the treatment offered. The
treatment offered in your country will depend on national guidelines.

Since there are now two cases of TB in the household, infection prevention and control measures
are especially important and should be reinforced during the visit, as well as adherence to
treatment. Identifying the 13-year-olds contacts will also be an important focus.

Slide 27

In this module you have learned that TBCI is a person-centered process that focuses on the index
person with TB disease during all activities, including:
• Interviews with the index person
• Medical records review
• Field investigation, risk assessment and prioritization
• TB screening and diagnostic evaluations
• Cases referrals and linkage to care
• Treatment and follow-up for contacts

The specific decisions you make and actions you take should be based on your country’s guidelines
and best practices.

Documenting all findings, employing good communication skills, and using standardized approved
screening, data collection, and reporting tools are vital for ensuring quality TBCI.

You are now ready to take a quiz for this module. Although passing the quiz is not required to
continue to the next module, we encourage you to review the quiz and learn from any incorrect
answers.

Slide 28 (Module quiz)

Slide 29

This is the end of Module 3. You may take a break or continue to the next module. Please click Exit
to leave the module, then exit the activity to return to the eLearning homepage.