3/2/2012 1 Contact Investigation in Congregate Settings Principles and Policies Karen Galanowsky, RN. BSN,MPH Nurse Consultant New Jersey Department of Health & Senior Services Tuberculosis Program 1 Definition of a Congregate Setting • Congregate setting is defined as an environment where a number of people meet or gather and share the same space for a period of time • Examples - jail, prison, shelter, workplace, school, child care center, nursing home, social club, rehabilitation facility, residential living or treatment facility 2 New Jersey Department of Health and Senior Services Practice Standard for Contact and Source Case Investigations3/2/2012 2 Congregate Setting Assessment • First step in a contact investigation in a congregate setting is an assessment • The assessment can be valuable in identifying additional potential contacts who may have been exposed to the index case 3 Effect of the Assessment on the Index Case • Congregate setting assessments and investigations can be VERY difficult for the individual diagnosed with M.Tb. • These assessments commonly elicit fear of stigma is a social, school or residential setting, or loss of employment in a workplace • This fear can be real and should not be disregarded in the decision to perform congregate site assessments 43/2/2012 3 Polling Question What is the main objective of a congregate site assessment? • Identify potential contacts in the congregate setting • Get to know the worksite and provide education • Minimize anxiety • Assess risk of transmission 5 Objectives of a Congregate Site Assessment • Meet with appropriate authorities to identify potential contacts in the congregate setting • Provide education to authorities and potential contacts in the congregate setting • Minimize anxiety due to TB exposure 63/2/2012 4 Objectives of a Congregate Site Assessment - 2 • Assess the risk for TB transmission and the individual risk of contacts for progression to TB disease • Build credibility and maintain control over the evaluation process by using sound public health practice – identify those contacts at highest risk for exposure and proceed to low risk contacts ONLY if results indicate the necessity to do so 7 Required Congregate Setting Assessments • Child care or school setting – serving infants and /or children ≥5 years of age whenever the index case is infectious or potentially infectious – A congregate site assessment must occur regardless of the risk for transmission of the index case • Schools, elementary and secondary, whenever the index case is at high risk for transmission 83/2/2012 5 Required Congregate Setting Assessments- 2 • Congregate living facilities – Whenever the index case is or was an employee or volunteer during his/her infectious period AND the facility serves a vulnerable resident population, regardless of the risk of transmission • Congregate living facilities – Whenever the index case is or was a resident at any time during his/her infectious period, regardless of the risk for transmission 9 Required Congregate Setting Assessments- 3 • Local Jails – Whenever the index case is a current or former inmate or employee who was incarcerated or employed at any time during his/her infectious period and is deemed to be at high risk for transmission 103/2/2012 6 Clinical Findings That May Warrant Expanding to a Congregate Site Assessment • Persons with suspected or confirmed potentially infectious TB in a congregate setting at any time during their infectious period with one or more of the following characteristics: – Laryngeal TB – Sputum smear positive pulmonary TB – Cavities on chest x-ray or CT scan- – History of cough or hemoptysis, OR – Pulmonary or extra-pulmonary TB in children <5yrs or age for identification of the source case 11 Clinical Findings That May Warrant a Congregate Site Assessment - 2 • Congregate site assessments should not be routine • Assessments should only be performed if one or more of the conditions justifying a congregate site assessment are met • These conditions require household and social contacts be identified and evaluated before a congregate site assessment occurs 123/2/2012 7 Additional Justifications for a Congregate Site Assessment • Congregate site assessments are justified when at least one of the following criteria is met during the testing and evaluation of household and social contacts, regardless of the risk of transmission of the index case: 1. Additional suspected or confirmed TB cases are identified among household or social contacts 2. The rate of infection among household and social contacts is above 10% for U.S. born contacts or 35% for foreign-born contacts 13 Additional Justifications -2 3. LTBI is identified in any U.S. born child sharing a residence with a foreign-born index case so long as the child has no history of previous TB exposure or travel outside the U.S. 4. No contacts are identified outside the congregate setting 5. A child <5 yrs. of age with suspected or confirmed pulmonary or extra-pulmonary TB disease, with no potential source case, is identified in the household or immediate family who is cared for by a licensed or unlicensed daycare center 143/2/2012 8 Confidentiality • Disclosure of the index case is frequently necessary to assess the exposure for potential contacts – Authorities within the congregate setting often need to assist the investigator to determine individuals shared the same air space with the index case and for what period of time The disclosure of the name of the index case should be given ONLY to the person or persons assisting in the site assessment 15 Confidentiality - 2 • The index case must be told about the need or potential need to disclose his/her identify prior to any visit to the congregate site • The individual(s) to who you disclose the identity of the index case must be informed of their obligation to keep this information confidential from other persons in or outside of the congregate setting and from any inquiries by the media 163/2/2012 9 Essential Forms • Several forms have been developed to assist the health care worker determine and document the infectiousness of the TB patient, the risk of transmission in a congregate setting, and determine who should be tested for LTBI • These forms are in the New Jersey Department of Health, Practice Standards for