Stacey A. Davis, MPH
Communicable Disease Section
San Bernardino Department of Public Health
Background
County
 San Bernardino County: > 2million people
 TIP indicator county (>55 cases per year)
 Largest geographic county in continental
US
TB Control Program Core Staff
 2 RN case managers,
 1 FTE communicable disease investigator,
 4 health service assistants, 0.7 FTE LVN
Public Health Clinic Services:
 TSTs, CXR, MD follow-up for uninsured
patients & contacts;
 no Quantiferon testing for contacts
Questions
1. Are we identifying contacts at highest risk for infection
and morbidity?

What proportion of contacts complete evaluation, by
contact priority level?
2. Can we identify areas for improvement in our contact
investigation process?




Identification
Evaluation
Treatment initiation
Treatment completion
Methods
 Identify Cohort:
Class III (active TB) cases with contact investigations counted in the Q1
and Q2 of 2010, Jan 3 – Jul 3, 2010
 Identify Variables

Investigation-level variables

Contact-level variables
1.
High
Risk classification (High/Med/Low) *
1)
2)
Prolonged or frequent contact with smear + or
cavitary CXR TB case or,
Exposed to any pulmonary TB case & at high risk
for morbidity & mortality (immunocompromised,
<5yo, HIV+)
Medium
1)
2)
Less intense exposure to sm+ case or,
Sm - index: Shares house or room w/case,
extended contact, aerosol-inducing medical
procedure
Low
Any contact not high or medium priority, limited
exposure to index patient
Methods
Contact-level variables cont’d.
2.
Fully evaluated?
3.
Reason for missing evaluation
4.
Follow-up by PMD or PHD
5.
Treatment initiation for LTBI
6.
Was contact identified primarily via phone interview or home visit?
 Data extraction: chart review using data collection tool
 Data entry: MS Excel
 Data summary & analysis: MS Excel
Results: Cohort description
Sputum smear +
Smear - , Cx +
Other Pulmonary
Contact
Investigations
18
6
0
# Contacts
260
34
0
HIGH priority
167
6
0
MED priority
88
25
0
LOW priority
5
3
0
0
1*
0
Average contacts per
case
14.4
5.7
0
Range contacts per
case
2-89
2-13
0
Cases w/ no
contacts
*1 Contact Investigation: conducted in State Hospital where >200 contacts tested, but
DPH had little control over contact identification & evaluation
Results: Cohort description
Contacts to Smear + Cases
(n=260)
Medium
priority
34%
Low
priority
2%
Contacts to Smear -, Cx + Cases
(n=34)
Low
priority
9%
High
priority Medium
64% priority
73%
High
priority
18%
Results: Contact Identification
 Contact Identification (D1): proportion of sputum smear
(+) cases with at least one contact identified
Smear + Cases
Smear -, Cx + Cases
18 of 18 cases=100%
5 of 6 cases=83.3% *
*Includes the contact investigation conducted in the State Hospital where 0
contacts were identified and evaluated according to DPH standards
Results: Home Visits by Case Type
 Method of Contact Identification by Case Type
Contacts to Smear + cases (n=256)
Phone
32%
Home visit
68%
Contacts to Smear -, Cx + cases
(n=34)
Home
visit
9%
Smear + cases
(n=18)
Smear -, cx +
cases (n=6)
CDI home visit
12 (66% )
3 (50%)
RN home visit
12 (66%)
4 (66%)
Phone
91%
Results: Contact Evaluation by Case
Type
 Contact Evaluation (D2): proportion of identified
contacts to sputum smear (+) cases who complete
evaluation for TB infection or disease
Total (n=294)
124 (42.2%)
Smear + cases (n=260)
114 (43.9%)
Smear – , cx + cases (n=34)
10 (29.4%)
Results: Contact Evaluation
Rate
by
Contact Evaluation: Smear + cases
(n=260)
Priority Level
100%
Smear +
cases
(n=256)
ALL
113
(43.8 %)
Smear -,
Cx + cases
(n=34)
10
(29.4%)
High
priority
84
(50.9%)
3
(50.0%)
Medium
priority
29
(33.0%)
7
(28.0%)
83
0
(0%)
0
(0%)
5
50%
84
0%
Not
Evaluated
Evaluated
29
0
High
Medium
Low
Contact Evaluation: Smear -, cx
+ cases (n=34)
100%
80%
Low
priority
59
3
60%
18
3
40%
20%
0%
3
7
0
High
Medium
Low
Not
Evaluated
Evaluated
Results: Contact Evaluation—Here
or There??
Follow-up: Contacts to Smear +
cases (n=260)
San Bernardino County Contacts to
Sm+ Cases: Contact Evaluation Rates
(n=220)
Not
evaluated
55%
Evaluated
45%
Contacts
f/u IJR
14%
IJR Contacts to Sm+ Cases: Contact
Evaluation Rates (n=36)
Contacts
f/u in SB
County
86%
Not
evaluated
64%
Evaluated
36%
Results: Contact Evaluation—Here
San Bernardino County Contacts to
or There??
Sm - Cases: Contact Evaluation Rates
(n=33)
Follow-up: Contacts to Smear -,
Cx + Cases
Contacts
f/u OOJ
3%
Contacts
f/u in SB
County
97%
Evaluated
30%
Not
evaluated
70%
IJR contacts to Sm – Cases:
0 of 1 contacts completed
evaluation
Results: Type of Medical Evaluation
Type of Medical Evaluation: Contacts to
Smear + Cases
Followed by
Both PMD &
PHD
9%
Unknown
0%
Followed by
PMD
14%
Followed by
PHD
77%
Type of Medical Evaluation: Contacts
to Smear -, Cx + Cases
Followed
by Both
PMD &
PHD
0%
Followed
by PHD
47%
Unknown
0%
Followed
by PMD
53%
Results: Evaluation Outcome by Case
Type
Smear + (n=256)
Smear -, cx + (n=34)
Evaluation Complete
113 (43.5%)
10 (29.4%)
TB Disease
1 (0.9%)
0 (0.0%)
Latent TB Infection
35 (31.0%)
2 (20.0%)
Not infected
77 (68.1%)
8 (80.0%)
Not Evaluated/Disease
Status Unknown
143 (55.9%)
24 (70.6%)
Results: Why were contacts not
completely evaluated?
Reasons Not Evaluated: Contacts to Smear +
Cases (n=146, 56.5%)
IJR
15%
Doc UTC
Refused
5%
6%
Reasons Not Evaluated: Contacts to
Smear -, Cx + Cases (n=24, 70.6%)
IJR Doc UTC
4%
4%
PMD
0%
LTFU
74%
Refused
13% PMD
0%
LTFU
79%
Results: Treatment Initiation &
Completion
 Contact Treatment Initiation (D3): proportion of infected contacts to
pulmonary cases started on treatment for LTBI
 Contact Treatment Completion (D4): proportion of contacts w/ LTBI
completed treatment
Reasons Treatment Not Completed:
Contacts to Smear + Cases (n=16, 59.3%)
Contacts to
Smear +
Cases
(n=35)
Contacts to
Smear -, cx
+ Cases
(n=2)
Treatment
Initiation
Rate (D3)
27 (77.1%)
1 (50.0%)
Treatment
Completion
Rate (D4)
Incomplete
data
0 (0.0%)
Contact
Adverse Effect
Active TB Moved (followProvider of Medicine
Developed up unknown)
Decision
0%
0%
0%
0%
Death
0%
Unknown
6%
Contact Chose
to Stop
6%
Contact is Lost
to Follow-up
19%
Still on
Treatment
69%
Conclusions
1. Contact Identification (D1)
 Identify ≥1 contact per case
 Could we increase % investigations with at least one
home visit?
Conclusions
2.
Contact Evaluation (D2)
a)
By contact priority level


b)
By case type

c)
Majority of contacts are lost to follow-up
Local vs. IJR follow-up

e)
Below CA average rate for contacts evaluated (44%, 29%, respectively)
Reasons for incomplete follow-up

d)
High priority contacts to both types of index cases: ~50% evaluated
Medium priority contacts to both types of index cases: ~30% evaluated
Only 14%, 3%, respectively, followed out of jurisdiction
Types of medical evaluation (PMD vs. PHD)

53% of contact to smear -, cx + cases were followed by PMD do we need
to establish better tracking mechanisms or relationships to follow
evaluation?
Conclusions
5. Contact Treatment Initiation (D3)

Can improve treatment initiation by complete medical
evaluation
6. Contact Treatment Completion (D4)

How can we eliminate the LTFU (19%, contacts to smear +
cases)
Next Steps
 Update action plan for contact investigation indicator
improvements
 Reconvene focus group on contact investigation protocol
 Examine complete evaluation by home visit status
 Regular cohort review
 Regularly conduct cohort reviews using established tools &
baseline
 Regularly assess contact prioritization & investigation
strategies
 Regularly track progress of our contact investigations