Free 50007.pdf - Indiana

TUBERCULOSIS CONTACT INVESTIGATION SUMMARY REPORT AND WORKSHEET
State Form 50007 (R2 / 7-08)

Indiana State Department of Health
Information submitted on this form is confidential pursuant to IC 16-41-8-1 INSTRUCTIONS: Attached to the front of this form. Page ___ of ____

First Report/Date ____________

Second Report/Date ____________

Final Report/Date ___________

CONTACT INVESTIGATION SUMMARY REPORT Case Manager __________________________________ Infectious Period _________________________________________
POTENTIAL SITES/DATES OF EXPOSURE:__________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ INDEX CASE: CASE NAME: COUNT DATE: STATE CASE NUMBER: COUNTY: BIRTHDATE:

SPUTUM SMEAR POSITIVE SPUTUM SMEAR NEGATIVE BUT CULTURE POSITIVE OTHER

Are there any contacts for this investigation? If no contacts, why not?

YES

NO

High/Medium Risk Priority for Investigation 1st Number of Contacts Identified Number Evaluated TB Disease Window Treatment Previous Positive TST or IGRA (QFT-G, etc.) New Latent Infection ( 5 mm TST or IGRA positive) Candidates for Treatment of LTBI Started Treatment Completed Treatment
DO YOU NEED HELP WITH THIS CONTACT INVESTIGATION?___________ OTHER COMMENTS:

Low Risk 1st Report 2nd Final

Report 2nd Final

CONTACT INVESTIGATION WORKSHEET
Part of State Form 50007 (R2 / 7-08) Case Number/Identifier_______________________ First Report/Date ____________ KEY Priority H- High M- Med L- Low Exposure H-Household W-Workplace S-Social C-Congregate O-Other Second Report/Date ____________ Final Report/Date ___________

Page ___ of ___

Signs & Symptoms (S+S) Chest X-Ray (CXR) N-None N-Normal C-Cough ANC-Abnormal/NonCavitary NS-Night Sweats AC-Abnormal/Cavitary WL-Weight Loss F-Fatigue O-Other
Signs and Symptoms: M L N F C NS O________ WL

Treatment Regimen Outcome Codes I-INH 1-Death 7-Provider Decision R-Rifampin 2-Moved 8-Treatment Complete P-PZA 3-Lost 9-No Treatment Required E-Ethambutol 4-Stopped 10-Refused O-Other 5-Active TB developed 11-Evaluation Not Complete 6-Adverse Effect
1 IGRA (QFT-G) Pos Neg Date_____/_____/_____ 2 IGRA (QFT-G) Pos Neg Date_____/_____/_____
nd st

Name & Address:

Priority: H

1 TST______mm Date____/____/____ 2 TST______mm Yes ______mm Date____/____/____ Date_______/_______/_______
nd

st

CXR: N

Outcome: ANC AC # __________ Date__________ O_________

Date _____/_____/_____ TX: I R P E

Exposure: H W S C O DOB:_______/_______/_______ Male Female Sex:

Previous Positive TST/IGRA:

Start_____/_____/_____End_____/_____/_____

Name & Address:

Priority: H M L

Signs and Symptoms: N F C NS O________ WL

1 TST______mm Date____/____/____ 2 TST______mm Yes ______mm Date____/____/____ Date_______/_______/_______
nd

st

1 IGRA (QFT-G) Pos Neg Date_____/_____/_____ 2 IGRA (QFT-G) Pos Neg Date_____/_____/_____
nd

st

CXR: N

Outcome: ANC AC # __________ Date__________ O_________

Date _____/_____/_____ TX: I R P E

DOB:_______/_______/_______ Male Female Sex:

Exposure: H W S C O

Previous Positive TST/IGRA:

Start_____/_____/_____End_____/_____/_____

Name & Address:

Priority: H M L

Signs and Symptoms: N F C NS O________ WL

1 TST______mm Date____/____/____ 2 TST______mm Yes ______mm Date____/____/____ Date_______/_______/_______
nd

st

1 IGRA (QFT-G) Pos Neg Date_____/_____/_____ 2 IGRA (QFT-G) Pos Neg Date_____/_____/_____
nd

st

CXR: N

Outcome: ANC AC # __________ Date__________ O_________

Date _____/_____/_____ TX: I R P E

DOB:_______/_______/_______ Male Female Sex:

Exposure: H W S C O

Previous Positive TST/IGRA:

Start_____/_____/_____End_____/_____/_____

CONTACT INVESTIGATION WORKSHEET
Part of State Form 50007 (R2 / 7-08)

Page ___ of ___ Chest X-Ray (CXR) Treatment Regimen N-Normal I-INH ANC-Abnormal/NonCavitary R-Rifampin AC-Abnormal/Cavitary P-PZA E-Ethambutol O-Other
st st

KEY

Priority H- High M- Med L- Low

Exposure H-Household W-Workplace S-Social C-Congregate O-Other
Priority: H

Symptoms (S+S) N-None C-Cough NS-Night Sweats WL-Weight Loss F-Fatigue O-Other

Outcome Codes 1-Death 7-Provider Decision 2-Moved 8-Treatment Complete 3-Lost 9-No Treatment Required 4-Stopped 10-Refused 5-Active TB developed 11-Evaluation Not Complete 6-Adverse Effect
CXR: N Outcome: ANC AC # __________ Date__________ O_________

Name & Address:

Signs and Symptoms: M L N F C NS O________ WL

1 TST______mm Date____/____/____ 2 TST______mm Yes ______mm Date____/____/____ Date_______/_______/_______
nd

1 IGRA (QFT-G) Pos Neg Date_____/_____/_____ 2 IGRA (QFT-G) Pos Neg Date_____/_____/_____
st nd

Date _____/_____/_____ TX: I R P E

DOB:_______/_______/_______ Male Female Sex: Name & Address:

Exposure: H W S C O

Previous Positive TST/IGRA:

Start_____/_____/_____End_____/_____/_____

Priority: H M L

Signs and Symptoms: N F C NS O________ WL

1 TST______mm Date____/____/____ 2 TST______mm Yes ______mm Date____/____/____ Date_______/_______/_______
nd

st

1 IGRA (QFT-G) Pos Neg Date_____/_____/_____ 2 IGRA (QFT-G) Pos Neg Date_____/_____/_____
st nd

CXR: N

Outcome: ANC AC # __________ Date__________ O_________

Date _____/_____/_____ TX: I R P E

DOB:_______/_______/_______ Male Female Sex: Name & Address:

Exposure: H W S C O

Previous Positive TST/IGRA:

Start_____/_____/_____End_____/_____/_____

Priority: H M L

Signs and Symptoms: N F C NS O________ WL

1 TST______mm Date____/____/____ 2 TST______mm Yes ______mm Date____/____/____ Date_______/_______/_______
nd

st

1 IGRA (QFT-G) Pos Neg Date_____/_____/_____ 2 IGRA (QFT-G) Pos Neg Date_____/_____/_____
st nd

CXR: N

Outcome: ANC AC # __________ Date__________ O_________

Date _____/_____/_____ TX: I R P E

DOB:_______/_______/_______ Male Female Sex: Name & Address:

Exposure: H W S C O

Previous Positive TST/IGRA:

Start_____/_____/_____End_____/_____/_____

Priority: H M L

Signs and Symptoms: N F C NS O________ WL

1 TST______mm Date____/____/____ 2 TST______mm Yes ______mm Date____/____/____ Date_______/_______/_______
nd

st

1 IGRA (QFT-G) Pos Neg Date_____/_____/_____ 2 IGRA (QFT-G) Pos Neg Date_____/_____/_____
nd

CXR: N

Outcome: ANC AC # __________ Date__________ O_________

Date _____/_____/_____ TX: I R P E

DOB:_______/_______/_______ Male Female Sex:

Exposure: H W S C O

Previous Positive TST/IGRA:

Start_____/_____/_____End_____/_____/_____

Indiana State Department of Health
Instructions for State Form 50007 Tuberculosis Contact Investigation Summary Report and Contact Investigation Worksheet
The Summary of Tuberculosis Contact Investigation Report is due to the Indiana State Department of Health (ISDH) TB Program in three stages. Please fax to (317-233-7747): o 3 weeks after the index case has been reported to the ISDH, (after the first round of tuberculin skin test (TST) or Interferon-gamma release assay (IGRA), o 12 weeks after the index case has been reported (after the second round of TST or IGRA) o 12 months after the index case has been reported (include the ISDH Contact Investigation Report with The Summary of Tuberculosis Contact Investigation Report when faxing to the ISDH). o List all contacts on worksheet. The local health department is responsible for completing the following sections of the contact investigation report. CONTACT INVESTIGATION SUMMARY: Infectious Period: Three months before symptom onset or first positive finding (e.g., abnormal chest radiograph, cough) consistent with TB disease, whichever is longer. The infectious period is closed when: 1) effective treatment for 2 weeks, 2) diminished symptoms, and 3) mycobacterial response (3 smear negatives.) Potential Sites/Dates of Exposure: List sites, other than household, that were a potential for TB transmission. Example: If person was homeless, in jail, or was involved in a frequent social setting: what is the name of the facility, address, and timeframe? If more space is needed, use a separate sheet of paper. Are there any contacts for this investigation? Answer Yes or No. If No, indicate why not. Number of Contacts Identified: Indicate the total number of high, medium and low priority contacts identified. High and medium risk priority contacts should include the following: · Household type such as live-in family members · Those with medical risk factors (such as HIV infection or other immune-compromising condition) · · Social such as close co-workers and friends · Exposure during medical procedures (such as bronchoscopy, sputum induction or autopsy) · Contacts with exposure in congregate settings as determined by patient interview and the concentric circle approach

Contacts <5 years old

Low risk priority contacts should only be counted for testing that has been done for good will or administrative purposes and should be minimal (example, worksite contacts that have no direct contact with the index case). A complete CDC overview of the diagnostic and public health evaluation of contacts can be found at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm

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Number Evaluated: Count the contacts as evaluated under the following conditions only: 1. Documented previous positive TST or IGRA currently screened for TB symptoms. If symptomatic, follow up testing must have been performed to rule out active TB (e.g., chest x-ray and/or sputum examination for acid-fast bacilli). 2. Newly positive TST or IGRA who have been screened for TB symptoms and had follow-up testing to rule out active TB (e.g., chest x-ray). 3. 1st TST or IGRA that is negative at least 8 weeks after last exposure to the index case. For contacts that are TST or IGRA negative on initial test and require a second test, do not count as evaluated until the second round test is completed. Do not count TST's that have not been read or verified and recorded by a trained health care professional. TB Disease: Record the number of contacts who have been evaluated and found to have active TB as a result of the current exposure. Example, if there are multiple members with TB in a family, it is important to determine who is the index case (source of infection) and only count other TB disease cases on the index case summary. Newly identified cases should be counted only once. Window Treatment: Record the number of contacts who are placed on prophylaxis prior to completing second round testing. After the second TST or IGRA, the contact should not remain in this category. If the second round TST or IGRA is negative and treatment is stopped, count as Evaluated. If the second round TST or IGRA is negative but treatment continues for the complete course, count as Latent Infection. If the second round TST or IGRA is positive, count as Latent Infection after active disease is ruled out. Previous Positive TST or IGRA: Record the number of contacts with documented previous positive TST or IGRA. Healthy contacts that have a previous positive test and were not previously treated for LTBI can be considered for treatment as part of this contact investigation. Any contact who is to be treated for LTBI should have a chest radiograph to exclude TB disease before starting treatment. New Latent Infection: Count newly positive TST (5 mm) or IGRA that are a result of contact with the current index case. Do not count previous positives in this category unless the treating physician determines that there is likely an exogenous re-infection, for which treatment for latent infection must be started. Candidates for Treatment of Latent TB Infection (LTBI): Count the number of contacts in the LTBI category that the treating physician determines to be candidates for treatment. This number should not exceed the New Latent Infection number. Started Treatment: Count the number of Candidates who have begun treatment with a recommended treatment regimen. The ATS/CDC treatment guidelines should be followed. Consider treatment started when the contact picks up the medication/ prescription. For the contacts that Started Treatment, it is very important to indicate the Actual date treatment began and ended on the Contact Investigation Worksheet. Note: the sum of all the dispositions should equal the number of contacts in the Started Treatment category for the combined columns High/Medium or Low Priority Contacts. Completed Treatment: Consider treatment completed if appropriate treatment is administered (Example, 9 months of Isoniazid treatment completed in 12 months.) Contacts who move out of jurisdiction can still be counted as Completed Treatment if follow up information is sought and verified with the treating jurisdiction. Interjurisdictional Forms should be on file to support the documentation. Only count completion for contacts that started treatment as a result of exposure to the index case. The number should be equal to or less that the Started Treatment number.

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CONTACT INVESTIGATION WORKSHEET: Priority: See definition on first page of instructions for information. Exposure: Pick the best answer that applies. A person can be a family member and not be a household member which would then be a social exposure. Signs and Symptoms: Choose all that apply. Previous Positives TST/IGRA: Document previous results if available. TST and IGRA: Document results. CXR: Choose one. TX: Indicate the medications prescribed along with start date of treatment and date of last known medication taken. OUTCOME: Death: Contacts on treatment for LTBI that expire while on therapy. Moved: Contacts on treatment for LTBI that move out of jurisdiction with a forwarding address, but follow up information is unknown. For contacts with a forwarding address, complete an Interjurisdictional Form and do not list as Moved if the disposition is pending and can be verified from the receiving jurisdiction. Lost to Follow-Up: Contacts on treatment for LTBI who cannot be located and do not contact the health department. (This would include contacts that moved but left no forwarding address.) Contact Chose to Stop: Contacts on treatment for LTBI who stopped taking medicine on their own. These patients fail to return for follow up visits and refuse to take any more medicine. Active TB Developed: Contacts that develop active TB while on treatment for LTBI. Adverse Effects of Medicine: Contacts who stop treatment for LTBI because of adverse effects of the medicine, as determined by the treating physician. Provider Decision: Contacts on treatment for LTBI who are ordered to stop therapy by the treating physician for social or medical reasons (other than adverse reactions to treatment). Example, a patient becomes pregnant while on therapy or the physician feels that the patient will not comply with a full course of treatment because of homelessness. Completed Treatment: See definition in previous section. No Treatment Required: Evaluation complete, contact does not require LTBI treatment. Refused: Contact declined evaluation or to take LTBI medication. Evaluation Not Complete: Contact did not return for follow-up evaluation.

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