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## Complete Summary

#### GUIDELINE TITLE

Guidelines for the investigation of contacts of persons with infectious
tuberculosis. Recommendations from the National Tuberculosis Controllers
Association and CDC.

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention (CDC). Guidelines for the
investigation of contacts of persons with infectious tuberculosis.
Recommendations from the National Tuberculosis Controllers Association
and CDC. MMWR Recomm Rep 2005 Dec 16;54(RR-15):1-47. \[179 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16357823)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Tuberculosis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Prevention\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Infectious Diseases\
Internal Medicine\
Pediatrics\
Preventive Medicine\
Pulmonary Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments\
Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

-   To provide expanded guidelines concerning investigation of
    tuberculosis (TB) exposure and transmission and prevention of future
    cases of TB through contact investigations

-   To discuss multiple related topics (e.g., data management,
    confidentiality and consent, and human resources)

#### TARGET POPULATION

Adults and children who are contacts of persons with infectious
tuberculosis

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation and Assessment**

1.  Initiation of contact investigation

2.  Investigation of index patient and site of transmission

3.  Assigning priorities to contacts

4.  Diagnostic and public health evaluation of contacts

5.  Voluntary human immunodeficiency virus (HIV) testing, counseling,
    and referral

6.  Tuberculin skin testing

7.  Evaluation of children 5 years of age and younger

8.  Evaluation of HIV infected or other immunocompromised contacts

**Management/Prevention/Treatment**

1.  Treatment (for contacts with *Mycobacterium tuberculosis* infection)

    -   Rifampicin

    -   Isoniazid

2.  Directly observed therapy

3.  Monitoring for adherence to treatment and adverse effects

4.  Use of enablers and incentives for treatment adherence

5.  Expansion of a contact investigation

6.  Communication through the media

7.  Data management and evaluation of contact investigations

8.  Ensuring confidentiality and consent

9.  Staffing and training for contact investigation

10. Contact investigations in special circumstances

11. Source case investigations

12. Providing culturally appropriate patient care

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of tuberculosis (TB)

-   TB infection rate in contacts

-   Adherence to treatment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

A working group consisting of members from the National Tuberculosis
Controllers Association (NTCA) and Centers for Disease Control and
Prevention (CDC) reviewed relevant epidemiologic and other scientific
studies and established practices in conducting contact investigations
to develop this statement. These published studies provided a scientific
basis for the recommendations. Although a controlled trial has
demonstrated the efficacy of treating infected contacts with isoniazid,
the effectiveness of contact investigations has not been established by
a controlled trial or study. Therefore, the recommendations have not
been rated by quality or quantity of the evidence and reflect expert
opinion derived from common practices that have not been tested
critically.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Decision to Initiate a Contact Investigation]{.underline}**

-   The features of the tuberculosis (TB) case under investigation
    inform decisions about whether to perform a contact investigation
    (see Figure 1 in the original guideline document). An investigation
    (i.e., seeking and evaluating contacts) is recommended for the
    following forms of suspected or confirmed TB because they are likely
    to be infectious: pulmonary, laryngeal, or pleural TB disease
    with 1) pulmonary cavities, 2) respiratory specimens that have
    acid-fast bacilli (AFB) on microscopy, or 3) both.

-   As time and resources permit and as recommended investigations are
    completed successfully, other pulmonary TB cases may be investigated
    if they are confirmed by culture of respiratory secretions.

-   Pulmonary TB cases without positive mycobacteriology results should
    not be investigated unless circumstances indicate otherwise (e.g.,
    if mycobacteriologic results are absent because of an error or if a
    priori information raises suspicion that contacts have been
    infected).

-   The only forms of purely extrapulmonary TB (i.e., cases without
    pulmonary disease) that should be investigated are laryngeal or
    pleural disease. For other forms, source case investigations can be
    considered under special circumstances (see section below titled
    \"Source-Case Investigations\").

**[Investigating the Index Patient and Sites of
Transmission]{.underline}**

-   Written policies and procedures for these tasks improve uniformity
    and efficiency.

-   Tasks should be assigned to trained and experienced public health
    workers.

-   Interviews should be in the index patient\'s primary language and be
    conducted by persons fluent in that language or in conjunction with
    fluent interpreters.

-   The index patient should be interviewed in person (i.e., not by
    telephone) [\<]{.underline}1 business day after notification for
    cases indicating infectiousness and [\<]{.underline}3 business days
    for others. For patients who have died or who are inaccessible,
    alternative sources of information regarding contacts should be
    sought.

-   The place of residence for the index patient should be visited
    [\<]{.underline}3 business days of initiating the contact
    investigation.

-   All potential settings for transmission should be visited
    [\<]{.underline}5 working days of initiating the contact
    investigation.

-   The contact list and priority assignments (see below \"Assigning
    Priorities to Contacts\") should be written into an investigative
    plan.

-   Information regarding the index patient should be reassessed at
    least weekly until drug-susceptibility results are available for the
    *Mycobacterium tuberculosis* isolate, for 2 months after
    notification, or until infectiousness has diminished, whichever is
    longer.

-   At 1-2 weeks after the first interview, the index patient should be
    interviewed again as necessary for clarification and additional
    information.

**Assigning Priorities to Contacts**

-   Priorities for ranking contacts for investigation are set on the
    basis of the characteristics of the index patient, the duration and
    circumstances of exposure, and the vulnerability or susceptibility
    of the contact to disease progression from *M. tuberculosis*
    infection.

-   The optimal exposure cut-off durations for assigning priorities to
    contacts have not been determined because available data lack this
    level of precision. The National Tuberculosis Controllers
    Association work group did not reach consensus on cut-off durations.
    On the basis of local experience and adjusting for resource
    limitations, public health officials should set local standards for
    the durations of exposure that define high, medium, and low
    priority.

**[Diagnostic and Public Health Evaluation of Contacts]{.underline}**

**General**

-   Health departments are responsible for ensuring that TB contacts are
    medically evaluated and treated.

-   Communicable disease regulations or laws in certain jurisdictions
    apply to contacts who are not responsive to requests to be examined.
    The least restrictive means should be applied first.

-   Each high- and medium-priority contact should be assessed initially
    [\<]{.underline}3 working days after being listed.

-   Each high- and medium-priority contact should be evaluated medically
    to determine whether TB disease and latent infection with *M.
    tuberculosis* are present or absent.

-   The same diagnostic methods are recommended for all contacts except
    when they have medical or constitutional conditions making TB more
    likely or more difficult to diagnose. A contact\'s country of origin
    and Bacille Calmette-Guérin (BCG) vaccination status are not
    included in algorithms for diagnosis or treatment.

**Voluntary Human Immunodeficiency Virus (HIV) Counseling, Testing, and
Referral**

-   Inform all contacts that HIV infection is the greatest known risk
    factor for TB disease progressing from *M. tuberculosis* infection,
    and ask whether they have been tested for HIV infection.

-   Offer voluntary HIV counseling, testing, and referral to TB contacts
    who do not know their HIV infection status. Collaboration with
    HIV-acquired immune deficiency syndrome (AIDS) programs is
    recommended for establishing systems that are convenient and
    flexible for patients.

-   Voluntary HIV counseling, testing, and referral are recommended for
    contacts of HIV-infected infectious TB patients.

**Tuberculin Skin Testing**

-   A tuberculin skin test (TST) is recommended for all contacts who do
    not have a documented prior positive test result or documented prior
    TB disease. The skin test can be administered at the time of the
    initial assessment. High priority contacts should receive a test
    [\<]{.underline}7 days after they are listed, and medium-priority
    contacts [\<]{.underline}14 days.

-   A two-step TST as defined for infection control surveillance is not
    recommended for contact investigations.

**Evaluation of Children Aged \<5 Years**

-   Contacts aged \<5 years exposed to an infectious index patient are
    assigned a high priority.

-   Contacts aged \<5 years should be medically examined and have a
    chest radiograph regardless of the result of the current or prior
    skin tests or history of prior TB disease.

**Evaluation of HIV-infected or Other Immunocompromised Contacts**

-   HIV-infected or other immunocompromised contacts are high-priority
    contacts.

-   In addition to a medical history, examination, and a TST, a chest
    radiograph is recommended for all these contacts. Sputum collection
    for acid-fast bacilli (AFB) microscopy and culture is recommended if
    the contact has symptoms consistent with TB disease or if the chest
    radiograph has abnormalities that could be caused by TB.

**Any Contacts Being Evaluated**

-   Contacts who have a positive TST result ([\>]{.underline}5 mm)
    should be medically examined, including a chest radiograph, to rule
    out TB disease. Contacts who have symptoms consistent with TB also
    should be medically evaluated, including a chest radiograph, to rule
    out TB, regardless of the results of the skin test, history of a
    prior positive result, or history of prior TB disease.

-   During the infectious period, those high- and medium priority
    contacts who have a negative skin test result \<8 weeks after their
    most recent exposure should have a second skin test 8-10 weeks after
    that exposure.

-   For low-priority contacts, the initial skin test may be delayed
    until 8-10 weeks after the most recent exposure if the contact does
    not have symptoms suggestive of TB disease. If the test is
    administered \<8 weeks after the most recent exposure, the decision
    to give a second, postexposure skin test can be made on a
    case-by-case basis.

**[Treatment for Contacts with *M. Tuberculosis*
Infection]{.underline}**

-   Treating contacts who have latent *M. tuberculosis* infection
    through completion is a health department responsibility to prevent
    communicable diseases.

-   High- and medium-priority contacts with positive TSTs who come from
    countries with prevalent TB should be treated, regardless of whether
    they have had routine BCG vaccination.

-   Treatment for latent infection should be offered to all contacts who
    have a positive tuberculin skin test result, after active TB is
    excluded. The emphasis of the program should be on completing
    treatment in high- and medium priority contacts.

-   Window-period prophylaxis (see section above entitled \"Diagnostic
    and Public Health Evaluation of Contacts\") is recommended as an
    option for contacts aged \<5 years who have a negative skin test
    result \<8 weeks after the end of exposure, after TB disease has
    been excluded. If a second skin test result 8-10 weeks after the end
    of exposure is negative, treatment can be stopped.

-   A full course of treatment for presumptive *M. tuberculosis*
    infection is recommended for HIV-infected or otherwise notably
    immune-suppressed contacts, after TB disease has been excluded, even
    if skin test results are negative \>8 weeks after the end of
    exposure.

-   The decision to treat contacts who have documentation of a previous
    positive skin test result or TB disease should be made on an
    individual basis. Treatment is recommended for HIV-infected contacts
    in this category, even if infection has been treated previously.

-   Rifampin treatment is recommended for contacts who, after TB disease
    has been excluded, have infection presumed to be isoniazid
    (INH)-resistant, rifampin-susceptible *M. tuberculosis* after
    exposure to an index patient with such an isolate.

-   Expert consultation is recommended for selecting treatment for a
    latent infection with presumed INH- and rifampin-resistant *M.
    tuberculosis*. Contacts with such an infection should be monitored
    with periodic examination for at least 2 years.

-   Directly observed therapy (DOT) for latent infection is preferred
    over self supervised. DOT preference should be assigned to these
    groups, in this general order:

    -   Confirmed or suspected TB disease

    -   Latent *M. tuberculosis* infection in contacts aged \<5 years

    -   Latent *M. tuberculosis* infection in contacts who have HIV
        infection or other conditions that limit immune response to TB

    -   Latent *M. tuberculosis* infection in contacts with documented
        change in tuberculin sensitivity, from a negative to a positive
        result

    -   Latent *M. tuberculosis* infection in contacts who might not
        complete treatment because of social or behavioral impediments
        (e.g., alcohol addiction, chronic mental illness, injection-drug
        use, unstable housing, unemployment)

-   Monitoring for adherence and adverse effects by home visits, pill
    counts, or clinic appointments monthly or more often is recommended
    for contacts on self-administered treatment.

-   Use of enablers and incentives and establishment of a positive
    rapport with contacts who are taking treatment are recommended for
    enhancing adherence.

**[When to Expand a Contact Investigation]{.underline}**

-   Inclusion of lower-priority contacts generally is not recommended
    unless objectives for high- and medium-priority contacts are being
    met.

-   Consider expanding the scope (i.e., number of contacts) of an
    investigation if any one or more of the following criteria exist:

    -   Unexpectedly large rate of infection or TB disease in
        high-priority contacts

    -   Evidence of second-generation transmission

    -   TB disease in any contacts who had been assigned low priority

    -   Infection in any contacts aged \<5 years

    -   Contacts with change in skin test status from negative to
        positive

-   After reviewing the results from the investigation to date (i.e.,
    for high- and medium-priority contacts), select the additional
    contacts by extrapolating the risks for infection as shown by the
    data.

-   When results from an investigation indicate that it should be
    expanded, but resources are insufficient, seeking assistance from
    the next higher public-health administrative level is recommended.

**[Communicating Through the Media]{.underline}**

-   Anticipatory media communication (e.g., with a press release) for
    large or highly visible TB contact investigations is recommended to
    capitalize on the opportunity for constructive public
    communications.

-   Coordination of media communications, both within the health
    department and with collaborating partners outside the health
    department, improves the clarity and consistency of media messages.

-   For efficiency, use of media message templates for contact
    investigations is recommended.

**[Data Management and Evaluation of Contact
Investigations]{.underline}**

-   Collection of specific data elements on index patients and their
    contacts is recommended. The data elements should permit calculation
    of program performance indices.

-   Data should be collected on standardized (paper or electronic)
    forms.

-   Data definitions and formats for use by persons who collect, use,
    and interpret contact investigation data are recommended.

-   Whenever feasible, data definitions and formats should be standard
    among jurisdictions.

-   Electronic data storage is recommended for quick analysis of interim
    results.

-   Policies for data management and storage are recommended, with
    assignment of responsibilities.

-   Training and policies for data accuracy, completeness, and security
    are recommended. Part of a staff-person\'s time should be dedicated
    to reviewing and monitoring contact investigation data.

-   Periodic summarization and review of data are recommended during a
    particular contact investigation and overall.

-   Program evaluation for contact investigation activities, at least
    annually, is recommended. It is an integral part of TB program
    responsibility.

-   Beyond standard data elements shown in these guidelines, specific
    additional elements can contribute to local program management.

**Minimal Recommended Data Concerning the Index Patient**

+-----------------------------------------------------------------------+
| **Identifiers and demographic information**                           |
|                                                                       |
| -   Case manager                                                      |
|                                                                       |
| -   Name and aliases                                                  |
|                                                                       |
| -   For minors and dependents, guardian information                   |
|                                                                       |
| -   Date of birth\*                                                   |
|                                                                       |
| -   Social security number                                            |
|                                                                       |
| -   Current locating information and emergency contacts               |
|                                                                       |
| -   Residences during infectious period if unstably housed            |
|                                                                       |
| -   RVCT number\* and local case number                               |
|                                                                       |
| -   Sex\*                                                             |
|                                                                       |
| -   Race\*                                                            |
|                                                                       |
| -   Ethnicity\*                                                       |
|                                                                       |
| -   Country of birth\*                                                |
|                                                                       |
| -   If foreign born, length of time in United States\*                |
|                                                                       |
| -   Primary language and preferred language                           |
|                                                                       |
| -   Methods of translation or interpretation                          |
|                                                                       |
| **Settings in which index patient might have transmitted tuberculosis |
| (TB) and associated timeframes**                                      |
|                                                                       |
| -   Living situation(s)                                               |
|                                                                       |
| -   Employment or school                                              |
|                                                                       |
| -   Social and recreational activities                                |
|                                                                       |
| -   Congregate settings (e.g. jail or homeless shelter)\*             |
|                                                                       |
| -   Substance abuse with social implications (e.g., crack cocaine)\*  |
|                                                                       |
| **TB information**                                                    |
|                                                                       |
| -   Health-care provider for TB (e.g., public health, private, both,  |
|     other)\*                                                          |
|                                                                       |
| -   Anatomic site of disease\*                                        |
|                                                                       |
| -   Symptoms and their dates                                          |
|                                                                       |
| -   Chest radiograph results, including presence of cavity\*          |
|                                                                       |
| -   TB medications with start and stop dates\*                        |
|                                                                       |
| -   Bacteriologic results (sputum smear, culture, and drug            |
|     susceptibility) with dates\*                                      |
|                                                                       |
| -   Previous history of TB disease and treatment\*                    |
|                                                                       |
| -   Previous history of exposure to other persons diagnosed with TB   |
|                                                                       |
| -   Infectious period (updated as new information arrives)            |
|                                                                       |
| -   HIV infection status\*                                            |
|                                                                       |
| -   HARS\*\* number                                                   |
|                                                                       |
| **Contact investigation**                                             |
|                                                                       |
| -   Date of initial interview with index patient                      |
|                                                                       |
| -   Dates of follow-up interviews with the index patient              |
+-----------------------------------------------------------------------+

\*Data items collected on the Report of a Verified Case of Tuberculosis
(RVCT) form.\
\*\*HIV/AIDS Reporting System.

**Minimal Data Recommended Concerning Each Contact of Persons with TB**

+-----------------------------------------------------------------------+
| **Investigator and dates**                                            |
|                                                                       |
| -   Contact manager or investigator                                   |
|                                                                       |
| -   Date listed                                                       |
|                                                                       |
| -   How or why contact was listed (e.g., named by index patient)      |
|                                                                       |
| -   Dates of interviews                                               |
|                                                                       |
| -   Start and end dates for exposure (updated as new information      |
|     arrives)                                                          |
|                                                                       |
| **Identifiers**                                                       |
|                                                                       |
| -   Name and aliases                                                  |
|                                                                       |
| -   For minors and dependents, guardian information                   |
|                                                                       |
| -   Social security number                                            |
|                                                                       |
| -   Date of birth                                                     |
|                                                                       |
| -   Locating information and emergency contacts                       |
|                                                                       |
| -   Sex                                                               |
|                                                                       |
| -   Race                                                              |
|                                                                       |
| -   Ethnicity                                                         |
|                                                                       |
| -   Country of birth                                                  |
|                                                                       |
| -   If foreign born, length of time in the United States              |
|                                                                       |
| -   Primary language and preferred language                           |
|                                                                       |
| -   Methods of translation or interpretation                          |
|                                                                       |
| **Relationship or connection to index patient**\                      |
| \                                                                     |
| **Social affiliations (e.g., work, school, church, clubs, or          |
| activities)**\                                                        |
| \                                                                     |
| **Environmental information about exposure settings (e.g., size or    |
| ventilation)**\                                                       |
| \                                                                     |
| **Frequency, duration, and time frame of interactions**\              |
| \                                                                     |
| **Previous history of TB disease or latent infection, and             |
| documentation**\                                                      |
| \                                                                     |
| **Bacille Calmette-Guérin (BCG) vaccination and date**\               |
| \                                                                     |
| **Medical risk factors for progression of infection to TB             |
| disease\***\                                                          |
| \                                                                     |
| **Population risk factors for prevalent *Mycobacterium tuberculosis*  |
| infection\***\                                                        |
| \                                                                     |
| **Evaluation for TB disease and latent infection**                    |
|                                                                       |
| -   Health-care provider for TB (e.g., public health, private, both,  |
|     or other)                                                         |
|                                                                       |
| -   Symptoms suggesting TB disease                                    |
|                                                                       |
| -   Tuberculin skin tests, with dates, reagents, and lot numbers, and |
|     reaction measurement                                              |
|                                                                       |
| -   Chest radiograph results with dates                               |
|                                                                       |
| -   Bacteriologic results with dates                                  |
|                                                                       |
| -   HIV infection status                                              |
|                                                                       |
| -   Final diagnostic classifications for latent *M. tuberculosis*     |
|     infection or disease                                              |
|                                                                       |
| **Treatment information for contacts with latent *M. tuberculosis*    |
| infection**                                                           |
|                                                                       |
| -   Dates of treatment                                                |
|                                                                       |
| -   Treatment regimen (medication, dosing schedule, and any changes   |
|     to these)                                                         |
|                                                                       |
| -   Methods of supervising treatment (e.g., directly observed         |
|     treatment.)                                                       |
|                                                                       |
| -   Adverse effects (specify each)                                    |
|                                                                       |
| -   Interruptions in regimen and dates                                |
|                                                                       |
| -   Outcome of treatment (e.g., completion, consistent with ARPE\*)   |
|                                                                       |
| -   If treatment not completed, reason\*                              |
+-----------------------------------------------------------------------+

\* Aggregate report for program evaluation.

**[Confidentiality and Consent in Contact Investigations]{.underline}**

-   Specific policies for release of confidential information related to
    contact investigations are recommended. These policies should be
    consistent with the Privacy Rule of the Health Insurance Portability
    and Accountability Act of 1996 (HIPAA) and Sections 306 and 308(d)
    of the Public Health Service Act and be developed in consultation
    from health department legal counsel. These policies typically
    include instructions for obtaining consents and for breaking
    confidentiality when required for public health as authorized by
    laws.

-   Patient confidentiality is a core element integrated with all
    activities in contact investigations, and training in its laws and
    practice is recommended for all personnel who participate.

-   Discussion with the index patient and contacts regarding their
    confidentiality beliefs and concerns is recommended. TB control
    program staff should explain to the index patient the measures that
    will be taken to maintain confidentiality.

-   Preparations for protecting confidentiality are recommended for each
    site visit during an investigation. Anticipatory discussions with
    any patients who might be affected contribute to the preparations.

-   Confidentiality applies to all private information and medical
    conditions in addition to TB.

**[Staffing and Training for Contact Investigations]{.underline}**

-   Certain functions in contact investigations require state licensure.
    Delineation of these functions is recommended for preparing
    personnel position descriptions.

-   Specialized functions and related skills are needed during contact
    investigations; they might be provided by sources outside of the
    health department (see Box 3 in the original guideline document).

-   Preparatory training and detailed on-the-job supervision as each
    function is encountered by new health department personnel establish
    the basis for expertise.

-   Direct observation by experienced personnel and opportunities for
    practicing skills are essential when any personnel assume new
    functions for contact investigations.

-   Clerical personnel, receptionists, and managers who help with
    contact investigations need to understand the overall purpose and
    methods of contact investigations.

-   When sources outside the health department serve essential functions
    in a contact investigation, the health department is responsible for
    assessing whether the skills are sufficient and offering training so
    that the functions are met correctly.

**[Contact Investigations in Special Circumstances]{.underline}**

-   A cluster of TB cases (i.e., a presumed outbreak) indicates
    potential lapses in TB control which should be investigated along
    with the outbreak. Assistance should be requested if the scope of
    the investigation exceeds local capacity or disrupts key activities
    of TB control.

-   When secondary TB cases are discovered unexpectedly (e.g., outside
    of a contact investigation), this indicates a potential outbreak.
    Review of the investigative strategy is recommended.

-   When contact investigations include congregate settings, officials
    or administrators at the setting should be enlisted as
    collaborators. Access to employee and occupancy rosters should be
    sought. Sensitivities and needs of the setting and its populace
    should be accommodated to the extent permitted by good public health
    practice.

-   When few contacts are listed because information cannot be obtained
    from an index TB patient, alternative or proxy methods, such as
    interviews in the extended social network, are recommended.

-   Contact investigations for multidrug-resistant TB do not require a
    change in procedures, but the reasons for the drug resistance should
    be explored.

-   Interjurisdictional contact investigations should be planned
    collaboratively from the inception. Assistance in coordinating such
    investigation should be sought from the next higher public-health
    administrative level.

-   Unusual exposures *to M. tuberculosis*-complex, such as laboratory
    accidents or tuberculous animals, should be investigated on site,
    and contacts should be selected in accordance with the event, in
    consultation with subject matter experts.

**[Source-Case Investigations]{.underline}**

-   Source-case investigations are not recommended unless investigations
    of infectious cases have been successfully completed and program
    objectives for investigating contagious patients and treating their
    infected contacts are being met.

-   Source-case investigations, if conducted, are recommended for TB
    disease in children aged \<5 years.

-   Data on source-case investigations should be reviewed for
    determining the value of these investigations in the local context.

-   Searching for a source of unexplained latent *M. tuberculosis*
    infection is not recommended, and if conducted, should be reserved
    for infected children aged \<2 years.

**[Other Topics]{.underline}**

**Cultural Competency**

-   Systems for providing culturally and linguistically acceptable care
    during contact investigations are recommended.

-   Training in cultural and linguistic sensitivity is recommended for
    personnel who conduct contact investigations.

**Social Network Analysis**

-   The methods of social network analysis are recommended for further
    research. However, certain concepts (e.g., setting-based
    investigations) are also applicable to current efforts.

#### CLINICAL ALGORITHM(S)

Clinical algorithms are provided in the original guideline document for

-   Decision to initiate a tuberculosis (TB) contact investigation

-   Prioritization of contacts exposed to persons with acid-fast bacilli
    (AFB) sputum smear-positive or cavitary tuberculosis (TB) cases

-   Priority assignments for contacts exposed to persons with acid-fast
    bacilli (AFB) sputum smear-negative tuberculosis (TB) cases

-   \"Prioritization of contacts exposed to persons with suspected
    tuberculosis (TB) cases with abnormal chest radiographs not
    consistent with TB disease

-   Evaluation, treatment, and follow-up of tuberculosis (TB) contacts
    aged \<5 years

-   Evaluation, treatment, and follow-up of immunocompromised contacts

-   Evaluation, treatment, and follow-up of immunocompetent adults and
    children aged [\>]{.underline}5 years (high- and medium-priority
    contacts)

-   Evaluation, treatment, and follow-up of low-priority contacts

-   Evaluation, treatment, and follow-up of contacts with a documented
    previously positive tuberculin skin test

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The working group reviewed relevant epidemiologic and other scientific
studies and established practices in conducting contact investigations
to develop this statement. These published studies provided a scientific
basis for the recommendations. Although a controlled trial has
demonstrated the efficacy of treating infected contacts with isoniazid
(INH), the effectiveness of contact investigations has not been
established by a controlled trial or study. Therefore, the
recommendations have not been rated by quality or quantity of the
evidence and reflect expert opinion derived from common practices that
have not been tested critically.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

The direct benefits of contact investigations include 1) finding
additional tuberculosis disease cases (thus potentially interrupting
further transmission) and 2) finding and treating persons with latent
tuberculosis infection.

#### POTENTIAL HARMS

False negative QuantiFERON®-Gold tuberculosis test result

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines do not fit every circumstance, and additional
considerations beyond those discussed in these guidelines must be taken
into account for specific situations. For example, unusually close
exposure (e.g., prolonged exposure in a small, poorly ventilated space
or a congregate setting) or exposure among particularly vulnerable
populations at risk for tuberculosis (TB) disease (e.g., children or
immunocompromised persons) could justify starting an investigation that
would normally not be conducted. If contacts are likely to become
unavailable (e.g., because of departure), then the investigation should
receive a higher priority. Finally, affected populations might
experience exaggerated concern regarding TB in their community and
demand an investigation.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Recommendations for staffing and training for contact investigations,
for data management and evaluation, and for data collection and storage
are provided in the \"Major Recommendations\" section of this summary
and in greater detail in the original guideline document.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention (CDC). Guidelines for the
investigation of contacts of persons with infectious tuberculosis.
Recommendations from the National Tuberculosis Controllers Association
and CDC. MMWR Recomm Rep 2005 Dec 16;54(RR-15):1-47. \[179 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16357823)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Dec 16

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

National Tuberculosis Controllers Association/CDC Workgroup on Contact
Investigations

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Workgroup Members*: Jon Tilinghast, MD (*Co-Chair*) Oklahoma State
Department of Health, Oklahoma City, Oklahoma; Zachary Taylor, MD
(*Co-Chair*) Division of Tuberculosis Elimination, National Center for
HIV, STD, and TB Prevention, CDC; Suzanne Banda, MPH, Evelyn Lancaster,
Oregon Department of Human Resources, Portland, Oregon; Rajita
Bhavaraju, MPH, Mark Wolman, MPH, Global Tuberculosis Institute, New
Jersey Medical School, Newark, New Jersey; Sue Etkind, MS, Massachusetts
Department of Public Health, Boston, Massachusetts; Kimberly W. Field,
MSN, Lorena Jeske, MN, Washington State Department of Health, Olympia,
Washington; Teresa Garrett, MS, Utah Department of Health, Salt Lake
City, Utah; James M. Holcombe, MPPA, Mississippi State Department of
Health, Jackson, Mississippi; Jennifer Flood, MD, Lisa Pascopella, PhD,
Joan Sprinson, MPH, California Department of Health Services, Richmond,
California; Dennis Minnice, MA, Chicago Department of Health, Chicago,
Illinois; Jeff Taylor, MPH, Charles Wallace, PhD, Texas Department of
State Health Services, Austin, Texas; Frank Wilson, MD, Arkansas
Department of Health, Little Rock, Arkansas; John Jereb, MD, Nickolas
DeLuca, PhD, Mary Reichler, MD, Phil LoBue, MD, Suzanne Marks, MPH,
Scott McCoy, Maureen Wilce, MS, Division of Tuberculosis Elimination,
National Center for HIV, STD, and TB Prevention, CDC

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The Centers for Disease Control and Prevention (CDC), their planners,
and their content experts wish to disclose they have no financial
interests or other relationships with the manufacturers of commercial
products, suppliers of commercial services, or commercial supporters.
Presentations will not include any discussion of the unlabeled use of a
product or a product under investigational use.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML Format](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm)

-   [Portable Document Format
    (PDF)](http://www.cdc.gov/mmwr/PDF/rr/rr5415.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

A Continuing Education activity is available from the [Centers for
Disease Control and Prevention (CDC) Web
site](http://www2a.cdc.gov/ce/availableactivities.asp).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on January 25, 2006.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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Date Modified: 11/3/2008