 Hello and welcome. In this video, we're going to cover the essentials of conducting a TB interview for contact investigation. The TB interview is an essential component of a TB control program. As a result of this interview, we can identify and medically evaluate individuals with latent TB infection and active in future TB cases. The goal of the TB interview is to identify close contacts. Although it sounds easy enough, the TB interview requires several skills. The interviewer must respect a patient's need for confidentiality, show great patience, and at times act as a sort of medical detective. These skills, and many others, are honed with practice. This video is designed to help you enhance your TB interviewing skills and techniques. We've selected three scenarios that are representative of key patient populations and situations you're likely to encounter. We're going to present a bridged version of each interview to focus on the areas unique to each situation. Key teaching points will be discussed by a series of experts who will provide commentary throughout the video. The interviewers and patients themselves will also react to the scenarios. We want you to be aware that the interviewers are health department employees who for learning purposes are demonstrating both appropriate and inappropriate interviewing techniques. The patients are being played by actors. As you watch their interactions, note both the verbal and non-verbal behaviors that hinder or enhance communication. Our first patient lives in a shelter and has HIV infection. This scenario illustrates some of the issues involved with patients who have competing concerns such as homelessness or a coexisting medical condition like HIV. Some of the things to watch for here are how the interviewer deals with the patient's special circumstances, the patient's distrust of authority, and his initial reluctance to cooperate. Jerry! Jerry! Jerry was a contact to a case we were investigating and I went out into the field and got him to come into the clinic for an evaluation. We tested him. He showed a positive cavity on X-ray and he's also HIV positive. The doctor evaluated him and felt that he should be hospitalized. While we were waiting to get him a room, he jumped ship on us so he's probably down at the soup kitchen because I know he was waiting for food and he knows that's where they serve it so I'm trying to track him down through them now. They told me they wanted to put me in the hospital. I don't like hospitals. My mother died in a hospital overnight. I don't want no problems with the hospital and they were going to give me some food and give me nothing. No food. Not even a coffee. Well right now I have to try to do a little bit of damage control. I guess I wouldn't really tell Jerry that he might be admitted to the hospital so he's probably a little upset at this point. So I have to try and convince him that it would be better off for him to go into the hospital. I'm sure he's not going to be too happy about that. They wanted to find out what the hell's going on but nothing going on. Yeah but you should go to the hospital man. I'm not cool. They could be in the hospital. You go and they're feeling pretty good and the next thing you know you're dead. They happened to my mother. She was in good shape and I took her to the hospital because she was- Jerry. Where you been? Oh him. I was looking for you at the clinic. He's gone. What happened? I don't want to go back to that place so don't start with me. Jerry you know those tests we did at the clinic there? We need to talk about those. You're not taking me back. I'm not going back. That's all. Can we talk away from your friend here? I don't want to disturb him while he's having his lunch. He's my buddy. We're in the same place. We can talk. Well I think some of the things we want to discuss we might want to discuss in private. Can we just go over to the side a little bit? Okay. We'll talk. Okay. I'll be here Jerry. I'll watch you. Don't take that. No I'll watch you. You never know when the conversation is going to switch to more sensitive subjects and it's always good to have a little bit of confidentiality. It gives the patient more leeway to say things to you that he otherwise might not. Remember that x-ray we did? Yeah. The picture. Yeah well guess what? You showed an actual hole in your lung. Okay. A what? A hole. They call it a cavity. I mean that means that you probably have TB okay and the doctor the reason that we left you there so long and I'm real sorry about that because the doctor was trying to get you a room at the hospital. No I don't. No I don't. I know you don't want to go. No. Give me some medicine. I'll take it. I'll take it. I promise you. Because those hospital comes out. Oh I don't. They come out you know they come out on the back. Don't worry Jerry we're going to take good care of you. One of the good news I have for you is that TB is curable. We can take care of it and you'll be fine. You'll be good as new. Okay. Pete may very good eye contact. We don't want interviewers having their eyes wondering, well because patients usually do that. So we want the interviewer to focus on the patient and make the patient feel important. He also did a great job in educating Jerry. He educated Jerry at the appropriate level, I think. He didn't talk over Jerry's head, nor was he condescending. He gave enough information so that Jerry could really understand what's going on in his body. He was graphic when he needed to be. Are you going to watch it? Are you sure everything's all right? Yeah. I'll be there with you every step of the way. Do you make more mistakes that they got right? The doctor has to just do a few more tests and we're going to start you on meds probably right away and within a couple of weeks you'll be getting better. When do we go? Okay. I'm going to get the car, I'll bring it around and I'll take you right over to the clinic. Okay? Great. Okay. I know he had been mishandled so I was trying to reestablish rapport with him by being personable and trying to make him feel comfortable. I thought I just had a cold and I thought this would make you a big stink over nothing. But he scared me. He scared me. And he's nice. And I thought, well, I'll go along with him and see if we can find out what's going on. I got to see firsthand exactly where he spends a good deal of his time, which gave me a better idea of how the air is handled in that particular facility and I was able to see that one of his friends there is probably already going to be high on my contact list. What I want to do now is answer any questions that you might have, especially about where this comes from and how you get it. I'm sure you're curious. TB is an airborne disease. Usually you get it from somebody else who's coughing and just like you are now because your body's trying to get rid of the germ and when you cough, that germ gets released into the air. I mean, you know, that's why, you know, we have... I'm in that shelter. There's 50 guys sleeping in the same room and they're all coughing. I could have gone from any one of them. They probably don't all have TB. I mean, can you see the difference between this cough and other coughs you've had in your life? Usually when you have TB, the cough is much more severe and it just doesn't go away. No, it doesn't go away. And that's the difference. The TB germ reproduces in the lungs. Now it is hot in here. As I was saying, eventually the bacteria get a foothold in the lungs and that's really caused the damage. Okay? TB can affect any part of the body. Once it's in you, it can get into the blood and it can cause other problems. So that's why we need to get you fully evaluated in the hospital. Checked out top to bottom. Now we're going to make sure you're A- okay. You okay? Can I get you a drink of water or anything? No, I'm okay. I had water available. As I said, the TB is airborne. That means when you cough, laugh, or speak to someone, the germ can be breathed into the air, okay? Somebody who's around you for a lot of time can breathe in enough of the germs so that they can get TB, all right? That's how it spreads. Now how long have you had the cough? Cough in for about three months. Three months? What? How long have you had these night sweats and everything? Last month or so. Last month? Month maybe or more. I wake up soap and wet. And you also lost some weight? Yeah. And uh... You want to see something? Sure. What's that? Look at this. Yeah. Wow, you did lose some weight. And when did you first notice that? I don't know exactly, but I think it's before I knew it because everything is just loose. Really? A couple of months I guess. Okay. So about two months. Really it was about three months ago though when you first noticed these symptoms beginning, is that right? Yeah. Jerry was a tough customer. He had a lot of other problems that were complicating his TB. And it was hard for me to address those other problems and get to the information which I needed to perform a good contact investigation. The fact that you were in contact with somebody else who had TB... He's a lousy of these things you gotta wear. I know. To go with my eye. Jerry was in an airborne infection isolation room. So in that situation I think it would be most appropriate for the patient, for Jerry, not to have to wear a surgical mask. However, since he's still potentially infectious it would be more appropriate for the interviewer to be wearing a personal respirator such as an N95 respirator. In the situation where he may not be in an airborne infection isolation room it would really be appropriate for Jerry to keep the surgical mask on to prevent dispersion of the aerosol as much as possible. As you can see the type of mask that he had on had very wide gaps. And so if somebody coughs you can imagine that small particles would escape out those areas. The recommendation suggests that that healthcare worker while interviewing the patient should be wearing an N95 respirator or a similar personal respirator to protect them from a potentially infectious patient. In a few weeks you won't need your mask anymore. Once you start taking the TB drugs you won't be contagious anymore. It takes a couple of weeks though on the meds, okay? How many medicines are there or do I have to take for this? You know we usually start you off on about four drugs, okay? Yeah, I have something to tell you. What's that? You know what my HIV? Yeah, I did see it. Yeah, three years ago they found out I got HIV. Uh huh. And you wanted to give me four things. I don't even take the other four because they're horrible. They give me headache. They give me upset stomach. They give me diarrhea. Sorry to tell you that. I mean they give you a lot of problems. And now you want to give me more stuff. Well, we give four different drugs to start out usually. This is because sometimes people are resistant to one or the other of the meds. And then if the tests come back okay then we drop you down to just two drugs. If you stay on the meds and you take them the way we tell you to, you should be totally cured, all right? Jury has the two competing things, HIV and TB. Sometimes it's easier to start focusing on the TB because you can present this as this is curable where the HIV is not and you, it's kind of like you focus on the TB and you said and we'll work on that on the HIV. Lots of times it's easier for the patient to handle one thing at a time because it just becomes too overwhelming when they're giving everything at one time. I think the interviewer should have been very concerned when Jerry said that he was not taking his HIV meds because that could be an indication that Jerry will not also take his tuberculosis medication which could cause a huge problem for Jerry and those around Jerry. So I think this would have been a perfect time to really talk to Jerry about being compliant and the need for compliance with the medication and maybe just introduce just very gently that Jerry could actually do himself a great deal of harm by not taking the medication or taking the medication when he felt like it or not as prescribed. The fact that you were in contact with somebody else who had TB means that you could have also by the same way given it to someone, okay? I don't know what you mean by contact. You mean that I went to bed with them or what? Well, I want really anybody that you feel you spent a lot of time with who could have... I went to New Year's party last year. There were a lot of people there who named all those names. I got invited, you know. And my friend A-Ann came to visit me and then we went out and she... We had pancakes at that... You hop? I hop. I hop. Okay, you know what Jerry, women? Actually, based on your symptom history, I really only need to know about the people that you had contact with from October 1st up to now. When you ask a TB patient a vague question, you're going to get a vague response. So Jerry was saying, well, New Year's Eve, and he started to ramble off some names, but Jerry needed direction. So Pete caught that and Pete backtracked a little bit and said, hold on a second, let me just tell you what I really need from you is between this time and that time tell me about the people that you were hanging out with. And that gives the interviewer and the interviewer direction. You wanted to find close contact for the patient so that they understand who's high priority for testing. We often look at the close contacts first, such as folks in a household work site and test them. And if we see that transmission actually occur, we will move on to those who are not considered close contacts, casual contacts. And I want you to think about the last three months up to today and the people that you spent a lot of time with as far as talking to them, hanging out, people who you might think have given this stuff. You go there and you tell them I'm sick. They're not going to let me back in there anymore, either shelter. One of the things that we do is we make sure everything is kept totally confidential. No one's going to know that you gave their name, okay? But it's very important that we get to these people and make sure they're okay. I mean, you're okay now. We're going to give you meds and you're going to be well. The guy named Tyrone was sleeping right next to me. When was the last time you were with Tyrone? Before I came down here. The meds are only this far apart. They're going caught, so they're only this far apart. How long have you known him? A year. A year? Yeah. How often do you see him usually? Every night. Every night? What does he look like? He's tall and he's skinny and he's black. Okay. Any place that you can think of where he frequents or, you know, goes to a lock? I don't know. I saw him on West Market Street a couple of times. Whereabouts on West Market Street? I don't know. I don't know the name of that cross street that goes across there. Somewhere on West Market Street. What is this? I feel like you're a cop. Well, I got to try to make sure I'm able to take care of Tyrone. Like I said, the same way I took care of you, I'm going to try to do the same thing for him. Getting contacts from homeless people is always hard because even with the names it's hard to track them down. Many times they are migratory. They go from city to city, or they don't like to stay in shelters. Who do you spend the most time with when you're there? Who's your buddy? I don't like too many people, but I really like one guy. He's really nice to them. I don't want to tell you. Was that the guy that was with you when I was over at the shelter? Yeah. Was that Phil? Yeah, Phil. How old is he? I think Phil must be about 50. Yeah. He's a nice guy. Yeah, he seemed really nice. And he doesn't sleep near me, so he didn't give me this TV. He sleeps at the other end of the room. Well, he met a quarter from me, though, see? That's why we got to make sure. We got to test them. We got to make sure he's okay. That's all. I don't want any of the guys. But he ain't going to talk to me any more. I can tell you that one. Oh, I'm sure he will. The thing about it is that he wants to be well, too. He was very persuasive without being assertive or very aggressive. He didn't turn Jerry off. In fact, Jerry just kept giving information, I think, in part because he wasn't threatened by the interviewer. The interviewer came off as a very nice guy, compassionate and understanding. As long as these other guys are out there who might have TV, we're not going to be able to get rid of it. You might just get it back when you go back to that shelter. I mean, one of the other things I want to do is try to get you out of that shelter. We're going to hook you up with some social services here. Now you're talking. Yeah. When he talked about getting me a place to live, that was the best thing he said. If you could find me a place to live, that's halfway okay. That's what I would like. Just by the fact that he's homeless, he's got other problems. And these other problems very often interfere with the treatment. And if you can't deal with these other problems, you're never going to be able to deal with this TV. You just want the names of the guys that are at the shelter? Well, I want really anybody that you feel you spent a lot of time with. Who could have? I saw my son. Thanksgiving. Your son? What's his name? Paul. What's his last name? Oh, God. Same as me. Netter. And, uh, how old is he? Oh, he's, uh, I don't see him that much, you know? He's, uh, about 39. 39? Yeah. You know where he works? What do you care? Well, it's like I said, I want to take care of him, too. I want to make sure he's okay. He's a dentist. He's a dentist? He's how he works for himself. That stuff out. How much longer are we going to go on? You're talking and talking, and I'm barking and barking. Jerry wanted to end the interview, but he was still giving me names of contacts. And as long as I'm continuing to get the information I need, I like to continue the interview, because when the person leaves, there's always a possibility you'll never see that person again. They walk out that door and they're gone. So whatever I have at the end of the interview, maybe all I'm ever going to get. When was the last time you did see him? Uh, Thanksgiving. We went to it. Thanksgiving? Yeah. He came up here, and his wife and his kid. How often do you see him? My name's Olivia. Nice kid. How old is she? My grandchild. The only one. How old is she? Olivia? Yeah. Maybe nine. Nine. Yeah, cute kid. I'm not going to answer many more. You better wind it down. Well, what's Paul's wife's name? She's English. What's her name? Where did they get you from? You go on and on. I told you I'm tired. You know what it is to be tired? I'm sweaty. I'm tired. I didn't sleep. I'm COVID. One more question. Well, I just wanted to know what... Francis. Francis. That's it. You got me all tired out. All right. Let me see if your room's ready. Okay, I'll see what I can find out. You can only push so far when the patient's beginning to get agitated. You really need to cut it off because then what turns out to be a good relationship can really turn bad really quickly by pressing and pressing. I think it took too long. Questions and so many questions and questions. And I'm very hot and very tired. You hear that. He was angry. He was impatient. He was sick. He was a little moody. He did show a little bit of humor also. But most of his reaction was being angry that he had to be involved in this entire process. And it took a little bit longer period of time to get information from him. And I think many of our patients, homeless or otherwise, present those types of emotions during an interview. I think it's going to require a re-interview on my part or perhaps on another interviewer's part. Sometimes it's more beneficial to have another person redo the interview so that they can approach it from a different angle. If his son is still out of state, which I think he indicated, we'll have to send that through the proper channels to the other state so that they know that he's a contact to a case of TB. And we'll have to get further locating information on the son, the wife. And I'm particularly concerned with the child. There'll probably be a group investigation involving the people at the soup kitchen, the supervisors there. And we're probably going to also have to go to that shelter and set up some type of group style contact investigation there as well. The interviewer in this scenario did a very good job of handling a less than cooperative patient. Patients who are homeless can present with special needs and issues that pose a real challenge to an interviewer. As you saw with Jerry, these might include unmet personal needs for food and shelter, a distrust of authority, the very real likelihood that he cannot be found for follow-up interviews, problems with adherence, and the inability to provide identifying or locating information. Jerry's reluctance to reveal names demonstrated why it's so important to explain the reason for and the importance of the contact investigation as early as possible in the interview. This requires patient education both about TB transmission and close versus casual contacts and defining a specific infectious period. Jerry's case also illustrated why it's important to be sensitive to patients' issues and to recognize that TB may not be their most pressing concern. Following the communication techniques demonstrated and attempting to meet the patient's basic needs can help build rapport and increase the likelihood of obtaining the information you need. This next scenario illustrates some of the issues you may encounter when interviewing a foreign-born patient. It's important not to generalize and think of the foreign born as a stereotypical group. Instead, we need to demonstrate cultural competency and treat each patient as an individual. Javier is a 37-year-old Mexican-born gentleman who came to this country three years ago. He works as the night shift supervisor at a shoe factory. He was diagnosed with suspected pulmonary TB, and so Khalil, a public health worker, was assigned to conduct an investigation. While reviewing the hospital file, Khalil noticed that although Javier speaks English, the staff expressed some concerns about his fluency, so Khalil brought along a co-worker to act as an interpreter. The two conducted the initial interview while Javier was still in the hospital. The scene you're about to see is a re-interview. Our re-interview is conducted 7 to 14 days after the initial interview to determine additional information the patient might not have shared for one reason or another and to confirm previously obtained information. When possible, the re-interview should be conducted in the patient's home. This is so that the interviewer can observe evidence of other contacts and see firsthand the patient's lifestyle. Watch how the interviewer deals with cultural perceptions of illness, the language barrier and his use of an interpreter, home remedies, the distrust of authority arising from immigration issues, and the clues he finds in the home. It's been a little over two weeks since I last interviewed Javier. He's clinically improved. He's been adherent on the appropriate therapy, and he has three negative smears. So he's no longer considered infectious. We're back. I told you that we'd be back to finish up our interview to find out if there are any other people who you didn't mention when you went to hospital. You know, back in your own environment, you might have a clearer thinking mind now. It's a nice place. Whose house is this? My uncle. Your uncle's? My uncle. Really? Okay. They live here? Yes. When the interviewer asked Javier whose house is this, I think it was in an appropriate statement given that it has certain implications such as you're not a homeowner, you live here with someone else, and all those other things. I think I had them down the first door, man. I had your wife and your children. Okay. What is your aunt's name? Tell her that I don't want my aunt to know, that I can't get her out of my house. I want her to know that I'm a woman. I understand how you feel. He's concerned that his aunt will throw him out of the house because of the fact that he has TV. So that's one of his main concerns. And I told him that I couldn't say how he feels. Well, we are going to make sure that your aunt is tested, make sure that your uncle's tested. But by law, we can't reveal to them that you have TV. Only thing we can say is that you've been exposed to someone with TV and that you need to be tested. We can't tell your aunt. Javier has TV, you need to be tested. Okay? Okay. The interviewer probably could help the family if he was there to explain with Javier's permission because the family is bound to know that it's Javier and if he could relieve tension just by simply educating. People from all races, from all walks of life, from all backgrounds, all occupations can get it. Okay. So it's nothing to really feel ashamed about. Remember, TV is airborne. Anybody can get it. So it might be in your best interest to just be honest to your aunt. Just let her know that you are being treated and that you're not infectious because you're not. I checked the record before I came here. I see that you've been taking your TV meds like you're supposed to on a daily basis, which is why you're getting better. You're not infectious. You're not coughing anymore. We are available to be here when you talk with your aunt. So we can just try to, like I said, answer any questions and dissuade her from putting you out of the house. Okay. Just level with your aunt and use this as a support system. Okay. So just think about that. Okay. You don't have to make a decision right now. Okay. Okay. I think one of the main things that I see repeatedly with airborne patients is the stigma attached. Often they come from areas where TV is endemic and people with TV are treated very badly, basically. Unfortunately, a lot of the countries they're coming from, a lot of people die from TV. And about how old is your uncle? 65, 50 seat. Okay. Any other people that live here besides you, your wife, your children, your aunt and uncle? No. No? No small kids? No. In this situation you look and see evidence or clues of exactly what people are living in that home and sometimes because the patient is reluctant and a bit suspicious, initially they don't tell you all the household members or they don't consider some people being household members who are actually living there. So a face-to-face, one-on-one interview gives you all the opportunity to actually get a very complete list of who's residing in that home. Who do you also belong to? Who plays with these? My kids. Your kids? Yeah. Really? Okay. Let's go over the kids again, the names and ages, okay? You say you live here with Betty, your wife, okay? And what are children's names again, the ages? Francis, Julissa. How old is Francis? Fourteen. Fourteen. How old is Julissa? Yeah. How old is she? Ten. Who else? Julio. Julio. How old is he? Five. So Francis, Julissa, Julio. Yeah. No other children here? No. Okay, because children, small children are very, very susceptible to TB, meaning that they can get it easily because their immune system isn't strong so they can't fight it off, they can't fight off the germs. So it's very important if you've been around any family who might have small babies that we find out who they are and get them tested as soon as possible. No babies, no babies at all. All right. Sometimes when patients flat out refuse to answer personal questions, you may have to re-approach it in a different way and you may have to engage in some social conversation and kind of slide it in there later on or just kind of wait for the timing. Sometimes you'll have to press and say, I know you really don't want to answer this, but I really do need this information. Outside of your family, any other people live here? No. Okay, because like I said, TB is airborne. All you have to do is be around somebody for a certain amount of time and they can come down with the TB infection and we're also trying to find out who might have given it to you. So just think real hard. Anybody else that you haven't mentioned? No. Now, your family's already been tested, so we need to get your aunt and uncle tested to make sure they're okay. And then we're going to also go to the work site. What's wrong? Some nasty stuff? Yeah. What is that? It's a thing that makes me mad. Mm-hmm. Yes. You know, the chameleon, the red onions. Oh. He says that what he's drinking, it's like a homemade remedy. And what consists of is either this onion, he mentioned red onions on honey and also aloe. Would you happen to know what else is in it besides the aloe and the honey? No. The reference made by the interviewer, that's nasty stuff. And if you looked at the interviewer's face, he also had a look of disapproval, which might send the wrong message to the patient. In some countries, home remedies are a way of treating certain diseases. And I think we have to acknowledge that and be sensitive to it. And when it does come up during an interview or during any patient-health-care-work interaction, we need to accept the fact that this is important to the patient, and we need to, however, check with the medical staff to make sure it's okay that the remedy continues or perhaps it may discontinue. How long have you been drinking this? Two, three weeks. Okay. Well, we definitely want to find out what else is in that because we want to make sure that that's not interacting with the TB medicine. So let's kind of hold off on that. De veras? He said that since he's been drinking it, he's been feeling a lot better. This might make you feel better, but we definitely want to make sure that you take the medication. Okay. That's what's going to help cure you. Now, Julio was five, right? Yeah. I don't know, five years old. You know, I have a two-year-old myself, and this is some of the stuff that she likes to play with. You know, a son who's five, he still plays with this and a walker. He said that his wife, she's a babysitter. Oh, okay. Yeah, and then she gets money. Okay. Okay. All right. There's no problem with that. We just need to know who the children are. Okay. How many kids does she babysit? Three or four. Three or four kids? Okay. She babysits them every day? Some of the immigrants have a tendency not to want to discuss any jobs that are carried out from their home. They may not have social security numbers, so some of the ways to earn money is through babysitting or taking in laundry or sewing and doing those types of activities. And if we immediately discussed all these other people who are involved in work that's taking place in the home, that may jeopardize a very much needed income. Well, thank you for telling me that, because like I said, that's very important that we know that. Because children, again, they can't fight off the disease. Okay, so we really have to make sure that the kids are okay. All right. Do you know the names by any chance? No. Okay. All right. I'll have to come back and get that information. Okay. Because we want to get the children tested as soon as possible. What else? Any other concerns? My work. Do you tell everybody in my work? No. No one. No. We will speak to higher management, because they'll identify any people who you might have been around that you might forget. But by law, they can't reveal it either. You know, and we let them know that. Tell them why we have to go into the work site. I don't know why. Okay. All we want to do is make sure that they get tested and treated if necessary. Okay. Like I said, also we want to find out if possibly the person who infected you was there. I have a friend who works for me. I'm not legal. I don't have a certificate or anything. How many? Four. He's concerned. He said he has about two or three friends at work if they are illegal aliens, which they don't have any green card, nothing, no papers. So he's concerned about that. Okay. Well, we're not going to call immigration or INS on them. That's not what we go there for. We just want to find out if they've been infected or if there's anybody there who has TB who's not on treatment. That's the only reason why we go in. Okay. You understand that? Yeah. Okay. It's interesting that the only time the interpreter spoke was when Javier was saying something in Spanish because he didn't trust the interviewer. The appropriate use of an interpreter is that he or she interprets everything. The interviewer should have had a pre-session and should have instructed the interpreter, please repeat everything Javier is saying in the first person. Do not add or omit substitute or give any advice. Also, the interviewer at that point could have said, are you interpreting exactly what Javier is saying? Do you have any questions? No. Okay. All right. Well, Javier, thank you for your time. Cuide se. Cuide se. What's that? I told him to take care of himself. Thank you. Muchas gracias, señor. Espero que se acuide. Okay. You're welcome. I think we connected a bit more. And we did it in the hospital. Well, it was easier to talk to him also because I didn't have him to mask. He was more friendly. And he was telling me everything about the people he was going to contact to see there was the one that gave me this disease. I'm going to probably get in contact with the family to make sure that they're tested. And then I'm going to try to set up an interview with management where he works to actually go inside the shoe factory and find out if anyone needs to be tested. The second interview was highly recommended. It's not something that's mandated by programs, but we believe that a re-interview is necessary because so much information is given to a patient at one time. It's hard for the patient to remember everything. As you can see from the re-interview that there were lots of things that were not discussed or were not brought out in the initial conversation. You didn't learn about the other family members, the living conditions, and even some of the work conditions as far as the patient's wife working in the home. So those things you would never have known had you not done the second interview. This scenario clearly demonstrates why a re-interview particularly in the home is so beneficial. In verifying the patient's personal information, Khalil was able to clarify and expand his list of close contacts. And he was persistent when he spotted evidence of other contacts. This scenario also illustrates the challenges involved in conducting a TB interview with someone from a different cultural background. The interpreter, while useful, did not translate the patient's words verbatim. Since the patient was bilingual, Javier used her as more of a safe haven when he needed to bring up sensitive information. It is a responsibility of the interviewer to observe the patient's body language for cues to understanding and comfort level. As was pointed out, cultural sensitivity plays a crucial role in the success of a TB interview with a foreign-born patient. If you're assigned to interview such a patient, remember to show respect for the patient's beliefs, respect their customs and practices while in the home, both to make them feel at ease and so that you're made to feel welcome. If necessary, bring along a medical interpreter and always be aware of how the individual might react to being labeled a TB patient. This may seem like a lot to keep in mind when you're in the midst of an interview. But if you just remember that the patient is an individual with their own needs and concerns, you'll find that these points come very naturally. Our final scenario highlights some of the issues involved in conducting TB interviews with patients in non-urban settings and under private care. Sheila is a stay-at-home mom in a non-urban area who was diagnosed by her private physician last week. She was instructed to remain in home isolation and wear a mask until she becomes non-infectious. A public health nurse called her earlier in the week the patient was reluctant to have the interviewer come to her house but after taking some basic information the nurse was able to persuade Sheila to cooperate. As you watch this scene, notice what would have been missed had the nurse not visited the home. Watch for Sheila's non-verbal cues and what you can learn from them. Notice how this interviewer deals with Sheila's emotional state and finally look for potential infection control issues. Sheila is a 38-year-old African-American woman who's had a cough for about six weeks. She refused admission to the hospital by her private physician because she has childcare issues. So we need to go out and find out what's going on with her. Hi, Sheila. Hi, and McEvoy public health nurse. Nice to see you. How are you? Pleasure to see you. Do you know what, she just fell asleep. Do you mind if I take her upstairs, Mary-Ann? No, go ahead and I'm going to put my mask on. Okay, you do that. Thanks. We asked patients about their perception of personal respirators and the most startling thing was that only 50% of the patients had had a healthcare worker explain to them why they were wearing a personal respirator. But most of the patients, once they understood why the healthcare workers were wearing respirators, thought that it was quite appropriate and in fact preferred to know that people were being protected against a disease that they did not wish upon anybody. You don't mind the kitchen, do you? No, thank you. It's a beautiful place. I can't see right here. Thank you. Excuse me. Sheila, as I mentioned when I first came in that I'm wearing a mask to protect myself and it would be a good idea if you wore a mask too. Would you mind putting it on now? No, right now. It's important that you wear a mask while you're in your house so that you don't transmit germs to your family members. And carrying a tissue doesn't help that at all? Well, carrying a tissue or covering your nose and your mouth with the tissue is somewhat helpful but it's better if you use the mask. After you cough the particles stay in the air for a long period of time, anywhere from minutes to hours and then someone else can rebreat those particles and that's one of the ways that TB is spread. Okay, I understand. In all honesty, I remember most of the time to put that on but I'm figuring if we're all infected, what's the point? It's an incorrect assumption to make. Sheila should have worn the mask at all times and Mary never would have known that if she was conducting to build a telephone. The patient was wearing an N95 mask and we always like that to be a surgical mask for the patients. The N95 respirators because they do fit more tightly may have a little more resistance to breathing, making more work of breathing so for patients that are compromised by pulmonary tuberculosis that may be difficult. If the patient is still considered infectious though then the guidelines suggest that the healthcare workers or other visitors who may go into the home should be wearing a personal respirator. Usually for healthcare workers that's an N95. The nurse was wearing one type of N95 respirator so some confusion comes up because of the different designs of the N95 respirators so some are cup shaped, some have a duck bill type of shape, some have a molded shape but one feature is that they usually all have at least two straps which contribute to the tighter fit. So what I want to do today is ask you some information about who your contacts are, who you live with, who you work with, who you socialize with. We all know that TB interviewing is ultimately about identifying contacts, getting them evaluated, getting them on treatment, getting complete treatment but the interview is about other things as well, building trust and rapport, educating the patient, exchanging information and so I think as an opening statement I'm here to talk about identifying contacts just jumped right in it. You're married? I am married. And what's your husband's name? That would be John. All right. And he lives here with you? He's here. Okay, so same address. And when is his birthday? It's October 30th, 1962. Okay. And do you know if he has any history of having tuberculosis or an infection with tuberculosis? Not to my knowledge. Okay. Was he born in this country? Yes. Okay. All right. Has he had a skin test? Yes, he has. He did. And do you know what the result was? I don't know the results. Okay. Who did that test? Our doctor. Okay. And who's his doctor? Dr. DiRazio. Okay. Do you know if he had a chest x-ray? I don't know. I believe he did when he went to see the doctor. Okay. When will your husband be at home? He works long hours. If we're lucky, he'll be home by eight this evening. Okay. So if I call after 8 p.m. or if you could ask him that information for me and I can give you a call tomorrow. Okay. If not, then I can contact the doctor. The doctor directly. Okay. Who else lives in your house? I have a daughter. And what's her name? Dasha. D-A-S-H-A. Okay. That's that beautiful little baby that you had in your arms when I first came in. And when is her birthday? Was Dasha a newborn baby? Was Sheila actually infectious prior to giving birth to Dasha? And if she was, did she go to parenting classes, OBGYN clinics, was she around other pregnant moms who maybe also could have possibly become infected? How much time did Sheila spend in these settings? Okay. Does Dasha go to childcare? No. I'm a stay-at-home mom. I'm with her all the time. Okay. Do you do any childcare in your home? No, I don't. Okay. Is there any other children in the home? I do have a boy. Okay. Troy. He's eight. And does he have the same last name? Yes, he does. Okay. Excuse me for a second. Hello. Hi, mom. How are you? Well, I'm hanging in there, mom. Right. I'm going to be back about 11. I'll leave instructions for the baby up on the refrigerator. Thanks, mom. Love you. Bye-bye. So you said your mom's coming over? Right, right. Mom's coming over to take care of Dasha tonight. Okay. And where are you going? We have tickets for a play that I've been dying to see for about seven months now. Sheila, do you realize that your doctor has emphasized with you and as well as me that it's very important that you not go out? Well, you know, I've had tickets for seven months. Am I not permitted to go out at all? You're not permitted to go out to a public place like a theater, you know, because there's a great, great big chance that you could transmit this disease to other people. No, I didn't understand that when he said that. I can't go out in my mask. No, you can't go out. The only time you could really go out is if you're going to your doctor's office for a visit or treatment or to the hospital. And how long is that going to be? Well, you probably will be in what we call self-isolation here in your house for at least two weeks. But the truth of it is that it could be longer than that because you are contagious. I was so glad that she had received that phone call while I was sitting there. Otherwise, I wouldn't have known that she had planned on going to the theater tonight. So hopefully that stopped that behavior from occurring. You know, I had tickets for a long time and it's something I really wanted to see. But I'd have to say she convinced me not to go. I felt, I think, more awful about the fact that I might go and possibly affect other people than, you know, getting over the simple fact that, you know, tickets go or don't go. At that point, Sheila was getting kind of frustrated. It was like, I can't do this. I can't do that because things weren't explained up front. Upon arrival, the nurse could have actually explained to Sheila exactly what home isolation is and to make certain that Sheila's adhering to all of the guidelines for home isolation. And then Sheila would have realized that going to a play was not a part of, it's not something she should actually be doing at that point. Okay. What else do you need? Well, I need your mom's name. That would be Barbara. Okay. And what's her last name? Her last name is Smith. I'm sorry, Sheila. I know this is a really tough time for you. It is very tough. But sometimes it's important to consider the risk to others. Mary Ann did a wonderful thing by reaching out and touching the patient. I think the patient was touched by that and that could never be accomplished over the telephone. I felt more, you know, more comfortable when I realized that she was treating me more like a person. This wasn't just some job. Let me get the information and get out. So the people that live in your house are your husband, your daughter, and your son. Is there anyone else that lives in your house? No. All right. How long have you had the cough, Sheila? About six weeks. About six weeks. Okay. So judging by health department guidelines, I would say the infectious period began about October. So what I'm going to be looking for, I'm going to be asking for who you've been in contact with since October. We want the patient to talk. And if we ask the patient yes or no questions, the patient is going to answer yes or no. So we need to be aware of how we asked. We want to ask the right questions. We want to ask them the right way and open in the questions. Generally speaking, it's the right way to ask the question. Are there other people that you attend religious services with regularly or that you have recreational activities with? Or if you say you're unemployed, but since October, did you have any employment? Well, let me think. Oh, I'm a soccer bomb. Okay. And I'm usually the mom who drops the van. Okay. Could I have infected those children? Well, there's always the possibility. That'll be my job to find that out. So can you tell me the children that are in the car pool with you? It seems that because the patient was in a rural setting, she was probably a distance from most activities. So one would assume that travel in a car, as she did mention in the interview in a van, will take a greater period of time. Hence, increasing the amount of time that people have to spend in the car with an infectious case. What I will also need from you are their phone numbers and addresses. Okay. I will get them for you there. That's fine. Okay, so that was what I would consider some recreation. Is there anything else that you do on your own without the children, or is there anything else you do with Troy? I was attending a writing class at the county college. Okay. I haven't been there for a couple weeks, though. And what time was the class? We met Wednesdays at six. One time a week? One time a week. Okay. How many people were in your class? There were ten students. Okay. Are you going to need to know them as well? Possibly. How long of the class was this? Six o'clock till? What time did it end? Why do you need to know that? Well, the more time you spend with people, the greater the chance of being exposed. So the contact with somebody doesn't have to be, I don't know, sexual in nature, or kissing, or you can be in somebody's environment. TV isn't spread by kissing or having sex. A patient's nonverbal cues sometimes can tell you much more than what the patient has actually verbally said to you. If they're clenching their fists or rolling their eyes or furrowing their foreheads, or just doing an awful lot of sighing and tells you how uncomfortable or how comfortable the patient may be with the interview or the topics that you're introducing at that point. Tuberculosis is spread in the air by coughing, speaking, singing, those kind of activities. So you're putting that particle, that germ particle into the air, and then it's sitting there, it's staying there, it's not dropping down to the floor as if it were a cold virus. And then the next person comes in and rebreathes that air. So why is it necessary for you to know how long my class has lasted? Being in a classroom is being in a classroom. Well, if it's one hour or four hours, it can make a difference. So was it a one-hour class? It was a two-and-a-half-hour class. And then what happened at 8.30? Did everybody go home, or did you just hang out for coffee? Oh, yeah, just a study partner. Okay, and who was that? Is it necessary? Well, just to make the investigation complete, it is important to get all the information, and then we can kind of sort it out. His name would be Tom Hanham. Okay. And what happens with that information? I mean, you find out something, and what happens then? It's very personal information. And I don't think I realize the extent of everything, especially when we started talking about contacting everyone that I'm in touch with. That's tough. That's real tough. She was cooperative as much as can be expected. If I was on the other end, I think I'd feel the same way, a little resistant, who's going to know my name and my diagnosis. So I understand and respect her fears. Sheila, as I told you before, this information is confidential. I don't have to reveal your name to anyone, but I have to let them know that they had the potential to be exposed to someone with tuberculosis, and what I would be asking them to do is to take a skin test to see if they tested positive. It's your option, though, to reveal that you have tuberculosis to some of these people that you're mentioning to me, but you don't have to do that. The misconception about healthcare work is telling patients that everything you're telling me is confidential. I think we need to move away from that, because it's very misleading for patients, particularly if a patient who's infectious or potentially infectious that attends school or works or lives in a shelter, we need to explain to patients that their identity may be revealed on a need-to-know basis in order to conduct a quality investigation. There's some other questions that I'm going to ask you. Again, some of these are very personal questions, and I want to assure you that this information is just going to be shared between us and the health department. Have you ever been tested for the HIV virus? Yes. And do you know your result? I am negative, Chris. Do you know the last time you or when were you tested? Within the past five years. Five years? Okay. Have you ever been in a correctional facility? Have you ever been in prison? Oh, no. Thank God, no. Okay. I know. I sit there kind of... Have you ever used or are you now using any injecting drugs? No. For contact investigations, we need to know everything about a patient during the infectious period, and if a patient is giving a history of substance use during what we established as the infectious period, it gives us an idea of a lifestyle, obviously, and perhaps there are other contacts, social-casual contacts that are high-risk contacts that we want to know about. Normally, when people have tuberculosis in the early periods, they are hospitalized, isolated, so that they don't give the disease to other people. So it's very, very important that you abide by what the doctor is saying. All right? I got you. Are you taking your medicine? I sure am. May I see them? Sure, I am right here. Sick. All right. Well, these are the standard medications that we use for tuberculosis or actually they're anti-tuberculosis medications. And how do you take them? Are you taking them at the same time, all at once every day? I take them once a day and all at the same time. Okay. That's the way they should be taken. Okay. Have you noticed any side effects? No. Has anybody come into your house and actually watched you take your medication? Did your doctor send anyone from his office? No, that sounds kind of ridiculous. Actually, it's one of those things that is important that we want to ensure that you take your medication because this is, it's transmittable. Other people can get this disease, so we don't want it to be transmitted. So we'll just bring somebody else in and watch the traffic go in and out of here, county logo on the cars. Well, we don't have to necessarily bring our county cars. We can drive personal cars. But what time do you normally take your medication? I take it first thing in the morning. Is that 8 o'clock? About 8, 8.15. Okay. So how about if we have somebody here early in the morning at about 8 o'clock and they'll come, they'll watch you take your medications, they'll just see and ask you how you're feeling and then they'll scoot right out of here. The nurse could have described DLTs by telling her that this is actually the standard practice that we have to provide DLT and explain the nature of the illness itself that at first you're very ill and so therefore taking the medication is high priority and you think about it constantly, but as you take the medication, begin to feel better, the illness is such that you no longer exhibit the symptoms or feeling ill or bad and so therefore you tend to forget and this is only human. And then I think the nurse could have explained some of the consequences of not taking the medication constantly and for the length of treatment prescribed. So can I ask you? Fine. All right. That's good. Please, we need to try and keep a little discretion involved here. I really appreciate that. Those people are part of the health department staff and they're bound by confidentiality. All right. Now I have a little TB booklet for you if you have any questions. You can maybe get some of the light answers in there. You might want to share that with your family. Here's my card with my name and phone number if you want to call me and ask me any questions. There's my business hours. Great. All right. Only business hours. You're not there if I have that breakdown at 12.30 a.m. right now. If you need, if you have some mental health issues then I can certainly refer you to someone that can help you with that. I know it's a tough road ahead but it is curable and you will be able to get outside again. The public health nurse did not ask Sheila if she had any questions. Had she asked Sheila if she had any questions Sheila might have actually asked things and that's extremely important to her care but the nurse didn't ask and so therefore she doesn't know. She doesn't have any understanding of just what it is. Sheila understands about her illness and its treatment. She was definitely still infectious, hadn't been on medication long enough and that young child could very definitely be infected and develop into active TB disease in a very, very short period of time and I would have wanted someone to address that issue and the nurse didn't know during the interview that there were young children in the home. In some instances we asked the family to remove children that age from the home for a period of time until we can have the children tested to make sure that they're okay at that point. Alright so I just want to emphasize again to do what your doctor asks you to do. Wear your mask, take your medication, cover your mouth when you're coughing. Alright and those are the important things. And don't go out, don't forget that. And stay in until you get approved to go back out. Alright you're grounded. Look at it like that. Thank you. Alright thank you. Thank you Mary Ann. I still need more information. I need to follow up with her household contacts with her parents and get some information from them in terms of data births, verifying that and phone numbers. I also need to follow through on the van pool, the car pool with the soccer team members and I'll have to contact the college to get in contact with the study buddy and possibly other members of the class. This scenario highlighted some of the challenges involved in conducting TB interviews in a non-urban setting. Given the wide service area and a small staff it may be tempting to conduct an interview over the phone. But as you saw in Sheila's case the home visit is very important. The interviewer would not have known that Sheila was taking off her mask nor would she have learned about her plans for that evening. The in-person communication also allowed for rapport building that wasn't possible by phone. Sheila displayed obvious discomfort in her body language and Mary Ann was able to comfort her very effectively prompting Sheila to be more open with her. But the interviewer didn't properly educate Sheila. Things weren't explained until she got upset. Had the interviewer provided adequate education about TB early in the interview Sheila may not have reacted as she did. As a TB interviewer it's critical to determine who are the high-risk contacts and ensure that these people are quickly identified and evaluated. While she's concerned about maintaining her confidentiality securing Sheila's participation will help the investigation go more smoothly. I think a good interview has to have a blend of knowing when to be assertive, when to back away, when to be sensitive, when to be persistent, no one to stop a stalled interview. I think part of that is learning how to read people so to speak, learning how to listen to the verbal and non-verbal cues as to what you can get away with at this time and getting a sense of time and what's the right time because some things may have to wait till later. I think people who are generally interested in other people make good interviewers. People who can be accepting of other people's attitudes and beliefs without saying that their belief system is 100 percent right and anybody who disagrees with that is not acceptable to them. I say a good interview is a people person, someone who obviously shows that they're very interested in other people and that they like them. This video has shown you some of the challenges you're likely to face in a variety of TB interviewing scenarios. Regardless of the situations you're confronted with keep in mind the basic elements of the TB interview. Using good communication skills throughout will make the interview go more smoothly. As early as possible, you want to build trust and rapport, provide education on transmission and infection control, and explain to the patient the purpose of the interview to encourage cooperation. Then work with the patient to help identify contacts in a variety of settings. And finally, address any questions and concerns the patient may have. Active TB interviewing requires skill and practice, but by improving your skills you're providing an essential role in helping to control the spread of TB.