A 32-year-old male construction worker from Delhi presents to the primary health centre with a 3-week history of productive cough, fever, and night sweats. Chest X-ray shows an upper lobe infiltrate with cavitation. Sputum smear microscopy is positive for acid-fast bacilli (AFB). His household contacts include his wife (28 years, non-pregnant) and two children aged 6 and 9 years. What is the most appropriate next step in management?

Explanation

## Management of Newly Diagnosed Pulmonary TB with Household Contacts ### Correct Approach: Simultaneous Patient Treatment and Contact Screening **Key Point:** In a smear-positive TB patient, the priority is dual: (1) initiate standard ATT without delay, and (2) simultaneously screen household contacts to identify active TB and prevent transmission. **High-Yield:** According to NTEP (National TB Elimination Programme) guidelines and WHO recommendations, contact tracing must begin as soon as the index case is diagnosed. Delaying contact investigation increases the risk of secondary transmission, especially to children under 15 years. ### Why This Is the Best Next Step 1. **Immediate ATT initiation:** A smear-positive patient is infectious and requires treatment without delay. Standard first-line regimen (HRZE) should begin immediately. 2. **Simultaneous contact screening:** All household contacts should undergo: - Tuberculin skin test (TST/Mantoux test) - Chest X-ray (CXR) to rule out active TB - Clinical assessment for TB symptoms 3. **Special consideration for children:** The 6-year-old child is at high risk for rapid progression to disseminated TB. If TST is positive or CXR shows infiltrate, isoniazid preventive therapy (IPT) or full ATT is indicated. 4. **Wife screening:** Non-pregnant status allows full investigation; if pregnant, TST and CXR are safe. ### Contact Classification and Management | Contact Type | Action | |---|---| | **Household contacts with symptoms** | Investigate for active TB; start ATT if confirmed | | **Household contacts TST+ / CXR normal** | Isoniazid preventive therapy (IPT) for 6 months | | **Household contacts TST− / CXR normal** | Repeat TST at 8 weeks; IPT if conversion occurs | | **Children <5 years (any TST result)** | IPT or full ATT depending on TST/CXR findings | ### Timeline **Immediate (Day 1):** - Start ATT in the index case - Initiate contact tracing **Within 1 week:** - Complete TST and CXR in all contacts - Classify contacts and initiate preventive therapy if indicated **High-Yield:** Early contact tracing prevents an estimated 5–10 secondary cases per smear-positive patient in high-burden settings like India [cite:Park 26e Ch 8].