Technical Instructions

Immigrant and Refugee Health

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Required Evaluations - Tuberculosis Screening and Treatment for Countries using 1991 Technical Instructions

Important Update: All Countries Required to Use CDOT TB TIs by October 1, 2013

The CDC Quality Assessment Program (QAP) has set a final date for implementation of the CDOT TB TIs. All countries should begin using the complete CDOT TB TIs when they are able to do so, but no later than October 1, 2013. See the CDOT TB TI’s.

Technical Instructions For Medical Examination Of Aliens

Preface

III. Required Evaluations
1. Communicable Diseases of Public Health Significance
  - 1. Infectious Tuberculosis

Appendices

Preface

The Centers for Disease Control (CDC), United States Public Health Service (PHS), is responsible for ensuring that aliens entering the United States do not pose a threat to the public health of this country. The visa medical examination is one means of evaluating the health of aliens applying for entry into the United States.

These instructions are for the use of panel physicians and consular officers who are evaluating aliens applying for immigrant visas and aliens applying for refugee status at locations outside the United States.* Other aliens, not applying for an immigrant visa, may in some instances be referred for an examination. These technical instructions also apply to those examinations. This document supersedes the June 1984 Guidelines for Medical Examination of Aliens.

*Other instructions have been prepared for the examination of aliens applying for adjustment of status at locations within the United States.

III. Required Evaluations

A. Communicable Diseases of Public Health Significance

1. Infectious Tuberculosis

a. Overview

The panel physician, using a chest radiograph (or tuberculin skin test for persons under 15 years of age) will determine whether the applicant is infected with Mycobacterium tuberculosis, and if evidence of tuberculosis is found, whether the applicant is likely to transmit the infection to others. It is the likelihood of transmission rather than the presence of disease that determines whether an applicant is excludable.

b. Definitions

Active tuberculosis - clinical, laboratory or radiologic evidence of a current disease process caused by M. tuberculosis (pulmonary or extrapulmonary). For purposes of this examination, only active tuberculosis that is in an infectious state (smear positive) is excludable.

Infectious tuberculosis - tuberculosis that can be readily transmitted to others, as evidenced by an abnormal chest radiograph consistent with pulmonary tuberculosis and a sputum smear that is positive for acid-fast bacilli.

Tuberculosis, noninfectious - presence of an abnormal chest radiograph consistent with pulmonary tuberculosis, and sputum smears, obtained on 3 consecutive days, that are negative for acid-fast bacilli, or evidence of extrapulmonary tuberculosis

c. Required evaluation for tuberculosis

Table 1: Required Evaluation for Tuberculosis
Procedure	Required for	Minimum Requirement
Review of history	All applicants	Inquire about history of TB. If application has history of TB, obtain treatment records.
Chest radiograph	All applicants 15 years of age or older Applicants less than 15 years of age whose skin test is positive (see below)	Obtain old chest radiographs, if possible. Chest x-ray film must be large enough to include entire chest (usually 14" X 17" or 36 X 43 cm)(Photofluorograms are not acceptable.) Date of examination and applicant's name must be on film. Use lead shielding for women of childbearing age.Pregnant women who are asymptomatic * may request that no chest radiograph be taken. Note this request on medical report form and advise applicant to obtain skin test after arrival in U.S. When reading radiographs: review all available radiographs; describe radiographic abnormalities by location, and appearance; indicate whether or not there has been any change over time (stable, worsening, improving); state whether the abnormal findings are compatible with TB or another condition (see appendix B).
Tuberculin skin test	Applicants less than 15 years of age who are suspected of having TB or who have a history of contact with known TB case	Read at 48 - 72 hours. Record mm induration on medical report form. For this examination, any reaction (erythema or induration) is a positive test. A chest radiograph is required for all applicants with positive skin tests.
Sputum smear examination	Any applicant with a chest radiograph suggestive of clinically active pulmonary TB **	Examine smears obtained on 3 consecutive days. Collect sputum in a laboratory or a doctor's office, under direct supervision (no self- collection of sputum is permitted). Examine sputum smear in accordance with recommended procedures (see appendix C).

* Pregnant women with symptoms suggestive of active TB must receive a chest radiograph. If the radiograph is compatible with active tuberculosis, sputum smears must be obtained.

** Applicants whose chest radiographs show only calcified granuloma, calcified primary complex, calcified lymph node, or fibrosis, scarring or pleural thickening, with no radiologic or clinical evidence of active tuberculosis are not required to have sputum smears. Revised 6/15/92

d. Reporting results of examination for tuberculosis

Table 2: Reporting Results of Evaluation for Tuberculosis*
Test Results	Record on Medical Report Form
Normal chest radiograph - (i.e., no parenchymal, pleural, or other intrathoracic abnormality)	Normal
Abnormal chest radiograph or series of chest radiographs suggestive of current pulmonary tuberculosis and One or more positive sputum smear examinations for acid-fast bacilli	Class A - Tuberculosis, Infectious (Start recommended treatment [see appendix D] or refer for treatment.)
Abnormal chest radiograph or series of chest radiographs suggestive of active tuberculosis, and History of one or more sputum smears positive for acid-fast bacilli and Currently on recommended treatment and Sputum smears are negative for acid-fast bacilli on 3 consecutive days	Class A - Tuberculosis, Infectious, "Noncommunicable for travel purposes" (Continue recommended treatment and provide medication sufficient for travel plus 30 days.)
Abnormal chest radiograph or series of chest radiographs suggestive of active tuberculosis and Sputum smears are negative for acid-fast bacilli on 3 consecutive days	Class B1 - Tuberculosis, clinically active, not infectious (Start recommended treatment if applicant is symptomatic [see appendix D] or refer for further evaluation.) (Provide medication for travel plus 30 days.)
Radiographic or other evidence of extrapulmonary tuberculosis, clinically active	Class B1 - Extrapulmonary tuberculosis, clinically active, not infectious (Start recommended treatment if clinically indicated [see appendix D] or refer for evaluation.) (Provide medication for travel plus 30 days.)
Abnormal chest radiograph or series of chest radiographs, suggestive of tuberculosis, not clinically active (e.g., fibrosis, scarring, pleural thickening, diaphragmatic tenting, blunting of costophrenic angles). (Sputum smears are not required.)	Class B2 - Tuberculosis, not clinically active.
Abnormal chest radiograph or series of chest radiographs. Only abnormality is calcified hilar lymph node, calcified primary complex, or calcified granuloma. (Sputum smears are not required.)	Class B3 - Consistent with tuberculosis, old or healed.
Abnormal chest radiograph not consistent with tuberculosis	Class B - other chest condition