Public Health Service Centers for Disease Control and Prevention (CDC) DEPARTMENT OF HEALTH & HUMAN SERVICES Atlanta, GA 30333 MEMORANDUM To: All Civil Surgeons From: Immigrant, Refugee, and Migrant Health Branch, Division of Global Migration and Quarantine (DGMQ) Date: May 1, 2008 Subject: Release of New Civil Surgeon Tuberculosis (TB) Technical Instructions This memo announces the release of the new TB Component of the Technical Instructions for the Medical Examination of Aliens in the United States. These new TB Technical Instructions replace the TB section of the June 1991 Technical Instructions. The new Instructions supersede all previous Technical Instructions, Updates to the Technical Instructions, and memoranda and letters regarding the Technical Instructions, as pertains to TB screening. The new TB Technical Instructions are effective May 1, 2008. Highlights of the major changes in this release of the TB Technical Instructions are: * Sputum cultures for M. tuberculosis, and drug susceptibility testing for positive cultures, are required for applicants with chest radiograph findings suggestive of active TB disease. These new tests are mandatory in addition to the previously-required sputum microscopy for acid fast bacteria. Health department practitioners will decide if these tests are needed for applicants with chest radiographs suggestive of inactive TB and for applicants with clinical presentations. * Applicants with Class A (either smear or culture positive) TB must complete a full course of TB treatment. Completion of therapy is required prior to medical clearance for TB by the civil surgeon, for purposes of this examination and the United States Immigration and Citizenship Services (USCIS). * A chest radiograph is required for all applicants with a tuberculin skin test (TST) reaction of 5 mm or greater of induration, including pregnant (or possibly pregnant) women. Previously, the chest radiograph could be waived for a pregnant applicant if she had a scar or other evidence of BCG vaccination and denied having any TB-related symptoms. This exception is no longer permissible. If the applicant decides to undergo a radiograph during pregnancy, the possible risks of radiation to the fetus should be explained to her and informed consent obtained, confirmed by a signed consent form. If she wishes, the applicant may defer the radiograph until after delivery, but the civil surgeon cannot sign the medical examination form until the radiograph is performed and interpreted, and treatment for Class A pulmonary TB disease, if needed, is completed. * A chest radiograph is now required for applicants with a TST reaction of less than 5 mm of induration (including no induration) who have: o Signs or symptoms consistent with active TB disease. o Immunosuppression for any reason (e.g., HIV infection; immunosuppressive therapy equivalent to or greater than 15 mg/day of prednisone for one month or longer; or history of organ transplantation). * Definitions of chest radiographic findings that are suggestive of TB disease are provided to assist the civil surgeon in determining the proper TB classification. These descriptions are presented in Appendix B of the TB Technical Instructions. * A new TB classification (Class B: Latent TB Infection Needing Evaluation for Treatment) should be used for all applicants who are recent arrivals to the United States (less than 5 years) from countries with a high TB prevalence, with a Mantoux TST reaction of 10 mm or greater of induration, and no evidence of TB disease. See Section V of the TB Technical Instructions for other conditions for which referral for evaluation for treatment of latent TB infection is recommended. The civil surgeon should pro-actively contact the TB Control Program of the local health department to identify specific sources of treatment for latent TB infection and make the appropriate referral. * Class B3 (consistent with old, healed TB disease) has been eliminated. * TST Instructions. Appendix A includes directions for the proper procedures that civil surgeons must follow in the storage of purified protein derivative (PPD), and the administration and interpretation of the TST. The new TB Technical Instructions are available at http://www.cdc.gov/ncidod/dq/civil.htm. This site also contains the 1991 Technical Instructions for the non-TB portions of the medical examination (other infectious diseases, mental health conditions, etc.) and the Vaccination Technical Instructions. The civil surgeon should continue to follow these other Technical Instructions for the non-TB portions of the examination. Updates to the Technical Instructions are posted at http://www.cdc.gov/ncidod/dq/updates.htm. DGMQ/CDC has posted a link at http://www.cdc.gov/ncidod/dq/civil.htm for Frequently Asked Questions (FAQ) about the new TB Technical Instructions. If clarification or further guidance is needed, contact CDC/DGMQ by fax at (404) 639-4441. Address the fax to “Civil Surgeon TB Technical Instructions”. The new TB Technical Instructions are to be used in conjunction with the new I-693 form which is being released concurrently by USCIS. The new I-693 form can be identified by the list of seven TB classifications found at the bottom of its first page. The new I-693 form is available on the USCIS website; the I-693 Form is not distributed by CDC/DGMQ. Technical Instructions for Civil Surgeons Tuberculosis Medical Examination 3