508 Compliance Document for: 

TUBERCULOSIS COMPONENT OF TECHNICAL INSTRUCTIONS FOR THE
MEDICAL EXAMINATION OF ALIENS IN THE UNITED STATES

Table 1. Requirements and Recommendations for Referral 

Table 1. Referral to Health Department TB Control Program by Civil Surgeons 

Referral is required for a chest radiograph suggestive of TB disease (active or inactive), or signs or symptoms of TB, regardless of chest radiograph findings or tuberculin skin test (TST) result. Referral to the health department TB Control Program is recommended for evaluation for treatment of latent TB infection in the following circumstances: a TST result greater than or equal to 10 mm, or a TST reading greater than or equal to 5mm in 
	
i. an HIV-infected person
ii. a recent contact of a TB patient
iii. a person with a history of organ transplantation
iv. any immunosuppressed person

  
Table 2. TB Classifications and Summary of Appropriate Related Actions. For the conditions below, classification cannot be determined until evaluation of applicant by the Health Department TB Control Program has been completed.

The table headings are: classification, criteria for classification, refer to the health department for further work-up, check classification box on I-693, clear applicant for TB and sign I-693 form, and re-classify after treatment.  

For “Class A–Pulmonary TB Disease, Active, Infectious”, the criteria are an abnormal chest radiograph suggestive of active TB disease plus one or more sputum smears positive for acid-fast bacilli (AFB) and/or one or more cultures positive for 
M. tuberculosis complex. Referral to the health department TB Control Program, based on the chest radiograph findings, is required. The classification box should be checked on the I-693 form at the time of initial evaluation. The applicant cannot be cleared and the I-693 form cannot be signed at this time. After treatment is fully completed, the classification should be changed to B2, at which time the applicant can be cleared and the I-693 form signed. 

For “Class B1–Pulmonary TB, Active, Non-infectious”, the criteria are an abnormal chest radiograph suggestive of active TB disease plus three sputum smears negative for AFB and three cultures negative for M. tuberculosis complex. Referral to the health department TB Control Program, based on the chest radiograph findings, is required. When the results of the health department work-up are known, the classification box should be checked on the
I-693 form. The applicant can be cleared and the I-693 form signed. 

For “Class B2–Pulmonary TB, Inactive”, the criteria are an abnormal chest radiograph suggestive of inactive TB disease.  No sputum smears or cultures are required or performed1. Referral to the health department TB Control Program, based on the chest radiograph findings, is required. When the results of the health department work-up are known, the classification box should be checked on the I-693 form. The applicant can be cleared and the I-693 form signed. 

The other three conditions listed on this table are covered in detail in the text. 

If the applicant has TB signs or symptoms, he or she should be referred to the health department TB Control Program for further evaluation regardless of TST result or chest radiograph appearance.

Footnote:
1 If Health Department TB Control Program performs sputum smears and cultures, categorize as Class A or B1 depending on results


Figure 1. Process for Classifying TB and Other Chest Conditions. This classification system is designed to assist state and local health department TB Control Programs to prioritize their efforts to most effectively diagnose and treat applicants with TB conditions. 

A tuberculin skin test (TST) is performed on all applicants ? 2 years of age. A chest radiograph is performed if the TST is ? 5mm induration.  If the chest radiograph is suggestive of active or inactive TB disease, referral to the local health department TB Control Program is required. Signs or symptoms of TB, regardless of the TST or chest radiograph results also require referral. If the health sputum performs smears and cultures, and the smear and/or culture is positive, the resulting TB classification is Class A, Pulmonary TB. If all sputum and culture results are negative, the classification is Class B1, Pulmonary TB.

If radiographic or other findings are suggestive of extrapulmonary TB disease and there is no evidence of pulmonary TB, referral to health department TB Control Program to further evaluate for extraplumonary TB is required. If biopsy or other confirmatory test is positive, the classification is “Class B1 Extrapulmonary TB”. If the results are negative, the classification is “No Class A or Class B TB”.

If the TST is “positive” (see p. 21 of text for specific criteria), and there is no evidence of 
active TB disease, the classification is “Class B, Latent TB Infection” or LTBI. Referral to the health department TB Control Program for evaluation for LTBI treatment is recommended.

If the chest radiograph is abnormal but not suggestive of TB, the classification is “Class B--Other Chest Condition”.  The civil surgeon should advise the applicant about the chest radiograph findings and the type of referral needed.