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No. 4, 2012


TB Screening Practices of Civil Surgeons Evaluating Status Adjustors Seeking Permanent Residence in the United States -- New England, 2011

The authors presented this report as a poster at the 2012 National TB Controllers Workshop in Atlanta, Georgia. The poster was the second place winner in the NTCA poster competition.

From July 1, 2010, to June 30, 2011, a total of 32,734 foreign-born individuals in New England applied to adjust their status to permanent residents (status adjustors or SAs). Screening SAs is one strategy for detecting infection with Mycobacterium tuberculosis in this high-risk group. SAs must undergo medical examinations, including TB screening, performed by licensed physicians designated by the US Citizenship and Immigration Services (USCIS). These physicians are called civil surgeons. CDC provides civil surgeons with technical instructions (TIs) for SA medical examinations. However, little is known about the characteristics and practices of these physicians.

In July 2011, surveys were mailed to all civil surgeons with viable addresses currently practicing in Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont. Respondents were asked about the characteristics of their practice, as well as their TB screening and follow-up procedures. Responses were analyzed using descriptive statistics; chi square or t-tests were used to test associations.

Of 143 civil surgeons to whom the survey was sent, 119 (83%) responded. The majority were in private practice (59%). The median number of years as a civil surgeon was 9. While their residency training was diverse, most (71%) attended medical school in the U.S; 34% received additional training beyond a primary residency.

All respondents used appropriate TB screening tests: 98% used tuberculin skin tests (TSTs) and 2% used interferon-gamma release assays (IGRAs). All respondents would obtain chest radiographs (CXR) for SAs with positive screening tests. The TIs also recommend a CXR for all SAs who are immunocompromised or have symptoms suggestive of TB. However, 57% and 29% of civil surgeons would not obtain a CXR for SAs who had a negative TST or IGRA and who were immunocompromised or symptomatic, respectively. If TB disease was suspected, 80% report or refer to the health department; 16% refer to a specialist only.

If LTBI was diagnosed, the majority of civil surgeons (70%) referred to specialists, other providers, or the health department, while 15% started treatment.

Of 119 respondents, 71 (60%) CS estimated the number of SA they evaluated in the past 12 months. The mean number of SA evaluated per year is higher among private providers than providers based at community health centers (CHC) (248 versus 46; p=0.001). Private providers were also more likely to have read the TIs (93% versus 67%, p<0.001) and to respond correctly to a case scenario about the interpretation of TSTs (90% versus 65%, p=.002). However, they were less likely than CHC providers to refer or start treatment for LTBI (87% versus 100%, p=0.028).

In conclusion, our results indicate that New England civil surgeons are largely adherent to the CDC TIs. Civil surgeons’ characteristics vary by practice location. All used appropriate screening tests. However, many did not obtain CXR as recommended by the TIs for immunosuppressed or symptomatic SAs.  Most civil surgeons refer SAs to other providers (e.g., a specialist, primary care provider, or health department) for TB disease and LTBI. Potential areas for future training include appropriate use of CXR in screening and follow-up of TB suspects.

—Reported by Kelley Bemis (CSTE/CT Department of Public Health),
Lynn Sosa and Alison Stratton, CT Dept of Public Health,
Andy Tibbs and Jennifer Cochran, MA Dept of Public Health, and
Mark Lobato and Alfonso Rodriguez Lainz, CDC


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