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No. 3, 2008

Release of New Civil Surgeon TB Technical Instructions

The new TB component of the Technical Instructions (TB TI) for the Medical Examination of Aliens in the United States became effective on May 1, 2008. These instructions, developed by the Division of Global Migration and Quarantine (DGMQ) at CDC, supersede the TB section of the June 1991 Technical Instructions.

Civil Surgeons are appointed by local offices of the Bureau of U.S. Citizenship and Immigration Services (USCIS) and perform the medical examinations of aliens in the United States. Aliens who require medical examination include persons applying for adjustment of immigration status (e.g., nonimmigrant visa holders) and other persons requiring a medical examination as determined by the Department of Homeland Security.

The new Civil Surgeon TB TI are to be used in conjunction with the new I-693 form, which was released by USCIS on May 1, 2008. The new I-693 form can be identified by the list of seven TB classifications found at the bottom of its first page.

A letter was sent via e-mail to the National TB Controllers Association on April 4, 2008, regarding the release of the new Civil Surgeon TB TI.

Highlights of the major changes in this release of the Civil Surgeon TB TI are as follows:

Sputum cultures for Mycobacterium 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 consistent with TB.

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 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–

  • Signs or symptoms consistent with active TB disease.
  • 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 proactively 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 Civil Surgeon TB TI state that QuantiFERON is not currently accepted in place of a TST. When additional information is available, an update to the civil surgeon TB TI will be posted on the DGMQ website. We expect this update to be available in 2009, following a consultancy sponsored by DTBE and other steps necessary to provide information to civil surgeons so that they may best utilize the test.

The following documents can be found on the DGMQ website:

  • The new civil surgeon TB Technical Instructions.
  • A memo to civil surgeons concerning the new TB Technical Instructions
  • Frequently Asked Questions (FAQs) regarding the new Civil Surgeon TB Technical Instructions.

The above website also contains links to the 1991 Technical Instructions for the non-TB portions of the medical examination (other infectious diseases, mental health conditions, etc.) and to the Vaccination Technical Instructions. Civil surgeons should continue to follow these other Technical Instructions for the non-TB portions of the examination. Updates to the Technical Instructions are found at the same site.

The I-693 Form is not distributed by CDC/DGMQ. It is available on the USCIS website.

If, after consulting the above website, clarification or further guidance is needed, CDC/DGMQ may be contacted via fax at (404) 639-4441. The fax should be addressed to “Civil Surgeon TB Technical Instructions.” Alternatively, Dr. Mary Naughton can be contacted at mnaughton@cdc.gov.

—Reported by Mary Naughton, MD, MPH
Div of Global Migration and Quarantine

 

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