CDC Immigration Requirements: Technical Instructions for Gonorrhea for Civil Surgeons
The medical screening for gonorrhea among persons applying for adjustment of status for US permanent residence and other persons required to have a medical examination, hereafter referred to as applicants, is an essential component of the immigration process. Because gonorrhea must be appropriately diagnosed and treated, these Technical Instructions provide a method for recording findings from the immigration medical examination and instructing civil surgeons on classifying applicants.
The instructions in this document supersede all previous Technical Instructions, Updates to the Technical Instructions, memoranda and letters to civil surgeons, and memoranda and letters to international refugee resettlement organizations. These Technical Instructions are to be followed for gonorrhea screening and treatment among all applicants and are effective as September 1, 2021.
Visit the Technical Instructions for Civil Surgeons webpage for more information about the medical examination for applicants for US immigration.
- All applicants aged 18 to 24 years must be tested for evidence of gonorrhea.
- Applicants aged less than 18 years or greater than 24 years must be tested if there is a reason to suspect infection with gonorrhea.
- The gonorrhea nucleic acid amplification test (NAAT) must be ordered by the civil surgeon at the time of the immigration medical examination. Tests performed elsewhere, or prior to the civil surgeon’s examination of the applicant, are not acceptable.
Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae. It is one of the most commonly reported communicable diseases in the United States. If symptomatic, persons with gonorrhea will most often present with urethral or cervical discharge and painful urination. However, gonorrhea is more frequently asymptomatic in both men and women, especially if the infection is in the pharynx, cervix, or rectum. Left undetected and untreated in women, gonorrhea may ultimately cause complications such as pelvic inflammatory disease (PID), tubal scarring, ectopic pregnancy, and infertility.
It is important that gonorrhea be correctly diagnosed among applicants for adjustment of status. Correct diagnosis of gonorrhea will ensure that affected applicants receive appropriate treatment, long-term sequelae are minimized, and further spread of the disease is reduced.
Obtaining the medical history must include inquiring about any genitourinary symptoms. Men with gonorrhea may report dysuria with penile discharge, while women who are symptomatic may experience vaginal mucopurulent discharge, pelvic pain, or dyspareunia.
The physical examination must include checking for signs consistent with gonorrhea in applicants 18–24 years of age (and applicants aged <18 years or >24 years if there is a reason to suspect infection with gonorrhea). Other manifestations of gonorrhea that should be evaluated include pharyngeal discharge, rash, ocular symptoms, and abdominal tenderness. However, a genital examination must not be performed for the gonorrhea portion of the medical exam. If you have reason to suspect a genital infection, proceed with laboratory testing.
A nucleic acid amplification test (NAAT) must be performed for screening and civil surgeons must use the least-invasive specimen type. For asymptomatic applicants without risk factors, a urine specimen (men or women) or a self-collected vaginal swab (women) must be used for the NAAT. Clinical judgement may be used to determine if another specimen type is more appropriate based on reported risk factors or symptoms, including oral or rectal swabs (men or women). Civil surgeons must use tests that have regulatory approval and closely follow the instructions on the product inserts to ensure the correct specimen is used for the laboratory test, as collection methods and specimen types vary.
While grams stains on urethral secretions may be diagnostic in symptomatic men, they cannot be used to rule out infection in asymptomatic men or on other types of specimens. Therefore, gram stains are not accepted for gonorrhea screening in the immigration medical exam.
Many gonorrhea tests automatically test for Chlamydia trachomatis. Although chlamydia is not listed in the diseases of public health significance in 42 Code of Federal Regulations (CFR) part 34, civil surgeons may use tests kits that screen for both gonorrhea and chlamydia if gonorrhea stand-alone test kits are unavailable; when combined test kits are used, applicants must be informed of results for both gonorrhea and chlamydia. Applicants who test positive for chlamydia only must be offered treatment in accordance with the CDC’s Sexually Transmitted Infections (STI) Treatment Guidelines; however, the applicant is not required to take this treatment as chlamydia is not a Class A condition. If an applicant is tested for chlamydia, the results must be documented on the Form I-693 in the section, “Other Medical Conditions.” If an applicant is diagnosed and treated for chlamydia, this must also be documented on the Form I-693 in the section, “Other Medical Conditions.”
All applicants diagnosed with gonorrhea should be advised to be tested for other STDs, including chlamydia, syphilis, and HIV. The consent for HIV testing should include the following:
- Applicants understand they do not have to be tested for HIV.
- Applicants understand that if they would like to be tested for HIV, they do not have to be tested for HIV by a civil surgeon.
- Applicants understand that civil surgeons must include the test results on the paperwork they complete.
If the applicant consents, civil surgeons should perform HIV testing consistent with current standards of care, including pre-test and post-test counselling for the HIV test.
Gonorrhea Screening Results
- Applicants with untreated gonorrhea are Class A for gonorrhea and will remain Class A until treated.
- After completing treatment, applicants are classified as Class B.
- The evaluation is complete when the required aspects of the medical examination have been completed and the applicant is assigned a gonorrhea classification.
Civil surgeons must treat gonorrhea according to CDC’s STI Treatment Guidelines, which are periodically updated, before the medical report form is completed and signed.
Treatment must be provided onsite and be directly observed. Civil surgeons should recommend that sex partners of infected applicants also be treated. Additionally, if an applicant is diagnosed with a gonorrheal infection using a stand-alone gonorrhea test kit and chlamydial infection has not been excluded, civil surgeons should offer treatment for chlamydia in accordance with the CDC’s STI Treatment Guidelines; however, the applicant is not required to take this treatment as chlamydia is not a Class A condition.
A test of cure immediately at the conclusion of therapy is not needed prior to completion of the medical examination following treatment for uncomplicated urogenital or rectal gonorrhea that is treated with any of the recommended or alternative regimens. However, any applicant diagnosed with pharyngeal gonorrhea must have a NAAT or culture test performed 14 days after treatment prior to completion of the medical examination, and the test must be performed by the civil surgeon. If the NAAT is used and is positive, the applicant must have confirmatory culture with drug-susceptibility testing before re-treatment.
Treatment failure should be considered in 1) persons whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period and 2) persons with a positive test-of-cure (i.e., positive cultures ≥72 hours or positive NAAT ≥7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period. In cases of suspected or documented treatment failure, civil surgeons must perform both culture and drug-susceptibility testing because non-culture tests cannot provide drug-susceptibility results. Culture cultures requires endocervical swabs (women), urethral swabs (men), or oral or rectal swabs (men or women). Additionally, gonococcal cultures require demanding nutritional and environmental growth requirements. Optimal recovery rates are achieved when specimens are inoculated directly and when the growth medium is incubated with an increased CO2 environment.
Any additional testing or treatment must be documented on the Form I-693 in the section, “Other Medical Conditions.”
Because a high prevalence of N. gonorrhea infection has been detected among persons previously treated for gonorrhea, all applicants treated for gonorrhea should be counseled that they should be retested 3 months after treatment. However, this post-treatment evaluation does not prevent completion of the medical exam for status adjustment.
- The Form I-693, Report of Medical Examination and Vaccination Record, must be completed in its entirety, signed, and placed in a sealed envelope, according to the form’s instructions. This includes assigning a classification on the Form I-693 if an applicant is Class A or Class B for gonorrhea.
For applicants requiring gonorrhea treatment, the civil surgeon is required to document the following on Form I-693 at Part 8, Civil Surgeon Worksheet, Section 1.C, Communicable Diseases, Gonorrhea:
- Laboratory test used to make the diagnosis and date of test.
- Drug regimen received (including doses, dosage units, and administration routes of all medications), start date, completion date, and any periods of interruption.
- Clinical course observed, if applicable, such as clinical improvement or lack of improvement during and after treatment, including resolution of symptoms and signs, as well as any drug reactions.
Glossary of Abbreviations
|CDC||Centers for Disease Control and Prevention, United States|
|DGMQ||Division of Global Migration and Quarantine|
|DHS||Department of Homeland Security|
|DOS||Department of State|
|HIV||Human immunodeficiency virus|
|NAAT||Nucleic acid amplification test|
|STI||Sexually transmitted infection|
|USCIS||United States Citizenship and Immigration Services|