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International Adoption Tuberculosis FAQs

As a parent adopting a child from a country outside of the United States, screening for tuberculosis (TB) is important to protect both the health of your child and, depending on the age of your child, people with whom your child interacts. The process can be confusing, so we hope answers to these Frequently Asked Questions (FAQs) are helpful to you and your family.

  1. What is TB and how is it spread?

Tuberculosis (TB) is a disease caused by bacteria that are spread from person to person through the air. TB bacteria get into the air when a person with TB disease in the lungs or throat coughs, speaks, or sings. These bacteria can stay in the air for several hours, depending on the environment. TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. People with TB can die if they do not get treatment. TB disease is different from a latent tuberculosis infection (LTBI). A patient with LTBI is infected with the TB bacteria (Mycobacterium tuberculosis), but does not have active TB. Active TB can be contagious while LTBI is not. It is not possible to get TB from someone with LTBI.

  1. Can children spread TB disease to others?

A young child can spread TB to others, although the chance of that happening is much less likely than it is for a pre-adolescent, adolescent, or adult who has TB. Doctors have more concern about a young child possibly spreading TB if the child has (1) a chest X-ray showing TB in many areas of the lung or one or more cavities (holes) in the lung; (2) a forceful and productive cough; or (3) known exposure to a person with multidrug-resistant TB (MDR TB) (see question #3) when the person with MDR TB was infectious (could spread TB disease to others). There have been several cases in which a child was found to be infectious and spread TB to others. These cases highlight the need to use caution when assuming that children with TB cannot spread the disease.

  1. How serious is TB disease?

TB is among the top 10 causes of death in the world. TB is the leading cause of death among people with known HIV infection, and one of the most common infections in people with weakened immune systems. Although the number of TB cases is still declining in the United States, the speed of decline has slowed since 2000. A four-drug regimen is usually used to treat TB disease. This is called first-line treatment. MDR TB caused by TB bacteria resistant to the best two first-line TB drugs (isoniazid and rifampin) remains a concern. This type of TB is both difficult and expensive to treat. Extensively drug-resistant TB (XDR TB) is caused by TB bacteria resistant to the most effective first- and second-line TB drugs. Thus, XDR TB is much more difficult to treat than MDR TB. Although XDR TB is very rare in the United States, it is much more common in certain parts of the world and the number of cases appears to be rising worldwide.

  1. What kind of medical exam does my child need to obtain an immigrant visa to enter the United States?

As required by US law, any child or adult who is applying for an immigrant visa to enter the United States needs an overseas medical exam, which includes testing for TB. This medical exam must be conducted by a panel physician, a doctor who has an agreement with the local US embassy or consulate to perform the exam according to Technical Instructions (requirements) determined by the US Centers for Disease Control and Prevention (CDC).

According to CDC’s Technical Instructions, several factors affect the choice of TB tests for a child. These include:

  • The child’s age
  • Whether the child has
    • Known HIV infection
    • TB signs or symptoms, or
    • A past personal history of TB disease
  • Whether the child is undergoing the panel physician examination in a country with a TB disease rate ≥ 20 TB cases per 100,000 people.
  1. What does each TB test involve?

Tuberculin Skin Test (TST)

A TST is performed to determine if your child has an immune response to TB. A TST can have a positive result because of TB infection or TB disease.

  • A TST is performed routinely in children 2-14 years of age who are examined in countries where TB disease rates are ≥ 20 cases per 100,000 people. In these countries, it is also performed in children younger than 2 years of age with known HIV infection or TB signs or symptoms. In countries with a TB disease rate < 20 cases per 100,000 people, a TST is required in any child younger than 15 years old with known HIV infection or TB signs or symptoms.
  • The test is performed by a healthcare worker, who injects a small amount of fluid (called tuberculin) just under the top layer of the skin of your child’s lower arm.
  • After 48-72 hours, your child returns to the healthcare worker, who looks for a raised, hard area or swelling at and around the injection site. A raised area measuring 10 millimeters or more is a positive TST test result, indicating that your child needs a chest X-ray to distinguish between TB infection and TB disease.

Interferon Gamma Release Assay (IGRA)

  • This is a blood test that can be conducted instead of a TST to detect and measure your child’s immune response to TB bacteria. It can have a positive result because of TB infection or TB disease.

Chest X-ray

  • This is an X-ray of your child’s lungs that is performed if your child has a positive TST or IGRA test, known HIV infection, TB signs or symptoms, or a personal history of TB disease.

Sputum Samples (3 total)

  • Sputum samples are needed if your child’s chest X-ray suggests TB disease, or if your child has a known HIV infection, or TB signs or symptoms. Under the direct observation of a trained healthcare worker, your child produces three samples of sputum (mucus that is coughed up) that are collected and tested for TB bacteria.
  • A child who is unable to cough up enough sputum for testing has the options of sputum induction or an early morning gastric aspirate.
    • In sputum induction, your child is given an inhaler with saline solution (a mixture of salt and water) to help him or her cough up sputum. This can work well if your child is old enough to cooperate with directions.
    • In an early morning gastric aspirate, a tube is passed through your child’s nose and used to collect from your child’s stomach lung mucus that your child has swallowed. This method can be very helpful if your child is too young to follow directions to cough.

Sputum Smear (3 total)

To confirm whether your child has TB, the sputum sample is processed, placed on a slide, and examined for TB bacteria under a microscope. There are several types of bacteria that can resemble TB, and therefore a positive smear is only suggestive of TB, and a negative smear does not rule it out that the child has TB.

Sputum Culture (3 total)

To confirm whether your child has TB, the sputum sample is processed, placed in a tube with growth nutrients, and stored in a lab for 8 weeks, where medical professionals watch for the growth of TB bacteria.

  • Sputum culture is the most accurate laboratory test that doctors can use to determine whether your child has TB disease.
  • If your child has TB, the bacteria should grow and be visible within 2-8 weeks, which means a positive diagnosis of TB disease. Because TB bacteria often grow slowly, a full 8 weeks must pass to allow the bacteria to grow.
  • If your child does not have TB disease, no growth of the bacteria will be present by the end of 8 weeks. This is called a negative TB diagnosis. However, sometimes, even if the laboratory tests are negative, if your child has persistent TB signs or symptoms, the doctor may make a clinical diagnosis of TB disease because not treating TB can have severe consequences.

Drug Susceptibility Test (DST)

If your child has a positive sputum culture, this laboratory test determines which medications can kill the TB bacteria. Based on the results of this test, doctors will be able to select and give your child the TB medications that are most effective against the strain of TB.

  1. What TB tests are required for my child to enter the United States?

In order to determine which TB tests are required for your child, you must first determine what the rate of TB is for the country in which your child is having their panel physician exam. The CDC accepts the World Health Organization’s Tuberculosis country profiles to determine the rate of TB disease for any given country.

Tuberculosis Algorithm: Countries With Incidence < 20 Cases per 100,000 Population

Tuberculosis Algorithm: Countries with incidence > 20 cases per 100,000 population

(click to enlarge)

Tuberculosis Algorithm: Countries With Incidence ≥ 20 Cases per 100,000 Population

Tuberculosis Algorithm: Countries with incidence < 20 cases per 100,000 population

(click to enlarge)

  1. How long do the results of the TB tests typically take?
TB test times
TB Test
Time typically required
TST
2-3 days
IGRA
less than a week
Chest X-ray
2-3 days
Sputum smears
1-2 days after last of 3 sputa collected
Sputum culture
8 weeks
DST
2-4 weeks

In recent years, molecular tests for TB (such as the GeneXpert MTB/RIF® and the Hain GenoType® MTBDR plus assay) have been developed to help diagnose patients with TB disease more quickly. While the results of these rapid tests are available more quickly than the results of the sputum culture test, studies have shown that they are less accurate than sputum culture tests. Because a molecular test cannot detect TB as well as a sputum culture, a negative molecular test result does not completely rule out that your child has TB. Therefore, sputum culture testing must still be completed before your child can be cleared for travel to the United States.

TB is treated with a combination of antibiotics determined by your child’s strain of TB. If your child is receiving medication to treat TB, a healthcare worker or other trained person will watch your child swallow each dose of medication. This treatment is called Directly Observed Therapy (DOT), and is the standard care. DOT typically takes at least 6 months to complete.

  1. Why do the TB tests my child needs depend on whether he or she has known HIV infection?

TB disease is the leading cause of death among people with known HIV infection and one of the most common diseases for people with weakened immune systems. Additionally, HIV infection is the most common risk factor that can cause latent (inactive) TB infection to become (active) TB disease. Without treatment, TB disease can be fatal. Therefore, it is especially important for people with known HIV infection to be tested for TB.
Because HIV infection weakens a person’s immune system, and some of the TB tests measure a person’s immune response to the TB bacteria, people with known HIV infection and TB may

  • Test negative on the TST or the IGRA and the chest X-ray, BUT
  • Test positive on the sputum smear and especially the sputum culture.

Therefore, to accurately determine whether people with known HIV infection have TB disease and to help them receive appropriate medical care as quickly as possible, they are required to undergo multiple tests.

  1. My child with known HIV infection is required to have a sputum test even if his or her chest X-ray is normal. Why can’t the chest X-ray be skipped?

If your child has known HIV infection, he or she must have a TST or IGRA (if younger than 15 years of age) and a chest X-ray before the sputum smears and cultures. Some people with HIV infection and TB disease in the lungs don’t have enough of an immune response to show their lung TB on chest X-ray; others will show TB disease in the lungs on X-ray.  For those who do show lung TB disease, the panel site radiologist can compare the panel physician examination chest X-ray with chest X-rays taken during and after treatment to help determine whether the medication your child is taking is effectively curing the TB disease.

  1. Prior to adoption, my child visited my family in the United States with a hosting program and was not required to have TB testing. Why must my child now undergo testing before being cleared for travel to the United States?

Children participating in hosting programs usually visit the United States on tourist visas. Under the Immigration and Nationality Act (INA), people applying for a tourist visa are not required to have a medical examination. However, also under INA, people becoming permanent US residents, such as your child, are required to have an immigrant visa. To apply for an immigrant visa, your child is required to have a medical exam, which includes testing for TB.

  1. After arriving in the country of adoption, do I have to wait until after the adoption paperwork is finalized to begin the TB testing process?

You may not have to wait. In many countries, CDC has worked with the adoption agencies, US Consular Sections, and panel physicians to have children evaluated by a panel physician before the adoption process is complete. The adoption agency, orphanage, or the Consular Section of the US Embassy with whom you are working in the home country of your child may be able to help with having the required medical exam performed before you arrive in country.

  1. I have heard of children with TB being granted a waiver to travel to the United States before their TB treatment is complete. What does this waiver process involve, and who qualifies for this waiver?

People who have TB and are applying immigrants to the United States must complete their medical treatment before traveling to the United States. However, for people with TB whose medical situation suggests that they would benefit from receiving their TB treatment in the United States, the Department of Homeland Security’s US Citizenship and Immigration Services (USCIS) may grant a waiver (also called a Class A waiver for TB) allowing them to travel to the United States before the end of their TB treatment. To learn more about Class A conditions, please see the Class A Conditions and the Waiver Process page.

  1. I’ve heard that some children are given an exemption to travel to the United States before sputum smears and culture samples have been examined. Who qualifies for this exemption?

Immigrant applicants (including internationally adopted children) older than age 10 cannot travel to the United States until culture results are ready.  However, applicants 10 years of age or younger who require sputum cultures, regardless of HIV infection status, may travel to the United States immediately after sputum smear analysis (while culture results are pending) if none of the following conditions exist:

  • Sputum smears are positive for acid-fast bacilli (AFB). If the applicant could not provide sputum specimens and gastric aspirates were obtained, positive gastric aspirates for AFB do not prevent travel while culture results are pending.
  • Chest X-ray that shows―
    • One or more cavities, or
    • Widespread TB disease in the lungs (especially in the upper area of the lung)
  • A forceful and productive cough
  • Known contact with a person with MDR TB who could have spread TB at the time of contact
  1. Are the TB screening requirements for any child or adult who is applying for an immigrant visa to enter the United States new?

The current TB screening requirements, called the Technical Instructions for Tuberculosis (TB) Screening and Treatment using Cultures and Directly Observed Therapy (DOT) were most recently updated in 2009. However, these requirements were first created in 1991, and have been updated throughout the years. These Technical Instructions have been implemented on a country-by-country basis since 2007. As of October 1, 2013, the Technical Instructions are being used by all countries that screen immigrants and refugees coming to the United States. These Technical Instructions include tests and procedures for diagnosing TB sooner and more accurately.

 

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