TB Technical Instructions for Civil Surgeons: Implications for Health Departments
April 3, 2013
E. Napolitano:
Good afternoon and welcome to the first medical update of this year. Today's
web-based seminar is entitled, TB Technical and Instructions for Civil
Surgeons – Implications for Health Departments.
My name is Eileen Napolitano and I am the Deputy Director of the New
Jersey Medical School Global Tuberculosis Institute. Today's program is
sponsored by the institute.
The objectives of this webinar are listed on the slide. TB control programs
have the responsibility and expertise for diagnosing and treating suspected
unconfirmed TB cases. Civil surgeons are to refer such cases to TB programs
as part of the medical evaluation for adjustment of status applicants. The
webinar will describe the roles of both partners and demonstrate how
appropriate application of the Civil Surgeon TB Technical Instructions can
make for better patient care and reduce transmission of TB in the community.
This webinar was developed for Health Department staff to create a better
understanding of the requirements for civil surgeons.
Our speakers today are Ms. Roselyn Brown-Frei, Dr. Mary Naughton, Ms.
Kelley Bemis, and Dr. Felicia Dworkin.
The seminar today will consist of several parts. After this introduction and
some brief housekeeping details, Ms. Brown-Frei will start us off with the
background and overview of the roles of civil surgeons and the adjustment of
status process. Then, Dr. Naughton will talk about the implementation of the
Civil Surgeon Technical Instructions for tuberculosis. We'll then hear from
Ms. Kelly Bemis, who will share information from the knowledge and
awareness survey. And finally, we'll end with the case presentation by Dr.
Felicia Dworkin.
R. Brown-Frei:
Excellent, good. Thank you very much.
Good afternoon and good morning depending on where you're located. Thank
you very much for having me. Again, my name is Roselyn Brown-Frei and I
also want to introduce Melissa Lin. Melissa Lin is my co-worker and we're
both adjudication officer at the United States Citizenship and Immigration
Services or short USCIS.
USCIS is part of the Department of Homeland Security and one of the
agencies which oversees legal immigration to the United States. In
accordance with this mandate, we adjudicate petitions and applications filed
by foreign nationals who would like to come to the United States either
temporarily or permanently.
So, last year, we handled over 4 million of such requests.
Today, I'm going to give you a presentation. In this presentation, I'm going to
talk about immigrants, why so many pending immigrants may seek
adjustment of status, why w have health-related grounds of inadmissibility
and why they are important to this process and the roles of all players – CDC,
the applicants, civil surgeons, health departments and also USCIS. I will
explain who civil surgeon is and also how one can become a civil surgeon.
Immigrants. We're talking here about immigrant and medical examination.
And an immigrant is a foreign national who seeks to permanently reside in the
United States. In contrast, there are individuals who come to the United
States but only for a temporary period. These individuals are called nonimmigrants and examples of whom are, for example, students who come to
study in the United States, temporary workers, or visitors for business or
pleasure.
Yet, others come to the United States because of humanitarian concerns and
they typically can remain in the United States as long as they satisfy that
concern. Examples list here are refugees and asylees who cannot return to
their home countries because of a past or a future well-founded fear of
persecution. To clarify, an immigrant is not a U.S. citizen. Before one can
apply to become a U.S. citizen, you have to be in the United States for quite a
considerable amount of time.
There are two ways to obtain immigrant status, depending on where you're
located. One is inside the United States or from outside the United States. If
an individual is outside the United States, he or she can apply at the U.S.
consulate abroad, which is the Department of State. If all paperwork is in
order then the consulate will issue then the visa that allows you to travel to the
United States and to enter as an immigrant.
These individuals who are coming like that as an immigrant are examined by
a physician from the Department of State so-called a trusted panel physician.
Because these individuals enter as immigrants, they do not need to seek
adjustment of status and they will also not be examined by civil surgeon.
However, if the individual is inside the United States, because they've entered
for example as an immigrant, he or she can get their immigrant status via
adjustment of status. And by the way, immigrant status is also often referred
to as green card.
The application for this process is filed with USCIS. And if it's approved, the
USCIS will issue the green card. These individuals generally need a medical
examination that is conducted by a USCIS civil surgeon and that’s what we’re
talking here about.
The requirements for adjustment of status vary depending on the category
under which the individual seeks adjustment of status. So, it typically doesn’t
matter when the individual comes in to the United States as long as once they
seek adjustment of status needs the legal provision under which he or she
seeks adjustment.
Typically, individuals seeking adjustment must be beneficiaries of a petition
and the petition is a request from a sponsor, such as a family member and an
employer who wants that individual to come to the United States. The type of
the petition determines then under what category the individual seeks
adjustment. Sometimes, however, the law allows for adjustment of status
because of the individual status alone or that is somewhat rare in the law it is
the case for refugees and asylees. So, typically, refugees and asylees can seek
adjustment of status if they have been present in the United States for one year
and if they otherwise meet the legal requirements of the law.
Irrespective or regardless of the category under which the individual seeks
adjustment, all individuals must be admissible to the United States before their
application can be approved. Inadmissibility is a condition that applies to the
individual and does not allow him or her to remain in the United States. There
are many reasons in the law why an individual cannot come to the United
States when inadmissible. For example, if an individual has committed a
crime, there are certain grounds of inadmissibility that will bar him or her.
However, the grounds in inadmissibility that matter most in this webinar are
of course the health-related grounds of inadmissibility and they're listed here –
communicable diseases of public health significance, failure to show proof of
required vaccinations, mental disorders with associated harmful behavior,
drug abuse or drug addiction. These conditions that the three there listed other
than the vaccinations are called Class A conditions and they make an
individual inadmissible and an adjustment of status application would not be
successful.
It is CDC, the government agency that determines what type of conditions
meet these inadmissibility grounds and what an individual can do in order to
not be inadmissible. For this purpose, CDC publishes regulations that address
the health-related grounds of inadmissibility and also issues guidelines,
technical instructions for the medical examination of aliens in the United
States that details the parameters of a medical examination.
If an individual is inadmissible on one of these grounds, they can, in most
cases seek a waiver. If the waiver is approved, then the individual may enter
the United States despite the inadmissibility. The condition of the waiver is
strongly oriented on the purpose of the medical examination ground or
medical inadmissibility ground and that is to protect the public health of the
United States. The waiver will only be granted if the individual gets the
appropriate treatment once in the United States.
Class A conditions are the conditions that make an individual inadmissible,
according to CDC's regulation. An individual may have another medical
condition upon coming to the United States as an immigrant, but these
conditions do not necessarily make the individual inadmissible. And there are
also typically other reasons why we would deny adjustment of status. In the
immigration world, both of these conditions are called Class B condition and
an example is diabetes.
Because all individuals coming to the United States must be medically
admissible, each foreign national who is an immigrant to the United States
must undergo the medical examination. This is where the role of civil surgeon
will come in, because immigration officers of course do not have any medical
knowledge. The admissibility determination is made by an adjudications
officer of USCIS based on the result of the medical examination conducted by
a civil surgeon.
So, medical grounds of inadmissibility, by the way, are in effect since 1882
and the medical examination at that time was conducted by the Public Health
Service as individuals were coming to the United States at the border.
According to the record of Ellis Island, for example, the initial medical
examination was called the six-second exam because that’s about how it
lasted just about six seconds. And it consisted of public health officers
observing immigrant looking upstairs to the Great Hall of Ellis Island to
determine whether an immigrant had a condition that would hinder him or her
to work or to take care of himself or that will pose a public health risk. So,
nowadays, the technical instructions are probably a little bit more detailed.
So, now, as we have kind of the basis on what is adjustment of status, I'm
going to summarize the roles of the players in the adjustment of status process
and let's start with CDC. So, CDC defines communicable diseases of public
health significance, as we said in earlier slides. It determines the vaccination
requirements. It promulgates regulations for the health-related
inadmissibility. They assess the parameters of the medical examination of
aliens in the United States. These technical instructions, by the way, are
binding on all of the players at the force of regulations and are listed here at
the website.
Finally, CDC advises USCIS if USCIS has to grant a waiver, because again
we cannot determine whether somebody has made sufficient arrangements to
treat the Class A condition; so they advise us.
Adjustment of status applicants. In general, an adjustment of status applicant
is required to have at some point in time of their immigration history a
medical examination. So it depends again a little bit on whether the person
seeks the status inside or outside the United States, but the extent of a medical
examination for an adjustment applicant is typically depending on the
category of the adjustment and also whether the individual has been examined
abroad.
For example, a nonimmigrant who is seeking adjustment of status has
typically not been examined abroad before coming to the states. So, if they're
seeking adjustment, they will have to have a full examination by a civil
surgeon.
A refugee, in contrast, if they're seeking adjustment of status, they typically
has been examined outside the United States and so once they seek adjustment
of status in the United States that medical examination is typically good
except for the vaccination requirements that the refugee has not received
overseas.
The role of the civil surgeon. The adjustment of status applicant will have to
make an appointment with the civil surgeon to complete the medical
examination before filing the adjustment of status applicant with USCIS. A
civil surgeon is a U.S. designated physician who has applied with USCIS to
be designated and who is a licensed MD or DO in the state in which he or she
conducts the medical examination. In addition, they must have four years of
professional experience.
Once designated, it is the duty of the civil surgeon to conduct the medical
examination according to CDC's Technical Instructions and also to complete
the results of the medical examination on Form I-693 that he or she then gives
to the applicant.
How do applicants find civil surgeons? Civil surgeons – their contact
information is listed on USCIS's website and it's at the link that I'm providing
at the end of the slides.
Sometimes, adjustment of status applicants have to go and see a civil surgeon
but then the civil surgeon may refer the adjustment of status applicant to
another physician or a Health Department. The reason for that is that it is the
duty of the civil surgeon to make referrals when required on the Technical
Instructions. And these referrals are sometimes either based on the fact that
civil surgeons found the TB condition or that the civil surgeon is otherwise
unable to make a diagnosis.
The Technical Instructions then require the civil surgeon to refer the
individual for further medical evaluation to the appropriate Health Department
in the case of TB or to another physician who can assist with resolving the
uncertainty. Whether there's a risk or not, it is the civil surgeon's duty to
complete the appropriate parts of the Form I-693 in order that the department
or this physician who actually receives the referral.
Finally, the role of the Health Department, of course, they administer the TB
control program in the United States and they do so irrespective of whether
the person is an immigrant, a U.S. citizen or - really doesn’t matter.
However, Health Departments may see the individual who is an adjustment of
status applicant if the civil surgeon who is required to refer the individual to
the TB Control Program after the medical examination reveals a TB concern.
The second function listed here has really nothing to do with the adjustment of
status process that Health Department administer health-related programs for
certain populations in the United States and these populations include refugees
and asylees who are eligible for health benefits based on the Department of
Health and Human Services mandate.
The third point, however, here has a lot to do with adjustment of status. So, in
general, Health Department physicians are blanket designated civil surgeons
who can complete the vaccination portion of the Form I-693 if the refugee is
seeking adjustment of status and Health Departments can only do that for
refugees, not for any other adjustment applicant. So, remember that I
mentioned that an individual who is a refugee and who seeks adjustment of
status does not need a full medical examination, because the refugee has
generally been examined abroad.
So, to make it easier for the refugee populations who are also recipients of
HHS benefits, USCIS blankets the Health Department physicians so that they
complete the medical assessment – the vaccination assessment of Form I-693.
A blanket designation means that the Health Department does not have to
apply for civil surgeon designation. And as long as the physician who is
employed by the Health Department meets all the requirements of the civil
surgeon and completes the form in accordance with the instructions of Form I693, USCIS will accept that documentation as part of the adjustment of status
application.
Finally, the role of USCIS. So, once the individual files his or her adjustment
application, including they have to submit all the paperwork including the
medical examination results, USCIS will adjudicate the application. As part
of that adjudication, we will verify that the applicant has received the required
medical examination from the civil surgeon and that the individual is not
inadmissible. If the individual is inadmissible, USCIS will adjudicate the
waiver request filed by the individual after having consulted with CDC and
the appropriate treatment. Finally, USCIS designates civil surgeons and of
course they administer the civil surgeon program.
In the next slide, I summarized kind of the process and you can take your time
maybe after the seminar, to look at them and if you have any questions we
will be happy to answer them. And here, I also summarized some of the
information where you can read up on immigration and adjustment of status
and also the civil surgeon.
And that will be for me and I'm looking forward to answering any questions at
the end of the seminar.
E. Napolitano:
Thank you very much, Roselyn, for sharing that clear description of
immigrants and the roles of all the partners in the status adjustment process.
Next, we'll hear from Dr. Mary Naughton. Dr. Naughton is a medical officer
with the Immigrant, Refugee and Migrant Health Branch in the Division of
Global Migration and Quarantine at the Centers for Disease Control and
Prevention. She will talk with us today about the civil surgeon's requirements
in the evaluations of adjustment of status applicants.
Mary, we'll turn it over to you.
Mary Naughton: Thank you.
So, I'll be talking to you today about – a little more about inadmissible
conditions, about the role the Division of Global Migration and Quarantine
and its partners and the civil surgeon examination, about the Technical
Instructions themselves, a bit about the role of Health Departments as
delineated in the Technical Instructions and then we'll just go through a few
frequently asked questions.
So, let's go on to the medical examination of aliens, the regulation. So, again,
the inadmissible or the Class A condition, communicable diseases of public
health significance. So, we're just talking about the communicable diseases
here that are inadmissible. They are active tuberculosis, Hansen's disease in
its infectious stage, untreated syphilis and then the other sexually transmitted
diseases when they are untreated.
As far as health department interaction with U.S. Immigration, I wanted to get
may be a little more specific than Roselyn did. We're talking about two
distinct groups and she did talk about the medical examinations completed
overseas by the panel physicians. And the Health Department will generally
see this population soon after their U.S. arrival. So, these will be immigrants
or refugees who arrived with TB classifications and you will then perform the
follow up or for refugees you will perform the comprehensive Health and
Human Services-funded post-arrival screening. So, you'll be seeing them
immediately after they come to the U.S. and they will have had panel
physician exams overseas.
And then, the second group is the change of status medical examination
group. So, these exams are performed by civil surgeons by and large these
applicants did not have a panel physician exam overseas. One example would
be the nonimmigrant visa holders and they basically can adjust status at any
time, depending on their category. The exception, as Roselyn was
mentioning, includes refugees who do undergo the exam overseas, but must
see a civil surgeon or a designated health department for the vaccination
requirements. So, they don’t receive the vaccines or the required vaccines
overseas, but must have them to adjust status one year or more after arrival.
And the only time that a refugee would require a full exam by a civil surgeon
is if they entered the U.S. with a Class A condition. And I just want to also
comment that it's very unusual for CDC to recommend that anyone enter the
U.S. with Class A condition. So, we recommend for a very few Class A TB
waivers and it's generally for children. And it has actually been – in my
memory it has been a couple of years since we've had a request for a Class A
waiver for someone adjusting status in the U.S.
So, as far as civil surgeon activities go for our division, our partners are the
Division of TB Elimination and then USCIS. USCIS administers the civil
surgeon program and they have had oversight of the civil surgeon program. In
distinction, it's clear that Division of Global Migration and Quarantine has
oversight of overseas medical screening. So, we do have oversight of the
panel physician program.
The Civil Surgeon TB Technical Instructions were released in 2008. There
was an important update in 2009 about the option of using IGRAs in place of
the tuberculin skin test. On our website, we have the TIs and the updates plus
frequently asked questions. The USCIS website contains the I-693 form that
the civil surgeons need to complete, the instructions for that form which
address the concerns of the applicants and the civil surgeon and also FAQs
about the form.
I just want to show you a few screenshots of the Technical Instructions. So,
as you can see, here's the title and all you have to do to go to these Technical
Instructions you actually don’t have to know the whole link. If you just
Google or otherwise search for CDC and civil surgeons, the link will come up
to the Civil Surgeon Technical Instructions. And so, this is one of the
Technical Instructions, you know. There are separate ones for vaccinations,
for the sexually transmitted diseases, for Hansen's disease, but there's a menu
along the left side of the page and you select the TB Technical Instructions.
So, here's the title. Here's the table of contents. And if you put your mouse
over any of these lines in the table of contents and click, it will take you
directly to the portion in the TIs that you need to look at. So, we can see here,
there's a portion on role of the civil surgeon in the health department. This
goes through past medical history, review of symptoms and then down here, it
gets more into the workup. It talks about the chest x-ray. I think what's
important to you required referrals to the TB Control Program of the local
health department recommended referrals and then talks about classification
of applicants and includes latent TB infection needing evaluation for
treatment. So, down the very bottom here, you can see there's a few
appendices and those include a few tables and charts, which again go into
referrals.
The civil surgeon role - this just includes a few of the roles of the civil
surgeon, but they are to confirm the applicant's identity by comparing facial
appearance and signature with the government's document. We want to make
sure or they should make sure that the person who is showing up for the
examination and also this should be done at the time that blood is drawn, that
the chest x-ray is taken is truly the person who is applying for the immigration
benefit; so applying to adjust their status. They are responsible for
administering the skin test or arranging for the IGRA and Appendix A and the
TI goes through, DTBE’s instructions about applying a TST. And they are
responsible for establishing a working relationship with the local health
department TB control program in order to report suspected and confirmed
TB cases as mandated by law and perform required and recommended
referral.
The required workup for TB includes cell-mediated immunity testing for
applicants two years or more of age in the U.S. This is different from
overseas where we have different requirements. But in the U.S., the applicant
is two years of age or greater. They have to have a TST or IGRA and this to
determine if a chest x-ray is needed. So, if the TST is 5 millimeters or greater
or the IGRA is positive, then a chest x-ray is required.
Sputum smears and cultures are required if the chest radiograph suggests TB,
if there are signs or symptoms of TB or if there is immunosuppression; if
there's HIV infection 15 milligrams of prednisone for one month or greater or
the equivalent or a history of organ transplant. And one thing that should be
said, however, is that the civil surgeon is required to refer the person to the
health department if the chest x-ray is suggestive of TB. So, while we say that
sputum smears and cultures are required, we expect these actually to be done
at the health department. And the referral to the health department is needed
because, as we know, the expertise for diagnosing and treating TB in the U.S.
resides at the health department and, you know, with very few exceptions.
So, we want the civil surgeons and we require the civil surgeons to actually
take advantage of that expertise. And we certainly don’t require referral
before the chest x-ray. But if the chest x-ray is suggestive, we do require the
referral.
Drug susceptibility testing if the culture is positive and then it's the civil
surgeon's responsibility, not the Health Department to properly classify the
person for tuberculosis. And that’s according to the Technical Instructions
and this goes back to the regulations. This reflects the Class A and Class B
designations that are in the federal regulation, so it's actually not the ATS
classification. Also, directly observed therapy throughout the course of
treatment for Class A TB and this is also what's required for overseas.
We do have this exception for cell-mediated immunity tests. If there are prior
positive results that are documented, then the civil surgeon can go directly to
chest x-ray. But there has to be written documentation by a healthcare
provider of a TST result that is 5 millimeters or greater or of a prior positive
IGRA that’s the most recent IGRA.
The only exception we make or we would accept history that’s oral from the
applicant is if there's a history of severe reaction with blistering to a prior
TST. And, as I said, in the above circumstances then the civil surgeon would
go directly to a chest x-ray. And we say that they cannot perform another type
of cell-mediated immunity test; that they need to go with one type or another.
The chest radiograph is required for all applicants with a TST that’s 5
millimeters or greater of duration or positive IGRA or if there are signs or
symptoms of TB or immunosuppression. And the chest x-ray should be
interpreted by a radiologist or other qualified physician who is trained and
experienced in reading chest radiographs, demonstrating TB or other diseases
of the lung.
The 2008 TB Technical Instructions require a chest x-ray. For women who
are pregnant, this chest x-ray can be performed during or after pregnancy, but
it must be performed before the civil surgeon can complete the examination.
The safety of the fetus must be considered in terms of childhood cancer. The
dose of radiation for a single chest x-ray is so low that we're really not worried
about adverse effects on the fetus, but other than childhood cancer which
would occur of course at a later time. But we do expect that the radiology
facility would be able to instruct the woman on the pros and cons of
undergoing radiation and would double lead shield the woman with the wraparound shield, which is what is routinely required in the U.S. for radiating
pregnant women.
And again, there's no requirement or recommendation for a civil surgeon to
refer an applicant through health department to obtain their chest radiograph.
As was mentioned by Roselyn, if a civil surgeon can't obtain a particular
service or make a diagnosis or classification, they are required to make a
referral. But it would be hard to imagine that there is a place in the U.S.
where a health department would be the only place that a chest x-ray could be
obtained. I used to practice is a very small rural area and there were other
facilities for a chest x-ray other than a health department.
Again, here we talk about required versus recommended referral to the health
department TB Control Program required referral if the chest x-ray is
suggestive of TB disease. And there is a glossary in the back of the TIs which
lists the findings for active or more suggestive of an active TB so it goes
through cavities, consolidation, adenopathy, certainly miliary disease, but also
talks about nodules whether they're well-defined or ill-defined, retraction. So,
it lists quite a variety of findings that can be suggestive of TB.
Certainly, there's required referral for signs or symptoms of TB and the
required referral for extrapulmonary TB is so that further investigation can be
made by a Health Department if needed. Recommended referral is for latent
TB infection needing evaluation for treatment. When we wrote these
Technical Instructions, we consulted quite frequently and closely with the
Division of TB Elimination. And at the time, they felt that we could not
require the referral for treatment for latent TB infection. Or, we couldn't
require the referral for LTBI, because not all Health Departments could
provide the treatment for LTBI, so they wanted the referral to be
recommended.
We cannot require treatment for LTBI, because the inadmissible condition is
active tuberculosis. It's not latent tuberculosis. And this is something that
we're looking at changing in the future. We had recent discussions with
DTBE, but as it stands, based on what DTBE told us at that time we can't
require the referral and based on regulations we cannot require the treatment
for LTBI.
But we do say and we make this clear three different places in the Technical
Instructions that it's the responsibility of the civil surgeon to speak with the
local health department to find out what their capabilities are. And if the local
health department can't treat for latent TB, what are the local health
department's recommendations can they make referrals to other places that
could provide treatment or can they guide the civil surgeon to do treatment for
latent TB infection. So, we make clear that there needs to be good
communication between the civil surgeon and the local health department.
Again, here we talk about why refer to the health department and of course it's
because TB – this is for active disease – TB is a significant public health
problem especially in the foreign born. TB patients in the U.S. are now in
common in private practice. Diagnosis and treatment issues have increased in
complexity, especially with drug-resistant TB directly if there's therapy as
needed for TB disease and the health department conducts contact and source
investigations.
This is what the TIs say about the role of the local or state health department,
to provide or arrange training in appropriate skin testing technique, provide or
recommend experienced radiology departments and radiologists to perform
and interpret test radiographs, evaluate applicants with abnormal radiographs
suggestive of TB disease, perform or refer mycobacteriology lab work,
provide TB case management and treatment including DOT and contact or
source case investigations, and provide or facilitate the evaluation and
treatment of applicants found to have latent TB infection needing an
evaluation for treatment.
This graph is rather busy here and I just want to draw your attention to the
green boxes. And these are the boxes where there is required referral to the
health department. And it says at the blue boxes that if the chest radiograph is
suggestive of active or inactive pulmonary disease, there is a required referral
to the health department TB control program for further evaluation. Likewise,
if there are signs or symptoms of TB regardless of the TST results and this
would also say the IGRA result or the chest radiograph findings, there should
be a referral to the health department. For radiographic or other findings
suggestive of extrapulmonary TB disease, there should be a referral to the
health department TB control program to further evaluate for extrapulmonary
TB. And the recommended referral is for the latent TB infection.
And after the referral is made to you, to the health department and you fill out
your portion of the form then that goes back to the TI, say – and actually as
the instructions for the I-693 form, say, that then goes back to civil surgeon
and they're responsible for filling out the remainder of the form. And the
instructions for the I-693 form also say that you should receive the entire
original I-693 form. The civil surgeon should make a copy of the form and
keep that in their office; so you should receive the original with the portion
filled out from the civil surgeon saying, "Why there is a required referral?"
They won't fill out portion out if they refer someone to you for latent TB
treatment. The portion on the form that needs to be filled out is only for
required referral.
And again, this is a busy table, but it again says – I'll see if I can bring this up
to show you. Yes, so this column here does refer to health department for
further workup and it shows where it's required. But this table actually is a
little confusing, because it shows that if the person ends up as a Class A, there
was a required referral. But it goes down here and shows basically, if the
chest x-ray is abnormal, there is a required referral. For latent TB, the referral
is recommended and it also tells the civil surgeon then how they should –
what boxes should be checked on the I-693 form.
These are the classifications that are used by the civil surgeons and these
again are based on the regulations that Class A is inadmissible so that Class A
pulmonary TB disease is inadmissible. And you might ask what inadmissible
is in someone who is already in the U.S. and Roselyn could explain this better
and may at a later time to you, but it means that their process will be held up
and they will not be getting their green card to become an immigrant until
they complete their treatment and then become a Class B.
And as I was saying before, following required referral to the health
department, the applicant returns to the civil surgeon with your evaluation and
treatment results and the applicant must complete treatment before they can be
cleared by the civil surgeon, so before their process can continue to get their
green card. If they are worked up by you at the health department and their
smears and cultures are negative, the civil surgeon can give them a B
classification and clear them for the TB portion of the examination.
And after you complete your referral and the civil surgeon signs the form,
they include your portion that you have filled out when they send the form
into USCIS. So, if you bring anything extra other than what is on the form
itself, they're required to send that into USCIS.
And again, latent TB treatment, the civil surgeon would not fill out the form
referral, does not defer medical clearance and starting ttreatment does not
defer medical clearance to divisions that I discussed earlier. The most
common criteria for referral are TST – I would think TST greater than or
equal to 10 millimeters or positive IGRA and an applicant from a country with
a high TB prevalence and applicants who have been in the U.S. less that five
years. But the Civil Surgeon Technical Instructions include the other criteria
for referrals. So, it would include persons with a TST that’s 5 millimeters or
greater, who say have HIV or persons with a TST that is 10 millimeters or
greater who have certain clinical conditions that place them at higher risk such
as diabetes. And in that second category, of course, children less than four
years of age or children or adolescents exposed to adults in high-risk category.
So, this is included in the text of the Civil Surgeon TIs and it's also included in
Appendix C of the Civil Surgeon TIs. So that the civil surgeon when they are
making referrals to the health department, they should include the information
about what other high-risk factors are so that you're aware of them.
A few FAQs here to finish up. If the applicant has an abnormal chest
radiograph which the civil surgeon do and all should be referred to the TB
control program of the local health department for further evaluation, should
applicants with clinical signs or symptoms suggestive of TB disease?
Should the civil surgeon communicate with the TB Control Program of the
local Health Department about the availability of latent TB infection
treatment? Yes. And this is a long answer that doesn’t fit on the slide. But as
I say, we go through this in three different areas in the Technical Instructions
that they should contact the TB Control Program of the local health
department to ascertain local policies and procedures and in turn to talking
about, you know, some health departments have more resources than others
and may have to concentrate on active disease more than latent disease.
And can the civil surgeon medically clear the applicant for TB even if the
applicant is going to receive treatment for latent TB infection? And the
answer is “yes.” And as I say, in the future this may change as we work more
towards, you know – we would need a change in the regulations actually in
order to do this. But this is something that may happen in the future and this
of course would be another way in order to have more people receive latent
TB treatment and decrease the pool of possible active TB in the future.
So, to contact us, as I said, you can use the long link or you can search for,
you know just CDC and civil surgeons. We can be contacted at CDC through
CDC-Info. And I have a picture on the next page here I believe, this is CDCInfo. You just put your subject, your email address and then your query. They
have a roster of questions that we have given to them with answers so that
they can answer the easy questions. If it isn’t an easy question, then it's
bumped up to us and there are about three of us in our group here in DGMQ
who answer civil surgeon questions. And so, I'm one of them, Dr. Drew
Posey is another and Pam McFadden is another.
And so, I answer questions from civil surgeons this way. I also receive phone
calls from civil surgeons and because I've give my card at some of the civil
surgeon trainings that we've had on site. And in the past, we had these, I
believe it was about three or four years ago and USCIS was able to put on
onsite civil surgeon trainings in various cities and they funded me to
participate in those. And they were for civil surgeons and for adjudicators and
in some cities for the general public. So, those are some of the ways that we
have to contact – refer civil surgeons to contact us for information.
And also, we do hear from health departments. I don’t know how many of
you might have contacted us when you have questions about civil surgeons,
about the Technical Instructions or about civil surgeon practices. And we are
open of course to hearing from you and from adjudicators also.
So, thank you.
E. Napolitano:
Thank you, Mary, for your presentation on the requirements for civil surgeons
related to the TB exam, for clarifying for us so nicely the roles of civil
surgeons and health separtment.
We will next hear from Ms. Kelley Bemis. Kelly is a Council of State and
Territorial Epidemiologists and CDC fellow with the Connecticut Department
of Health.
Kelly, the mic is yours.
Kelley Bemis:
Great. Can everybody hear me?
E. Napolitano:
Yes.
Kelley Bemis:
Great. Hello, everyone.
As Eileen just said, my name is Kelly and today I'm going to be reviewing the
results of a study we recently conducted in New England, California, and
Texas regarding TB screening practices of civil surgeons.
So, before we begin, I just like to go over two definitions and abbreviations
that I'll be using for the rest of my presentation. And unless you're just joining
us, these should look pretty familiar.
Status adjustors who I'll be referring to as ‘SA’ are foreign-born individuals
who apply to adjust their immigration status to permanent residents while in
the U.S. And civil surgeons who I'll be referring to as CS are the licensed
physicians who perform medical examinations for this purpose.
And since Roselyn and Mary have already covered who the civil surgeons are
and what they're required to do by the Technical Instructions, I'd like to
introduce our study by discussing our motivations rather than giving you extra
background. As Mary said in her presentation, the relationship between civil
surgeons and Health Department is really…
Attendee:
Can you speak louder?
Kelley Bemis:
Sure. Is this better?
TB among the foreign born is a significant public health problem and state or
local health departments are uniquely prepared to ensure that these cases are
treated correctly and to investigate potential transmission.
CS screening and the subsequent link to the health department can provide
opportunities to treat and screen cases as well as opportunities to treat latent
infection. Furthermore, educating and training CS for those public health
goals such as increasing screening among high-risk individuals, and treating
active and latent disease. In our study catchment area alone, there were over
200,000 applications for permanent residency filed in 2011.
So, if we estimate that approximately 18 percent of these people are infected
with latent TB, which is the most recent prevalence estimate available. This
means that there could have been around 40,000 opportunities for diagnosis
and treatment of TB infection in this group.
So, given the public health importance of CS screening, the state health
departments of New England decided to partner with California and Texas to
investigate the characteristics and TB testing practices of civil surgeons in our
region. We were also interested in whether CS TB screening differed by
practice type or awareness of a Technical Instructions or TI.
Beginning in July 2011 and ending in May 2012, surveys were mailed to all
CS and viable contact information on the USCIS website in Connecticut,
Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, which will
be grouped together as New England for the rest of the presentation, as well as
California and Texas.
The CS were sent two mailings and then received a series of follow-up phone
calls if their survey was not received. Fifty percent of the surveys were
returned in California, 55 percent were returned in Texas, and 84 percent in
New England. The survey contains questions regarding the CS’ medical
training and type of practice. There are TB screening procedures, as well as
two case scenarios in California and Texas and one case scenario in New
England.
Responses were then analyzed with descriptive statistics, and associations
were tested with Chi square, Fisher’s Exact or t-tests, depending on the type
of variable. So now, I’ll go into our results. The majority of civil surgeons in
all three regions were in private independent practice, ranging from
approximately 59 percent in New England to 98 percent in Texas. The
number of years as a civil surgeon and the number of SA evaluations
performed were highly variable within each region. However, the medians
were similar across the three regions.
The majority of survey respondents reported reading the technical
instructions. However, there were still 15 to 20 percent in each region who
either did not read instructions or weren’t sure if they had. Almost all of the
CS use appropriate test to screen for TB, although, IGRAs did not appear to
be very popular among our respondents.
One percent or fewer use chest X-rays to screen. However, this proportion
rose over 14 percent in California and Texas when CS were evaluating BCGvaccinated applicants. Also problematic, over a third of civil surgeons did not
select the proper cutoff of 5 millimeters for TST interpretation in status
adjustor exams.
Fortunately, when the CS were tested on the same knowledge using the case
scenario which is described in yellow on the side, around 80 percent in each
region did answer correctly. The vast majority of respondents would obtain a
chest X-ray for all SA with a positive TST or IGRA as required by the TIs.
However, many would not obtain chest X-rays for SAs who would be
evaluated regardless of TST result. Approximately 2/3 of respondents would
obtain a chest X-ray for SA with symptoms suggestive of TB, and under half
would obtain a chest X-ray for immunosuppressed applicants.
When a CS encounters an applicant with suspected TB disease, a large
majority would either report or refer the case to the health department.
However, 10 to 20 percent of respondents in each region would not.
Furthermore, when asked about a case with an abnormal chest X-ray
suggestive of healed TB, less than half of our respondents recognize that this
applicant would still require referral to the health department for evaluation
per the TIs.
Finally, when CS were asked about their response to applicants latently
infected with TB, around 90 percent would either refer for treatment or start
treatment themselves, an encouraging result.
In addition to describing behaviors and knowledge, we also look more in
depth at 6 key study variables to see if they vary by practice type or awareness
of the TIs.
We discovered that among our respondents, CS and private practice evaluate
more status adjustors and are generally more adherent to the technical
instructions. However, CS who practice out of community health centers are
more likely to recommend LTBI treatment.
We also discovered that awareness of the TIs is associated with correctly
interpreting a TST and obtaining chest X-rays for all of the groups required by
the TIs. However, it does not have an impact on whether a suspected case is
reported or whether LTBI treatment is recommended.
So, to summarize all of those results, the respondents on our survey appear to
be moderately adherent with the technical instructions. At the initial
screening step, they use appropriate tests, but might not be interpreting them
correctly. At the screening step – oh excuse me. Proper screening of BCG
vaccine SA could also be reviewed.
At the next step, CS are very good at obtaining chest X-rays for SA with
positive screening tests. However, they do not always obtain them for
immunosuppressed or symptomatic SA. And finally, upon completion of the
civil surgeon's evaluation, respondents in our survey were likely to report or
refer suspected disease to the health department and to recommend treatment
for latent infection.
However, it's extremely important that all civil surgeons are reporting
suspected active disease and then, even ambiguous cases, such as those that
appear have failed TB are evaluated further. These findings suggest that CS
would benefit from more frequent trainings on the technical instructions.
These trainings should review the major components focused on recent
changes and details that might have been overlooked when the CS reviewed
the TIs on their own.
Additionally, resources should be provided to help CS handle difficult or
ambiguous cases. As Mary mentioned, civil surgeons are already able to
contact CDC for questions regarding the TIs, but ensuring that CS also have
contact information for their state or local health department for other
questions requiring TB expertise would be helpful.
Any communication with the CS, whether it's through trainings or informal
discussions, one on one with the health department should emphasize current
priorities in TB control, such as supporting all active cases or treating latent
disease. And finally, we would recommend that health departments try to
build relationship with their local USCIS office. These relationships would
facilitate information sharing that could be used to target trainings with civil
surgeons or to assist in ongoing assessment of their adherence and knowledge.
And with that, I can turn it back to Eileen.
E. Napolitano:
Thank you, Kelley, for sharing those interesting results of the civil surgeons’
survey.
Next, we will hear from Dr. Felicia Dworkin, the Deputy Director for Medical
Affairs in the New York City Bureau of TB Control. She will share a case
presentation that will illustrate some of the discussion we have had today.
Felicia.
Felicia Dworkin: Thank you for having us speak this afternoon. So, we're going to present a
case that we see patients in New York City all the time. We have five chest
clinics that we, that the Department of Health uses to see TB patients as well
as well as patients admitted for – being brought from civil surgeons, being
referred to them.
So, the case today is a 79-year-old woman, and she was sent by a civil
surgeon for evaluation of a positive TST. The skin touch was 10 millimeters
as reported by the civil surgeon, and it was actually reported negative a few
years prior so she would be considered a conversion. She gave a history of
high blood pressure, diabetes, asthma and some esophageal reflux, and on
examination and history taking, she had no symptoms and signs of TB at this
time.
And this is her X-ray and here's the pointer, so up here, if you can see, there
might be some densities at the left apex, and maybe you could see them on the
lateral as well. And here’s an apical lordotic view which shows the densities
again.
So, like I said, the X-ray was reported officially by our radiologist later as
having bilateral apical linear changes. There was also a retrocardiac hiatal
hernia and maybe an infiltrate. The physician that saw her in her clinic
collected three sputums appropriately as this was an abnormal X-ray. And
when we consider anybody as a suspect, and we want to collect sputums, we
have to report that patient as a suspect to our program.
The smears actually were negative, and the cultures were of course, pending
cultures. The civil surgeon actually called our physician who saw this patient
and asked what was the delay in completing the form and 693 form. And, we
discussed this over the phone with the physician saying, you know, when we
do a wet reading in our clinic before the official radiologist – before the
official radiology report comes out, we do a wet reading, so the actual report
takes about a week to come back. And now, because she's awaiting sputa to
be finalized, that takes eight weeks, and we weren't going to fill out the 693
form because now she's pending as a possible TB case.
So, our recommendations actually at that time with the discussion of the civil
surgeon was because the patient had a X-ray findings that were abnormal, and
a new positive TST, we actually recommended that the patient can take four
TB meds for the first two months, and if the cultures were negative, then give
INH and rifampin for two more months and be treated for LTBI or the patient
can actually wait for the cultures to be negative and then take LTBI therapy.
And we would need to decide at that time if the culture – if the patient actually
had culture-negative TB or would we want to consider this patient as having
latent infection.
So, in discussion with the patient, the patient actually chose to wait for her
therapy, for her culture result and not take any therapy, either for suspected
disease or for LTBI. So, just to – just to give an overview of what actually
happens in New York City, we have, as I looked on the website, there are over
200 physicians that are listed as civil surgeons, just in the New York City five
boroughs alone. That doesn’t include the outlying areas.
Patients actually come to our health department clinics usually after the civil
surgeon has evaluated the patient from the skin test, maybe have done an X-
ray. Of course they usually refer them because the skin test or QuantiFERON
is positive. Usually, what ends up happening is the X-ray is actually done at
our health clinics, at our chest clinics. On occasion, the physician, the civil
surgeon will refer a patient with an X-ray that’s already been done. Maybe it's
abnormal, it might be actually normal.
On the other hand, if the patient only comes with the report, and the X-ray is
reported as abnormal by report, we will repeat the X-ray in our clinic, so we
can actually see what the abnormality is. And we do this as part of filling out
the patient’s 693 form. We only – we usually get from the civil surgeon, we
usually get a referral, not the required referrals as written out on the form,
which is usually sent as a separate referral with the form the patient brings
with them. And usually, in our clinic, in my experience, I will get the form,
the part of the form that I need to fill out. So, that tends to be a little
concerning because we're not really sure what other conditions the patient
may have. And sometimes we actually have to call a physician to find out
what else is going on with the patient if the patient doesn’t want to give too
much information.
We also tend to find out that the patient needs the form so that as soon as
possible, if there's an X-ray with an abnormality, obviously that’s not
possible. So, we thought this would be a good illustration of how we work
with civil surgeons. We usually work very well with them. Sometimes we
have some difficulty, sometimes there are concerns, but we usually have a
very good rapport with the civil surgeons that send patients to our clinic.
Thank you.
E. Napolitano:
Thank you, Felicia, for sharing this example of a civil surgeon referral to the
New York City Health Department.
We now have some time for discussion and questions. Joining the speakers
on the panel are Ms. Melissa Lin from the Unites States Citizenship and
Immigration Services, and Dr. Diana Nilsen from the New York City Bureau
of TB Control, and Dr. Lynn Sosa from the Connecticut Department of
Health.
I would now like to post the first question to Dr. Mary Naughton. Mary, how
are the recommendations in the presentation about the civil surgeon
knowledge survey being addressed and what are some other potential
opportunities being such as training, medical management resources and
required protocols for civil surgeons.
Mary Naughton: And thank you all for the presentations. It's quite interesting, and thank you,
Kelley, for the survey presentation and results. I would say, you know, to this
first question about trainings, I agree that trainings would be more helpful –
you know, more trainings would be helpful. And I don’t know if Roselyn
might want to say something at some point here.
USCIS at this point, they’ve conducted, about a year ago had some webinars
that we participated in, and that CDC participated in that concentrated a lot on
the form, which is what USCIS has to deal with, the I-693 form. And we
provided some of the medical. If you look at those webinars, I think you'll see
a lot about the forms, but was spoken on about the seminars themselves was
actually, a lot of it was about the medical requirements.
But I – you know, and I said before that, we did on-site trainings, but you
know, due to fiscal limitations, it looks like USCIS may not be able to
continue doing those and CDC isn’t able to do those. So, I think it would be
great if there are other venues for training and if DGMQ, DTBE and the
RTMCCs and the states and USCIS might be able to collaborate, I think that
would be a great idea. I think it would be helpful to have the state and local
health department points of view included.
Mary Naughton: So, I think that would be helpful to be able to collaborate on the trainings.
And I think it also is helpful that in addition to CDC having some, you know,
for us being able to answer the questions of civil surgeons and others that the
state health departments make themselves available, not so much to answer
questions about the technical instructions, which we realize are very technical
because this is a legal examination and the civil surgeons are required to do
some things differently than they might do in their other practice or that other
physicians will do in their regular practice, but to help and you know.
I think Kelley said this, help improve the communication, because in our TIs,
we say that the civil surgeon should communicate with their local health
department. And if the local health departments then would even be in the
state health departments, could make their contact information more available,
I think that would help, you know, from both sides.
As far as reporting suspected disease, I think most of the time, if the civil
surgeons are following the technical instructions, the diagnosis is going to be
made by the health department, because they won't be doing the smears and
cultures themselves. I think it would be relatively rare that somebody would
be appearing for an exam where they're symptomatic or where they would
actually tell the civil surgeon their symptomatic because this is an
examination for a legal purpose to gain admission to the U.S.
But again, that would be helpful for the civil surgeons to communicate with
the local health departments about who exactly is doing the reporting of the
case, so that it's very clear between the two who is doing the reporting. And
you know, we did talk over some, I think in our individual presentation, some
of the current limitations for, you know, there is a current limitation, and that
we can't require treatment of LTBI before someone is adjudicated and given a
green card, because the regulations address active tuberculosis, not latent
tuberculosis.
And this is the legal examination according to the regulations, but that may,
you know, it's supposed to be something that we will be addressing or maybe
addressing in the future. It's something that we've discussed here at CDC.
And of course, please keep in mind that the wheels turn very slowly in
government. This would require a change in the regulations, which means
something needing to be created, go through many levels of clearance, then go
to the federal register and get comments, you know. It's a long process, but it
is something that could possibly be done in the future that would help in this
regard.
So, those would be my comments, and I would just have one – I do have one
question for some of the, and this is for Kelley, we could address this at some
point. I’d be interested on the fellow who was 42 years old and was
Congolese and had findings the granulomous disease. If you were talking
about, if you ask the civil surgeon, if that was supposed to be an example of
LTBI, and if so, were they asked if they were required to refer, or a was a
recommended referral needed. Thank you.
E. Napolitano:
So, Kelley, that question then posed to you.
Kelley Bemis:
Sure. Can you guys here me? Am I unmuted?
E. Napolitano:
Yes, you are.
Kelley Bemis:
Great. So, that question was added by our California team. So, as far as the
intent, unless maybe one of them is on the webinar today, I believe the goal
was to test to see whether the civil surgeon would pick up that that was a
required referral. And the way the question was phrased is the case now was
presented, almost identical to how it was presented on the slide, and then we
just ask the civil surgeon what will be your next step.
And then, we gave them a list of options that included referral to the health
department, but I also included the required referral to a specialist, referral to
a primary care physician. I believe that do nothing was perhaps an option,
obtain a CT scan. And so, we look to see whether or not that referral to the
health department box is checked, either in itself or in a combination of
responses.
E. Napolitano:
Excellent. Thank you, Kelley. We have quite a number of questions that
have come in through the question and answer box. So, one of the first
questions, I think, would go to Roselyn, and that question is, is there any
recertification process for civil surgeons?
R. Brown-Frei:
Yes. Currently, once you've designated and you meet the licensing
requirements, there are no recertifications, but the local offices do those. It's
the local office that – it is the local offices that designate civil surgeons. They
do yearly checks. They also check on the licensing requirements, so that there
is no recertification program currently.
E. Napolitano:
Thank you very much. Another question which either can go to you or to
Mary. In general, how much time does it take or how much time is allotted
for an individual to go through the status adjustment process? Is there a time
frame in which they need to finish?
R. Brown-Frei:
It depends a little bit on when an individual is filing for adjustment of status,
but the medical examination always has to take place before the individual
even files with USCIS. So, the medical exam is kind of a snapshot in time on
the medical state, and then the documentation is submitted as part of – for the
officer to evaluate the medical inadmissability.
There is as much time as the individual needs, and it's as part of the gathering
all their required evidence for the adjustment of status package. It could be
that at some – so if the individual submits the assessment of status package
together with the medical examination, but an officer would see that
something was not done properly or that an officer might see that some tests
were missing, in this case, the form I-693 are turned to the applicant and the
applicant is instructed to return to the civil surgeon to perform the particular
test.
In this case, there is a time limit on it of 87 days. But that’s really the only
time. The technical instructions really function in a way that the civil surgeon
follows everything properly and individual is not medically inadmissible. So,
there should be nothing missing at the time, they submit the I-693. Does that
answer the question?
E. Napolitano:
Yes. I think that does. So then, there was another question about medical
inadmissibility which you may have just answered. That question was what
happens to applicants that are medically inadmissible and waiver is not
granted?
R. Brown-Frei:
Well, that individual would not be allowed to stay in the United States, very
technically. But as the technical instructions set out, really individuals are
treated for a condition, and then, this condition can be reclassified as a class
B, and that does not render an individual medically inadmissible.
So, if everything follows, is set up through the technical instructions, no
waiver should be needed, and has been fairly infrequent based on what Mary
also confirmed.
E. Napolitano:
Right. Thank you. Next question relates to temporary visitors. Why don’t
we require students, temporary workers or long-term visitors to have any
medical screening?
R. Brown-Frei:
So, I'll take that question again. So, the numbers of individuals coming to the
United States is fairly large. We have – I saw that question and I quickly
Googled the Office of Immigration Statistics, and we have about 2 million
permanent non-immigrants residing in the United States and we have over 159
million foreigners coming to visit the United States very brief and temporarily
under a separate submission. It doesn’t count as how many people coming to
the United States.
But everybody has to be medically admissible to the United States. There's
such a high number of coming in temporarily. It's probably more of a risk
assessment. It will be a question that maybe goes towards the State
Department that issues visas and also CDP who admits individuals to the
United States, but it's just a very large number. If an officer at the border
generally has the impression that something is wrong with the individual they
will order the individual is examined.
Mary Naughton: Mary, I can also answer that if you would like.
E. Napolitano:
Yes.
Mary Naughton: It's something that I mentioned earlier where I said we were looking into the
possibility of screening certain populations of non-immigrants. What we're
currently doing is we're looking into which of that – which subgroups of nonimmigrant visa holders have the highest likelihood of developing TB while in
the U.S.
So, one of the people in our group here has developed a model for looking at
this so that, you know, as we move – because this is a question that we've
asked for a while. While it would be very difficult to screen all non-
immigrant visa applicants, you know, that would make our program looking
just at them, not visitors and some of those other groups would be included in
that number that Roselyn gave.
If we were looking just at non-immigrant visa applicants, that would make the
program six to eight times larger than it currently is for immigrants and
refugees. And so, we're trying to narrow it down to certain groups that have a
higher risk for developing TB within the U.S., and look at the possibility of
screening them.
E. Napolitano:
Thank you. There are several questions that relate to the cut point for
tuberculin skin tests, and the fact that it is 5 millimeters in the immigrant
screening, and generally a 10 millimeter cut off would be used for foreignborn individuals who are already in the United States. Can you comment on
the use of the different cut points?
Mary Naughton: Yes. This is Mary again. I can comment. The 5 millimeters is for getting the
chest X-ray. The 10 millimeters is the same as – the cut points for LTBI
treatment are just the same as used throughout the United States. The 5
millimeters is for getting the chest X-ray, and what that 5 millimeters does is
it does allow you to include for referral for LTBI treatment, those people who
have findings on their chest X-ray suggestive of TB because you would refer
them for treatment at 5 millimeters, not at 10 millimeters.
Diana Nilsen:
So, Mary, this is Diana Nilsen. So, in New York City, we actually get
referrals for the chest X-ray from the civil surgeon that doesn’t – the group
that doesn’t do the chest X-ray for the patient. And we always run into a
problem with this because we would not get a chest X-ray for that 5
millimeter skin test. So, I know where you're coming from. So I think this has
always been a big source of debate among the people that are doing the actual
chest X-rays because a lot of this is a referral to us for the chest X-ray and the
evaluation and the filling of the form.
Mary Naughton: Well, actually, I would say that you should not be getting the referral for the
chest X-ray, and I would – you know, if you were the only facility in New
York City that did chest X-rays, I could understand why you're getting the
referral, but since you're not, I don’t – I don’t understand why you're getting
the referral.
I mean, I can say I don’t understand. I can think of a number of reasons why
you're getting the referrals for the chest X-ray, but I think it would be fine for
you to tell the civil surgeon that the requirement is for them to refer to you if
the chest X-ray that they obtain or have obtained is suggestive of TB.
Diana Nilsen:
OK.
Mary Naughton: Yes.
E. Napolitano:
OK. Thank you for that clarification. Another question also related to
tuberculin testing. A refugee post arrival screening, does this include a
tuberculin skin test for children two and under.
Mary Naughton: It's actually what you – it's up to you what you want to do and what your state
requires or what your state guidelines are. And actually, I guess we could
look up on, you know, I’m not involved in that aspect or in the guidelines for
post-arrival refugee screening. I know that some other members of our
division have put up some recommendations for post arrival TB screening on
our website, the DGMQ website. But my understanding is the way it goes is
often what the state, you know, what the state guidelines are.
E. Napolitano:
OK. Thank you.
Mary Naughton: Because actually, you know, the TIs, don’t, you know, we write the TIs for
the overseas screening, but then, don’t follow those overseas screening with
what should be done in the U.S. for people who have been screened overseas.
E. Napolitano:
OK. Thank you. A question for New York City. Does New York City have
any outreach or training programs that are directed toward civil surgeons?
Diana Nilsen:
No, we don’t. We do general World TB Day and many of the civil surgeons
are on the list, but we do not specifically target civil surgeons. We have
thought about doing it, but we have not done it specifically.
E. Napolitano:
A question has also come in regarding HIV infection. So Mary, I don’t know
if this is something that perhaps you can answer. And the question related to
why HIV was not considered a class A condition.
Mary Naughton: Well, as you probably know, it was considered a class A condition until the
beginning of 2010, and it had been considered a class A condition by law. So,
it was the only class A condition that had been determined in that way. All
the other ones had been determined by CDC.
And then, in 2009, it came off, it was no longer a legal requirement that it be
an inadmissible condition. And of course, it meant that it was inadmissible
not just for immigrants and refugees. It meant that if you were a visitor, you
could not come in to the U.S. with HIV, is my understanding. And so, what
happened when it was no longer a law, then it gave CDC the opportunity to
make the decision about inadmissible conditions that we had about every
other disease.
And it was decided at that point that it certainly wasn’t the situation that it was
easily transmissible, that it was a rare condition in the United States, and it
was felt that there were many people who were prevented from coming to the
U.S. who, you know, simply you know, for a two-week visit, for an HIV
conference for other reasons who should be allowed to come to the U.S., and
it wasn’t felt that the public health reasons stood up anymore to have it as an
inadmissible patient, and so it was removed.
E. Napolitano:
Thank you very much. Another question has come in through the question
and answer, relating to extrapulmonary TB. Again, I think this might go to
Mary. Is extrapulmonary TB or the suspicion on extrapulmonary TB a
referral to the health department and what are expectations around reporting
back to the civil surgeon?
Mary Naughton: That’s a good question. It is a required referral to the health department. The
reason for that is that it's felt that it's rare enough that the health department
would have the expertise in doing the workup and that the civil surgeon would
not. And again, the civil surgeon should fill out that required referral portion
of the form, and then the health department would fill out – you have a section
there where you fill out what you determined during the referral.
Extrapulmonary TB is a class B condition. So, as soon as you determine what
was going on, and the person was started on treatment, then you could fill out
the form and send it back to the civil surgeon. The fact that a person has
extrapulmonary TB won't slow down the adjudication process. The civil
surgeon can sign off on the form because it is by definition, extrapulmonary,
not pulmonary, so it's not transmissible, and it's not considered to be a public
health issue. I hope that answers your question.
E. Napolitano:
Thank you. So, I would like to open up the phone lines for – we have about
five more minutes. If anybody has a question for anyone of our speakers and
was unable to submit it through the question and answer feature, you can
unmute your phone and through pound six and ask your question. And then,
please remute yourself after your question is asked.
So, do we have any questions from the audience?
Female:
Yes, I have a question.
E. Napolitano:
Go ahead.
Female:
Why do we, as health departments, have to do the refugee assessment status
within a month of their arrival, because they’ve had one done before coming
to the U.S.
Mary Naughton: So, let me ask, are you talking about some – are you talking about class B
notifications or are you talking about the more general health assessment that
you do?
Female:
The class B.
Mary Naughton:
Well, the reason they haven't had a health exam generally, I mean, they have
– it's very rare, except for Mexico, that they have had a health exam within a
month of entry in the U.S. I mean, normally, it would be, you know, it would
be four months or it would be longer than that because they have three months
to enter the U.S. after their culture results are returned.
And for many people it takes that long to get through the process of coming
into the U.S. I'm not that familiar with many places where people enter as
soon as they have their culture results which would mean that it is two months
after they had their exam.
E. Napolitano:
Thank you very much, Mary.
I would like to thank all of the speakers and discussants today for great
presentations and answers to so many of our listener’s questions. And to all
of our participants, I thank you for joining us today and have a good
afternoon.
END