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From the Centers for Disease Control and Prevention
July 9, 2008

Notice to Readers: Revised Technical Instructions for Tuberculosis Screening and Treatment for Panel Physicians

JAMA. 2008;300(2):164. doi:10.1001/jama.300.2.164

MMWR. 2008;57:292-293

CDC's Division of Global Migration and Quarantine (DGMQ) has released the 2007 Technical Instructions for Tuberculosis Screening and Treatment for Panel Physicians. These revised technical instructions and a list of the populations whose applicants for U.S. immigration are being screened in accordance with them are available at http://www.cdc.gov/ncidod/dq/panel_2007.htm.

CDC has U.S. regulatory authority over overseas medical examinations for immigrants, refugees, and asylees immigrating to the United States.* Panel physicians, who are appointed by the U.S. Department of State, perform overseas medical examination of applicants for U.S. immigration in accordance with technical instructions provided by DGMQ.

The previous technical instructions for tuberculosis screening have been in effect since 1991. Under the 1991 instructions, applicants aged ≥15 years are required to have a chest radiograph and provide three sputum smears for acid-fast microscopy if the chest radiograph is suggestive of active tuberculosis; however, no cultures (or drug-susceptibility testing) are required. Applicants who are sputum smear-positive must undergo treatment until they are smear-negative before traveling to the United States, but the 1991 requirements do not specify the therapy they should receive.1 In addition, the screening algorithms used for the 1991 instructions are insensitive and miss smear-negative, culture-positive cases2; the algorithms also are inadequate to prevent importation of multidrug-resistant tuberculosis into the United States.3

To address these shortcomings, CDC has updated the tuberculosis technical instructions, and several important changes have been introduced. Applicants with chest radiographs suggestive of tuberculosis now are required to submit three sputum specimens for both sputum smears for acid-fast microscopy and mycobacterial culture. Drug-susceptibility testing is required to be performed on positive cultures. Before immigrating to the United States, applicants in whom tuberculosis disease has been diagnosed must complete treatment, which must be administered according to American Thoracic Society/CDC/Infectious Diseases Society of America guidelines and under a directly observed therapy (DOT) program. Guidance has been added for evaluation of contacts of tuberculosis patients. To reduce the risk of immigrants becoming infected with tuberculosis or activating latent disease, the period for which the examination is valid for travel has been reduced to 6 months for applicants with a normal evaluation and 3 months for applicants with a Class B1 classification (Table). The tuberculosis classification system also has been modified to better reflect the tuberculosis status of the applicant and to help ensure follow-up upon arrival in the United States.

CDC is working with the U.S. Department of State, panel physicians, the International Organization for Migration, and other organizations to implement these changes. The technical instructions are being implemented first in priority countries, as determined by immigration patterns and tuberculosis burden. By the end of 2007, applicants for U.S. immigration screened according to the new technical instructions included all applicants from Mexico, the Philippines, Nepal, and Thailand. CDC will notify state and local health departments when panel physicians in a country begin implementing this revised algorithm.

REFERENCES

3 Available.

*Medical examination of aliens. 42 CFR, Part 34.

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