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Updates on the Medical Examination of Aliens (Refugees and Immigrants)
Update: Image Formats from Digital Radiography Systems (Computed or Direct Digital Radiography) at Panel Physician Sites, effective June 1, 2008:
Posted May 28, 2008
This update provides technical information about digital image formats acceptable to CDC.
All refugees, immigrants, and other applicants who have a chest image obtained during medical screening overseas must bring a copy of that image into the United States. The chest image is used by receiving health departments in the stateside follow-up evaluation for tuberculosis (TB) infection and disease. For panel sites with digital radiography systems (computed or direct digital radiography), a recordable compact disk (CD-R) can now be substituted for a laser-printed film, if the image burned onto the CD-R is DICOM-standard* and noncompressed.
For panel physicians with digital radiography systems:
- Each applicant who has undergone a chest image overseas, even an applicant with no TB classification, must be provided with either a chest CD-R or a laser-printed chest film(s) by the panel physician. (The laser-printed image must be 100% in size.)
- The image(s) burned to the CD-R must be DICOM-standard and noncompressed. An average noncompressed chest image contains 8-10 MB of raw data. No rewritable (CD-RW) CDs should be used.
- Each CD-R must contain only one applicant’s images. (Images of more than one family member should not be burned onto the same CD-R.)
- Other image requirements still apply (e.g., clearly marked applicant name, facility name, and date of image exposure; appropriate positioning and degree of inspiration).
- The CD-R should be placed in an envelope marked on the outside with the applicant’s name, facility name, and date of image exposure. The envelope must fully enclose the CD-R and be sealed.
- The CD-R envelope should be given to the applicant with instructions to bring it into the United States and to keep it secure, so that it will be available for any follow-up evaluation.
- CD-Rs with raw data are superior to static radiographs (laser-printed films) because raw data can be optimized (e.g., contrast adjusted, magnified) by the interpreter. However, a laser-printed film is acceptable if the chest image cannot be burned onto a CD.
For receiving health departments in the United States:
- CD-Rs can be viewed in health departments or offices with analog (conventional film-screen) radiography systems or no radiography systems (see below)
- Many CD-R images are accompanied by a “viewer,” which allows the receiver to open and optimize the raw data of the image. If no viewer accompanies the image or if the accompanying viewer doesn't function on a particular computer, the receiver can download and use other viewers, such as ImageJ, a public domain, freeware viewer offered by the National Institutes of Health. It uses a Java image processing program and runs, either as an online applet or as a downloadable application, on any computer with a Java 1.4 or later virtual machine. Downloadable distributions are available for Windows, Mac OS, Mac OS X and Linux; technical instructions and a download can be found at http://rsb.info.nih.gov/ij/ .
- High-resolution monitors provide optimal viewing of CD-R images but are costly. As images obtained overseas have already been officially interpreted, they can be viewed for comparison on personal computers, if needed
Note: While digital radiography has distinct advantages over analog radiography, CDC supports the use of either digital (CD-R and laser-printed films) or analog (conventional film) formats for chest images of immigrants, refugees, and other applicants examined by panel physicians. Digitized analog images are not acceptable.
*Digital Imaging and Communication in Medicine
Update: Required Evaluation by Civil Surgeons for Tuberculosis (TB)
Posted March 9, 2007
Tuberculin skin test (TST) is required for all applicants 2 years of age or older.
The Technical Instructions for the Medical Examination of Aliens in the United States, June 1991 provided by the Division of Global Migration and Quarantine of the Centers for Disease Control and Prevention (CDC) state that all applicants 2 years of age or older are required to have a tuberculin skin test (TST) to determine whether the applicant is infected with Mycobacterium tuberculosis (TB). For applicants with a skin test reaction of 5 mm or greater, a chest radiograph is required.
Are there any situations in which the tuberculin skin test is not required for an applicant 2 years of age or older?
There are two situations in which the TST is not required. Applicants providing written documentation (with a health-care provider's signature) of a TST reaction of 5 mm or greater of induration or applicants who have a history of a severe reaction with blistering to a prior TST may be excluded from this requirement. Applicants in these two groups must undergo a chest radiograph. A verbal history from the applicant of a positive TST reaction is not acceptable.
Should a tuberculin skin test (TST) be administered if a BCG vaccine has been given in the past?
Yes. Because many BCG-vaccinated applicants have lived in areas where TB transmission is common, the civil surgeon must perform the TST on all applicants, regardless of a history or evidence of BCG vaccination, unless one of the two exceptions to TST administration noted in question #1 above exists.
How should the civil surgeon interpret the tuberculin skin test (TST) if the applicant has received BCG in the past?
There is no way to distinguish TST reactions caused by BCG vaccination from those caused by natural infection. Because many BCG-vaccinated applicants have lived in areas of the world where TB transmission frequently occurs, the civil surgeon should perform a chest radiograph on all such applicants who have a skin test reaction of 5 mm or greater of induration.
Update: Information on Td Shortage
The supply of adult tetanus and diphtheria toxoids (Td) should now be sufficient to administer the vaccine to applicants applying in the United States for adjustment of status or permanent resident status, who require Td as recommended by the U.S. Advisory Committee on Immunization Practices (ACIP) [detailed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5124a5.htm]. Now that Td is available to permit the resumption of the routine schedule, civil surgeons should review the vaccination of applicant applying for adjustment of status and administer Td as appropriate.The automatic waiver for Td vaccination that has been in effective from February 1, 2001, through October 31, 2002, will not be extended.
Update: Clarification of panel physician (overseas) medical screening recommendations for applicants younger than 15 years of age
Posted December 12, 2006
Concerning the medical screening by panel physicians of applicants younger than 15 years of age, the following guidelines should be followed:
- Each applicant undergoing screening must have a chest X-ray if he or she has a history of tuberculosis (TB) disease, has signs or symptoms of TB, or has possible exposure to TB disease (such as having been in contact with a family or household member with possible TB disease).
- Routine tests are necessary if there are reasons to believe possible infections exist (such as having a parent or parents known to have HIV or syphilis infection).
- The panel physician should use his/her discretion in determining the need for testing for infections such as TB, HIV, or syphilis if the medical history of the mother or parents is unknown (such as in an orphan or child from a group home).
Update: Action To Be Taken by Civil Surgeons Due to the Measles-Mumps-Rubella (MMR) and Varicella Vaccine Shortages
Updated June 2002
The Division of Global Migration and Quarantine (DGMQ) of the Centers for Disease Control and Prevention (CDC) has discussed the current measles-mumps-rubella (MMR) and varicella vaccine shortages with the National Immunization Program at CDC and the U.S. Immigration and Naturalization Service (INS).Applicants applying in the United States for adjustment of status or permanent resident status are required to have received vaccination against vaccine-preventable diseases, such as MMR and varicella, as recommended by the U.S. Advisory Committee on Immunization Practices (ACIP). MMR and varicella vaccines are in short supply at present, and the following recommendations are provided for civil surgeons.
For MMR
During this time of vaccine shortage, although there is no waiver for the first MMR vaccine, an automatic waiver may be granted for the second dose of MMR vaccine if vaccine supplies are insufficient to provide the second dose. If MMR vaccine is not available, applicants should be referred to the local health department.If the health department does not have sufficient MMR vaccine for the first dose of vaccine, the civil surgeon must wait until the vaccine is available to medically clear the applicant. If the vaccine is not available, antibody testing to determine immunity to measles, mumps and rubella should be performed.
For varicella
In response to the current shortage of varicella vaccine, the following prioritization of vaccine use are provided for civil surgeons who do not have adequate supplies to vaccinate all applicants who do not have a reliable written or oral history of varicella disease. Because of the increased severity of disease among adolescents and adults and the highest incidence of disease in elementary school-aged children recommendations for use (highest to lowest priority) of varicella vaccine for susceptible persons are:
- Applicants 13 years of age and older
- Children 5 to 12 years with focus on children entering school and adolescents 11 to 12 years.
- Children 2 to 4 years who attend a childcare center.
- Children 2 to 4 years who do not attend a childcare center
If varicella vaccine is not available, applicants should be referred to the local health department. Until adequate supplies of varicella vaccine are available, vaccination of children less than 2 years of age will receive an automatic waiver. If the health department does not have sufficient varicella vaccine for applicants 2 years of age or older, an automatic waiver for varicella vaccine will be allowed. Health providers should implement a call-back system when the vaccine becomes available so that unvaccinated applicants can be identified and recalled for vaccination.Because the Supplemental Form to I-693 (Adjustment of Status Applicant's Documentation of Immunization) does not have an "unavailable in country" box for vaccines, it is necessary for the civil surgeon to indicate in writing on the form, "referred to health department and vaccine unavailable." The automatic waiver for varicella vaccination and for the second dose of MMR vaccination is effective from January 1, 2002 through July 31, 2002. At the end of July 2002, the situation will again be evaluated and, if the shortage continues, the time period could be extended.
Update: Action To Be Taken by Civil Surgeons Due to the Td Shortage
Last revised March, 2002
The Division of Global Migration and Quarantine (DGMQ) of the Centers for Disease Control and Prevention has discussed the current Td (tetanus and diphtheria toxoids) and TT (tetanus toxoid) shortage (detailed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5010a3.htm) with the U.S. Immigration and Naturalization Service (INS), Washington, D.C. The INS will address this issue in the field guidance for district and local INS offices it is developing, using similar guidance given when the influenza vaccine was unavailable last year (not considered to be an issue this year); therefore, an automatic waiver will be allowed for Td vaccination. Because the Supplemental Form to I-693 (Adjustment of Status Applicant's Documentation of Immunization) does not have an "unavailable in country" box for vaccines, it is necessary to indicate on the form, "not available."However in the interim, some INS offices might not be aware of the waiver. If civil surgeons encounter problems with local INS offices, please contact DGMQ (Fax: 404-498-1633, Attention Visa Medical Activity).The automatic waiver for Td vaccination is effective from February 1, 2001, through October 31, 2002. At the end of October, the situation will again be evaluated and, if the shortage continues, the time period could be extended.
Update: Medical Examination Required for new 'V' Nonimmigrants, October 2001
The Legal Immigration Family Equity (LIFE) Act of December 2000 created a new nonimmigrant status (V) which allows certain spouses and minor children of lawful permanent residents to reside and work in the United States while waiting to obtain immigrant status.
For Civil Surgeons
Eligible persons living in the United States applying for the 'V' nonimmigrant status are required to have a medical examination (Form I-693) completed by a designated civil surgeon. The vaccination supplement is not required.
For Panel Physicians
Eligible persons living abroad applying for a 'V' nonimmigrant visa with the Department of State at the U.S. Embassy or Consulate are required to have a medical examination (OF-157 or DS-2053 and worksheets) completed by a panel physician. The vaccination supplement is not required.
Update: Health care provider guidance for HIV and RNA viral load testing on newly arriving immigrants and refugees and returning visitors from Africa or other overseas locations
Certain enzyme immunoassay (EIA, or enzyme-linked immunosorbent assay [ELISA]) screening and Western blot confirmatory tests used in the United States reliably detect human immunodeficiency virus type-1 (HIV-1) infection, but not HIV-2 infection. Some HIV infections acquired in Africa, especially West Africa, might be HIV-2, and escape detection using assays optimized for HIV-1. Therefore, health care providers who perform HIV tests on people who might have been exposed in Africa (such as returning visitors or newly arriving immigrants and refugees) should use EIAs that are licensed for detection of both HIV-1 and HIV-2.Additionally, most commercially available tests that screen for HIV RNA viral load are effective for HIV-1 subtype B, but not other HIV-1 subtypes (such as A, C, D, or E). Many HIV infections acquired outside the United States might be HIV-1 non-B subtypes. Therefore, when testing people for viral load who might have been exposed in Africa or other overseas locations, assays that are effective for multiple HIV-1 subtypes (HIV-2 viral load tests are not commercially available) should be used.For the complete Guidelines for Laboratory Test Result Reporting of Human Immunodeficiency Virus Type 1 Ribonucleic Acid Determination: Recommendations from a CDC Working Group.
Update for Health Care Providers (refugee health programs and civil surgeons): Revised guidance for treating immigrants and refugees with latent tuberculosis (TB) infection (LTBI)
Twenty-one cases of severe liver injury associated with a 2-month rifampin and pyrazinamide (RIF-PZA) regimen for LTBI have recently been reported to the Centers for Disease Control and Prevention. Because of the numbers of patients treated for LTBI is unknown, comparative risk estimates for liver injury in patients receiving the 2-month rifampin and pyrazinamide regimen compared to other LTBI regimens cannot be estimated at the present time. CDC is currently investigating risk factors and rates for liver injury associated with the RIF-PZA regimen; in the interim, the American Thoracic Society and CDC, with the endorsement of the Infectious Diseases Society of America, have made recommendations that supercede previous guidelines (detailed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5034a1.htm).Treatment is still recommended for foreign-born people with LTBI who have resided in the United States for less than 5 years and who are from countries with a high prevalence of TB. Nine months of daily isoniazid (INH) remains the preferred choice of treatment; 4 months of daily RIF is an acceptable alternative. RIF-PZA may be used in selected cases, but requires more intensive clinical and laboratory monitoring than previously recommended.