1. Screening International Adoptees
Drew L. Posey, MD, MPH
Team Leader, Medical Assessment and Policy Team
Immigrant, Refugee, and Migrant Health Branch
Intergovernmental Panel Physicians Training Summit
March 30, 2017
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

2. Learning Objectives and Agenda
After this session, you should be able to
Understand why we screen international adoptees
Know solutions to common conundrums

3. Question 1
You screen a 2-year-old orphan being adopted by US parents. Those parents ask why the child needs a medical exam. What is the best answer?
CDC Technical Instructions
Risk of communicable diseases
Immigration and National Act (INA)
Consular Section requirement

4. Adoptees in Immigration Law
Adoptees receive immigrant visa
Adoptees are subject to same medical screening requirements as all other applicants for immigrant visas
Therefore, Technical Instructions for the Medical Examination of Aliens applies

5. Question 2
You examine a 9-year-old adoptee in a country with a tuberculosis (TB) rate of 35 per 100,000. Which aspect of the Technical Instructions has an exemption for this child?
Physical examination
Tuberculosis
Mental health
Vaccinations

6. Vaccination Exemption
Amendment to INA
Adoptees 10 years of age and younger
Parents sign an affidavit
Vaccinations can be provided after arrival to the United States
Adoptees 11 years of age and older
Follow Vaccine Technical Instructions

7. Question 3
You diagnose a 7-year-old adoptee with TB disease. Which of the following are factors more specific to adoptees than other immigrants?
Parents live in another country
Family not from country of examination
Parents may have just met their child
Family already has travel arrangements
All of the above

8. Question 4
You examine a 5-year-old on anti-retroviral therapy. The parents want to confirm the HIV diagnosis. What tests are the panel physicians obligated to perform?
HIV-1/HIV-2 rapid test
Western Blot
Viral load
CD4 count
None

9. HIV Testing
Applicants on HIV treatment should be considered to be HIV positive
HIV testing not required for any applicant since January 2010
CDC unable to adjudicate whether an applicant has HIV infection

10. Tests with Known HIV Infection Any WHO TB Rate
<15 years old
TST or IGRA, chest x-ray, sputum smears and cultures
If culture-positive – DST
≥15 years of age
Chest x-ray, sputum smears and cultures

11. Tests Without Known HIV Infection WHO TB Rate ≥20 per 100,000
<2 years old
No tests if no signs or symptoms of TB
If signs or symptoms
TST/IGRA, CXR, sputum smears and cultures
2-14 years of age
TST/IGRA if no signs or symptoms
CXR if TST/IGRA positive
15 years old & up
CXR
If CXR suggests TB or if TB signs or symptoms
Sputum smears and cultures 

12. Question 5
The WHO TB rate in your country is 33 per 100,000. Your laboratory can no longer import purified protein derivative (PPD). One laboratory in your city performs IGRA. What should you do?
Suspend examinations for children until PPD available
CXR on all children 2-14 years of age
CXR on all contacts
Use IGRA from laboratory in my city
Perform Cepheid Xpert MTB/RIF on children with symptoms

13. TST or IGRA Required for applicants:
2-14 years of age if WHO-estimated TB rate ≥20 per 100,000 in country of exam
Who are TB Contacts
0-2 years of age with HIV infection or TB signs or symptoms, regardless of country’s WHO-reported TB rate
<15 years of age if known HIV infection or TB signs or symptoms, in countries with a WHO-reported TB rate <20/100,000

14. PPD Shortage Worldwide shortage of PPD
IGRA must be performed if TST or IGRA is required but PPD is unavailable

15. Question 6
A 9-year-old orphan is malnourished, has a chronic cough, has an infiltrate on chest x-ray, and is smear-positive. You begin treatment for TB. After speaking with the parents of the 5 year old, the family informs you they would like to seek a Class A waiver. When should you have first thought about the possibility of a Class A waiver?
When they arrived for their examination
When you knew the adoptee had HIV
When you saw the chest x-ray
When you made the adoptee Class A
When the family asked

16. Waivers
For applicants who are eligible and would like to complete treatment in the United States
Adoptee's parents should ask the Consular Section about the waiver process

17. Waiver Information
Anticipate data needed by Consular Section, CDC, and United States Citizenship and Immigration Services (USCIS)
Be organized
Send pertinent information immediately to CDC when situation becomes known
If additional information is requested by CDC, send within 24 hours

18. Waiver Adjudication
Adoptive parents complete the waiver application
CDC reviews
Reviews medical information from panel physician and identification of US health department
Makes a recommendation
Department of Homeland Security (DHS) approves or denies waiver request
If approved, Department of State issues visa

19. Waiver Information for CDC
Summary of case
Clinical course
Whether the child is a contact to a person with drug-resistant TB
Laboratory results
Smears, cultures, DST
Chest radiographs
Digital
Label each image clearly

20. Question 7
Who should know the waiver process?
Panel physician
Adoptive parents
Immigrant Visa Chief at Consular Section
DHS/USCIS officer at US Embassy
All of the above

21. Awareness of Process
Consular Section, DHS/USCIS staff, and panel physicians all need to know the process
Panel physicians need to be able to convey pertinent information
CDC cannot and does not know the waiver process in all countries
Suggest panel physicians routinely meet with pertinent officials to ensure continued understanding

22. Question 8
You examine a 13-year-old orphan. He had a cough for 1 month. IGRA was negative. His CXR showed a slight infiltrate. Three sputum smears are negative. What is the quickest way the applicant can travel to the United States?
Place on treatment and apply for Class A waiver
Allow to travel with cultures pending
Apply for waiver of culture results
Wait for culture results to be returned

23. TB Diagnosis and Waivers
A diagnosis of TB does not guarantee applicant will travel before culture results are returned
When waiver applications are reviewed, strong consideration given for the risk of drug resistance
If elevated risk, applicants will be in-country until culture results and DST are known

24. Question 9
A family s you from the United States asking if their HIV-positive child can have a Cepheid Xpert MTB/RIF test to be cleared quickly. Which of the following is the best information to provide to the parents?
CDC Technical Instructions
Xpert product insert
Xpert is more sensitive than sputum smears
Xpert is less sensitive than cultures
Xpert can test resistance to rifampin but not other drugs

25. GeneXpert More sensitive than sputum smears
Less sensitive than liquid cultures
May not
Clear applicant for travel
Replace TST/IGRA
Replace cultures for monitoring progress to therapy
Excellent test
Quickly determine if smear-positive applicant has nontuberculous mycobacteria or Mycobacterium tuberculosis
Quickly determine if someone at high risk for drug resistance may have multidrug resistant (MDR) TB

26. Resources
Panel Physicians Portal:
CDC international adoption:
Waivers:
WHO TB rate data:

27. Thank you cdcQAP@cdc.gov http://www.cdc.gov/panelphysicians
For more information, please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA
Telephone: CDC-INFO ( )/TTY:
Visit: | Contact CDC at: CDC-INFO or
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

28. Answers C D E A