1. Zachary White, MPH Drew L. Posey, MD, MPH
US First Timers
Zachary White, MPH
Drew L. Posey, MD, MPH
Medical Assessment and Policy Team
Immigrant, Refugee, and Migrant Health Branch
Tuesday, March 30, 2017
Panel Physicians Training Summit
Zack White and Drew Posey – MAP Team
Purpose: This session is for those of you who most likely have not attended a summit before. This will be a cased based session with the goal of learning and applying the technical instructions using real life examples. We hope you can take the information from this session and apply to your daily practice as a panel physician.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

2. Learning Objectives
Understand the roles and responsibilities of the panel physician
Apply CDC technical instructions to successfully examine immigrants and refugees
Identify common mistakes to avoid and achieve best practice at the panel site
Here are the main points which we hope you will be able to take home with you after attending this session:
We will be using the handouts of the case throughout this session (make sure everyone has the handouts of the case). We will start with the description of the case scenario.

3. Background
Each year, approximately 400,000 immigrants and 50,000 refugees enter the United States
CDC’s Division of Global Migration and Quarantine (DGMQ) has regulatory authority to stipulate the requirements of the overseas medical examination via Technical Instructions
The Bureau of Population, Refugees, and Migration (BPRM) is the US Department of State bureau responsible for refugee resettlement
BPRM has contracted with the International Organization for Migration (IOM) to perform the medical screening for approximately 80% of the refugees
Panel physicians are using Cultures and Directly Observed Therapy Technical Instructions for Tuberculosis (TB TIs)

4. Question 1 Have you diagnosed a tuberculosis case at your panel site?
Yes No
The main focus of this session will be using the Culture and Directly Observed Therapy Tuberculosis Technical Instructions to screen applicants at your site. We will now go through a real life case study which will let you apply knowledge of the technical instructions.

5. Share Experiences as a New Panel Physician
Successes?
Problems?
Quick 5 minutes to share experiences and problems as a new panel

6. Case Example Ten-year-old child screened May 4, 2016
According to the child’s guardian, he was diagnosed with TB in November 2015 and received treatment that ended April 2016
The guardian does not have record of the treatment medications
The following information was gathered during the exam: The child has suffered from fever, night sweats, cough for 5 days, and weight loss, and was hospitalized
The TST result was 0mm
This session will revolve around a case example.

7. Given this information, what are your next steps?
Case Example
Additional Information Obtained from Guardian:
Mother died from TB in 2013 but was HIV negative
No additional information about the father and other relatives
The child was hospitalized for first 3 months of treatment
The guardian gave the rest of TB medication
The child is suffering from acute respiratory infection
Given this information, what are your next steps?
Discuss with group and see if this information is necessary, important, and useful

8. Question 2
After reviewing the information, does this child need a Chest Radiograph (CXR)?
Yes No
Not enough information

9. Actual Case – DS-3030
Mention they classified the applicant as “no class” for TB

10. Actual DS-3026
The panel physician noted Fever, Cough, Night Sweats, Weight loss from the physical exam

11. Question 3
Which of the following on the DS-3026 should be considered as “signs and symptoms” for TB?
Cough
Fever
Night sweats
Weight loss
None of the above
All of the above

12. Question 4
Should this child receive sputum smears and cultures?
Yes No

13. DS-2054
No Class for TB
Acute Respiratory Illness

14. Important Resource
This page is essential for all panels to effectively implement the technical instructions and screen immigrants and refugees coming to the United states

15. TB Screening Algorithm
Explain the screening algorithm for TB for both Children and Adults

16. Cultures and Directly Observed Therapy TB Technical Instructions
If TB rate ≥20/100,000 or
2-14 years of age:
TST ≥10 mm or
positive IGRA
HIV or
TB signs or symptoms
Sputum smears and cultures (3)
DOT until cured
Class A waiver
Valid for travel within 3 months
In part from the results of that study, the screening algorithm, known as the Technical Instructions, was changed in The most important changes to the algoirthm are reflected in the title: the Culture and Directly Observed Therapy TB Technical Instructions or TB TI. Directly observed therapy or DOT is a strategy in which all doses of a patient’s regimen are administered by trained health care personnel and documented. We also introduced screening in children. Those 2-14 years of age living in a country with a WHO-estimated TB incidence rate of 20/100,000 or greater receive a tuberculin skin test or an interferon gamma release assay. If positive, a chest x-ray is required. Applicants diagnosed with TB must complete treatment before being granted a visa to travel.
All (-)
One or more (+)
Noninfectious
Class B1
Infectious
Class A

17. Importance of the Physical Exam
Always follow TB algorithm
Thorough physical exam and clinical judgment of panel physician are essential
If the applicant has signs and symptoms of tuberculosis disease, perform a CXR.
Applicants with CXR findings suggestive of tuberculosis, signs and symptoms of tuberculosis, or HIV infection should provide three sputum specimens for microscopy for acid-fast bacilli (AFB), as well as culture for mycobacteria and confirmation of the Mycobacterium species, at least to the M. tuberculosis complex level. 
Always follow the TB screening algorithm. Discuss signs and symptoms the panel should pick up during the physical exam even though TST might be zero

18. CXR of Applicant
We should get Mary to review and provide short bullets where we can present the abnormalities

19. Question 5 Who should complete and sign the DS-3030? Panel physician
Radiologist
Either the panel physician or radiologist
Any staff member at the panel site can complete the DS-3030

20. Chest X-ray Are there any concerns regarding the chest x-ray?
Should the child have been given a chest x-ray overseas?
What are the findings suggestive of tuberculosis, if any?
Should this applicant have received smears and cultures based on the chest x-ray and/or medical history?
Drew/Zack will say the findings of the CXR: His PA CXR showed extensive bilateral infiltrates throughout much of both lungs, most prominent in the left upper and right mid lung

21. Stateside Follow-up of Inadmissible Conditions
CDC has regulatory responsibility to provide information to receiving health departments (HD) of arriving aliens with a notifiable condition
Electronic Disease Notification System (EDN)
Replaces paper-based Immigrant and Migrant Populations (IMP) system
Provides HD access to recorded DS Form information and all scanned overseas DS Forms
Provide HD with an electronic system to record and evaluate outcome of domestic follow-up evaluations

22. EDN Quarantine Stations EDN-IOM Interface EDN – DATA ENTRY EDN – WEB
Overseas
U.S.
Data Entry Center
CDC HQ - Atlanta
EDN – DATA ENTRY
Local/State
Health Departments
EDN – WEB
Quarantine Stations collect Immigrant Medicals with inadmissible conditions and forward/mail them to EDN so a notification can be sent to the health department. Refugees screened through IOM have their paperwork electronically sent to EDN through MIMOSA.
Quarantine Stations
Overseas
Screening
Overseas
Forms

23. Health Department Report

24. Screenshot of Health Department report if needed as slides
Screenshot of Health Department report if needed as slides. We can also verbalize this if you do not want to have it as a slide

25. Screenshot of Health Department report

26. Teaching Points Always refer to the CDC technical instructions
Panel physicians should use clinical judgment to perform thorough examinations
Remember to collect in-depth medical history to determine the classification of an individual

27. Questions? CDCQAP@cdc.gov
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine