1. CDC Update on the 2007 TB Technical Instructions Sharmila Shetty, MD Immigrant, Refugee & Migrant Health Branch Division of Global Migration and Quarantine Centers for Disease Control and Prevention

2. Summary Overview of Immigrant, Refugee, Migrant Health Branch Epidemiology and trends of TB in the US Changes in 2007 TB Technical Instructions (TI)

3. Source: U.S. Department of Homeland Security Refugee admissions: 61,498 (2008) Annual Estimate of Migrants Entering the U.S. Refugees: 50,000-70,000 Immigrants: ~1 million Non-immigrants: 28 million Short-term transit: 30 million Others: 1.5 million Total: ~60 million

4. Immigrant, Refugee, and Migrant Health Branch (IRMH) Role Track and report diseases in these populations Respond to disease outbreaks in the US and overseas Advise U.S. partners on health care for refugee groups Educate and communicate with immigrant and refugee groups and partners. Provide medical screening and treatment guidelines (technical instructions)

5. Technical Instructions (TIs)  Consist of medical screening guidelines  Used by overseas panel physicians who conduct medical examinations for U.S.-bound refugees and immigrants  Identify applicants with medical conditions of public health concern

6. Inadmissible communicable diseases of public health significance  Tuberculosis, active  Syphilis, untreated  Chancroid, untreated  Gonorrhea, untreated  Granuloma Inguinale, untreated  Lymphogranuloma Venereum, untreated  Hansen’s disease (Leprosy)

7. Panel Physician Program: Basics Statistics  670 panel sites (1 or more panel physicians)  > 1,000 laboratory and radiology facilities Contracted through Dept. of State  TB=disease of greatest public health concern

8. Estimated TB Incidence Rate, 2007 No estimate 0-24 50-99 100-299 300 or more 25-49 Estimated new TB cases (all forms) per 100 000 population 1/3 of world infected 9.3 million cases of active TB 1.8 million deaths

9. TB Cases, United States, 1993- 2008 TB rate: FB 20.6/100K US 2.1/100K

10. MDR TB Cases, United States 1993-2007 XDR TB (’00-’06): 76%

11. Simplified TB Screening Algorithm CDC required TB screening  overseas medical exam: panel physicians TB follow-up exam requested Sputum work-up to identify active TB Abnormal CXR Normal CXR Post-arrival medical exam +

12. 1991 Tuberculosis Technical Instructions CXR if ≥ 15 years old; no screening for <15 yr If chest x-ray abnormal Serial AFB smears If AFB+ treat until smear negative complete therapy in US No cultures, no DST

13. Study of 1991 TB TI Culture versus Smears* 1,179 with CXR suggestive of active TB TB culture and AFB smears for all 183 culture positive --Only 63 (34%) smear-positive *Maloney SM, et al. Arch Int Med 2006;166:234-40 + 34% Sensitivity = AFB Smear Conclusion: 1991 protocol missed 66% of culture-positive active TB cases

14. Hmong Refugee Resettlement, 2004—2005 16,000 Laotian Hmong in Wat Tham Krabok, Thailand Five states identified 48 TB Cases (7 MDR) in newly arrived Hmong refugees TB culture added to screening

15. TB in US-bound Hmong Refugees # of RefugeesLocation Cases IdentifiedNRate/100,000 9482Wat Tham Krabok US 24 48 126 506 *Screened with 1991 TB TI TB Cases

16. TB in US-bound Hmong Refugees # of RefugeesLocation Cases IdentifiedNRate/100,000 9482Wat Tham Krabok US 24 48 126 506 TB culture added to screening algorithm 5801Wat Tham Krabok US 24 5 420 86 TB Cases

17. Recommendations Overseas: Expand screening, treatment, and overall TB control Focus on high-prevalence countries Improve TB screening To include culture To screen persons <15 years esp. high- prevalence countries Domestic: Support timely and complete post-arrival follow-up of immigrants and refugees with overseas TB classifications

18. 2007 TB TI CDC process to revise Technical Instructions began in 2005 Scientific literature reviewed Input from U.S. Tuberculosis Community : Advisory Council for the Elimination of Tuberculosis (ACET) National Tuberculosis Controllers Association (NTCA) National Coalition for the Elimination of Tuberculosis (NCET)

19. Chest x-ray for persons ≥15 years of age  and for persons 2-14 years with a TST>10 mm* or positive IGRA If chest x-ray abnormal, serial AFB smears  and cultures  Drug susceptibility testing (DST) for all TB isolates  Treatment to completion of therapy according to ATS/CDC/IDSA guidelines, delivered as DOT 2007—TB TI + + *countries with WHO-estimated incidence rate ≥20 per 100,000

20. Saint Luke’s Extension Clinic, Philippines FY 2007 (52,530 applicants, 1991 TB TI) vs. FY 2008 (41,793 applicants, 2007 TB TI) TB case detection rate 1991 vs 2007 TB TI: 554 vs. 1,208 (per 100,000)

21. Implementation TB culture facilities built -liquid culture w/ Bactec MGIT 960 Training of panel physicians Rollout in countries according to: #s of applicants TB rates In-country resources As of January, 2010 Populations from 27 countries on three continents are being screening according to the 2007 TB TI 53% immigrants >50% refugees

22. Implementation of the 2007 TB TI -Current Status Current status 27 countries 53% of immigrants >50% of refugees

23. Implementation of the 2007 TB TI -2010 Implementation Guatemala Summer/Fall India Summer/Fall Ghana Summer/Fall Nepal Spring Thailand Spring South Korea Spring Malaysia Spring Nigeria Summer/Fall Indonesia Summer/Fall Panel physician training India: January 13-15 Ghana: March 16-18 Dominican Republic: May 3-5 ACET/NTCA Vietnam

24. 2007 Technical Instructions: Impact on Prevention of Disease Improve detection of tuberculosis overseas More refugees that need treatment will receive it Improve stateside follow-up Decrease importation of tuberculosis Assist in global tuberculosis control efforts Improve tuberculosis expertise and infrastructure overseas

25. 2007 TB Technical Instructions Available at: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/pane l/tuberculosis-panel-technical-instructions.html http://www.cdc.gov/immigrantrefugeehealth/exams/ti/pane l/tuberculosis-panel-technical-instructions.html

26. Acknowledgments International Organization for Migration (IOM) Tom O’Rourke Warren Jones Raz Wali Dr. Yen Dept. of State Bureau of Population, Refugees, and Migration CDC Drew Posey Marty Cetron John Painter Greg Armstrong Luis Ortega Susan Maloney

27. Thank you!!

29. Sputum smears x 3 Infectious Class A Noninfectious Class B1 All (-)(at least one +) 1991 Tuberculosis Technical Instructions: for applicants ≥15 years of age Valid for travel within 6 months Treat until smear negative Class A waiver Signs and symptoms or

30. Sputum smears x 3 Infectious Class A Noninfectious Class B1 All (-)(at least one +) 2007 TB TI Valid for travel within 6 months Treat until smear negative Class A waiver + cultures If TB rate ≥20/100,000 2-14 years of age: TST ≥10 mm or Positive IGRA 3 cured DOT or HIV Signs and symptoms

31. 2007 Technical Instructions: Classifications Class 1991 Technical Instructions 2007 Technical Instructions No classificationNormal evaluation Class ATuberculosis disease Class B1- Pulmonary Abnormal CXR, sputum smears negative Abnormal CXR, sputum smears and cultures negative Class B1 – Extrapulmonary Extrapulmonary tuberculosis Class B2Inactive tuberculosis on CXR LTBI evaluation Class B3Old or healed tuberculosis Contact evaluation

32. Waivers for Medical Conditions Basic Points IRMH/CDC is involved in the waiver process for immigrants based on the following medical conditions: HIV Infection Mental/Physical Disorders with associated harmful behavior Tuberculosis

33. Class A Medical Conditions Inadmissible Treatment or waiver required for admission Examples TB (laboratory positive) HIV STIs (untreated) Mental Disorders with Harmful Behavior (including Alcohol Abuse) Substance Abuse (no waiver for immigrants)

34. Class B Medical Conditions Admissible Substantial departure from normal health Examples: TB (laboratory negative) STIs (treated), Mental Disorders without Harmful Behavior Substance Abuse (in remission) Stateside notifications for TB