Thank you for viewing this presentation on TB Class Arrivals in Minnesota: The role of local
public health agencies in ensuring post-arrival follow-up evaluation, recorded on November
5, 2013.
Alicia Earnest is the TB Follow-up Data Coordinator in the TB Prevention and Control
Program at MDH. One of her primary duties in the TB Program is to process TB Class
referrals for newly arrived refugees and immigrants.
1
There are three learning objectives for the presentation.
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A brief outline of the presentation:
First some background on TB Class designations will be reviewed, focusing on the questions
of “Who?,” “What?,” “Why?” and “When?.”
Then the Domestic TB Follow-up Evaluation will be discussed, starting with its purpose,
discussing a little bit of data, and briefly addressing the recommended protocol for the
evaluation.
Then the role of local public health (LPH) in this process will be discussed, specifically
focusing on differences in the role for refugee versus immigrant arrivals, going over some
data collection forms, and discussing barriers to evaluation.
Finally, there are a few resources at the end for those who would like more information.
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These are a few abbreviations that will appear frequently during this presentation.
4
This is an overview of the hierarchy of TB control. MDH TB Program receives funding from
the Centers for Disease Control and Prevention (CDC) to work on these core activities.
The primary and most essential activity is the diagnosis and treatment of active TB disease,
followed by contact investigations surrounding infectious TB cases. The third activity is
targeted testing and treatment of LTBI, followed by infection control measures in high-risk
settings.
TB Class Arrival Follow-up falls under number three – targeted testing and treatment of
LTBI. Of the risk factors for TB (such as homelessness, drug abuse, etc.), the Class B
designation focuses on the particular risk factor of being foreign-born in a country with a
high burden of TB.
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Why is TB Class Arrival follow-up for immigrants and refugees especially important in
Minnesota? It is because the majority of active TB cases in Minnesota were born outside of
the U.S.
This graph illustrates the number of TB cases by place of birth in Minnesota from 2003 to
2012. The red line shows number of TB cases in the foreign-born, the blue line is U.S. born
cases, and the total number of cases is represented by the green line.
Trends in the total number of TB cases reported in Minnesota closely reflect the number of
new TB cases in the foreign-born population. In turn, this number of foreign-born cases is
largely influenced by the high number of new refugee and immigrant arrivals to the state,
many of whom come from regions of the world where TB is prevalent.
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This graph shows the percentage of foreign-born TB cases in the U.S. and in
Minnesota from 2003 to 2012.
As one can see, the percentage of TB cases in Minnesota that are foreign born is
higher than the national percentage. This is a distinguishing characteristic of the
epidemiology of TB disease in Minnesota.
For 2012, 84% of TB cases in Minnesota were born outside the U.S., compared to
63% of TB cases reported nationally.
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How can cases of TB disease be prevented in Minnesota, especially among the foreign-born
population?
For foreign-born patients, there several potential opportunities for TB screening:
•The first opportunity is the overseas or “pre-departure” exam – performed by panel
physicians for all immigrants prior to coming to the U.S. This is where a TB Class
designation may be given, depending on exam results.
•For arrivals with “Refugee” status, ensuring a Domestic Refugee Health Assessment is the
responsibility of each state – as is the Domestic TB Class Follow-up for those arrivals with a
designated TB Class condition.
•The Adjustment of Status exam – when temporary residents who have lived in the U.S.
can apply for permanent residency - is performed by a Civil Surgeon.
•And primary care visits or physicals for school or employment are another opportunity for
screening.
It’s interesting and important to know that only the overseas or pre-departure visa exam
and the adjustment of status exam are mandatory. The state health department is
responsible for maintaining a system to ensure that refugees and TB Class arrivals have
appropriate TB screening – and the work is done by local public health nurses and private
providers. This presentation goes into a little more detail about two of these particular
opportunities for TB screening. The first is the Overseas Exam.
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Who needs to have the overseas exam to enter the U.S.?
Before answering that question, it is important to go over a few terms that the U.S.
Department of Homeland Security uses to define various groups of people who make up
the U.S. population.
Residing in the U.S. at any given time are citizens and non-citizens.
• Non-citizens can be further distinguished into immigrants and non-immigrants
• Non-immigrants include undocumented persons, students, business visitors, and
tourists.
• Immigrants include lawful permanent residents (LPRs), lawful temporary residents
(LTRs), and authorized employment.
Only persons immigrating to the U.S., that is, planning to live here on a PERMANENT basis,
need to have a medical exam overseas.
The next slide defines these immigrant categories in a little more detail.
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All persons applying for immigrant visas MUST have a medical exam done overseas as part
of their application process. Immigrant visas fall under two categories, the first is lawful
permanent residents. These people will receive their green cards shortly after arrival to the
U.S.
Lawful permanent residents include persons arriving to the U.S. under the following visas:
•
Relatives of U.S. citizens or LPRs
•
Fiancées
•
Adoptees
•
Employees and investors
•
Special immigrant visas - visa category created in 2009 especially for persons
from Iraq who assisted the U.S. during the war.
•
Diversity program – otherwise known as the lottery.
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The second category of persons immigrating to the United States who must have a medical
exam before coming are lawful temporary residents. These people must adjust their
immigration status to lawful permanent resident after one year of residing in the U.S. in
order to receive their green card.
The three visa categories of lawful temporary residents are:
1. Refugees, who are foreign-born residents who cannot return to their country of origin
because of a well-founded fear of persecution due to race, religion, nationality, political
opinion, or membership in a particular social group. Refugee status is generally given prior
to entering the U.S.
2. Asylees are foreign-born residents who cannot return to their country of origin because
of a well-founded fear of persecution, and this status is generally given after entering the
U.S.
3. A parolee is a foreign-born resident who has been given special permission to enter the
United States under emergency conditions (such as Haitian orphans after the earthquake
there a few years ago) or when that person’s entry into the U.S. is considered to be in the
public’s interest (such as Cubans, whose defections serve a strategic political purpose for
the U.S. government).
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These persons do not need a medical exam before entering because their presence in the
U.S. is not intended to be permanent. These visa categories include:
•
•
•
•
•
Students
Tourists
Those here on temporary employment
Business visitors
Famous persons such as diplomats, athletes, entertainers
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So why does the federal government require a medical exam for immigrants and refugees?
The purpose of the overseas medical exam is to screen for certain conditions relevant to U.S.
law.
• It is required for entry into the U.S. as an immigrant.
• The exam is administered by Panel Physicians at different sites within each country, who
receive training and guidance from the CDC.
• It is not a comprehensive medical exam, and it is NOT a substitute for a full physical
examination, consultation, diagnosis, or treatment by a primary health care provider.
• The exam does expire and must be re-done before travel if it is past the expiration date.
The overseas medical exam screens specifically for the presence of “excludable” conditions,
which include:
• Communicable diseases of public health significance (one of which is infectious TB – in
contrast to non-infectious TB)
• Physical and mental disorders with associated harmful behaviors, substance abuse, or other
physical or mental abnormalities. (Note that the presence of these other conditions does
not make a refugee non-admissible, but these conditions need to be properly documented
to ensure that the necessary resources are in place before travel.)
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The clinical guidelines produced by CDC specific to the TB portion of the exam are titled:
Tuberculosis Screening and Treatment Technical Instructions using Cultures and Directly
Observed Therapy for Panel Physicians (‘07 TB TIs).
They were developed in 2007 with the involvement of CDC’s Division of Tuberculosis
Elimination and Division of Global Migration and Quarantine.
The 2007 TB TIs are a huge revision and improvement from the 1991 TB TIs which did not
use cultures or DOT in the diagnosis and treatment of TB. The gradual introduction of the
new TB TIs at screening sites around the world has also served as a capacity-building effort
on the part of CDC to improve TB laboratory testing and treatment in traditionally lowresource settings. After several years of implementation efforts, as of October 1st of this
year (2013), all countries will be required to screen U.S.-bound immigrants and refugees
using these technical instructions. The photo on the lower right highlights in red the
countries that are using the ‘07 TB TIs as of mid-August 2013.
There was a small update was made to the technical instructions in 2009, so make sure if
you look these up online or in print that the version you have includes this update.
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The central components of the TB portion of the overseas exam are:
A medical history and physical examination.
For children ages 2-14, a TST or IGRA is administered.
For those ages 15 or older, a CXR is done, but NOT a TST or IGRA. A CXR is also done for
children who are TST or IGRA positive.
If the CXR shows any indication of TB, sputum smears and cultures are done. If either of
those are positive, the person is treated for active TB disease, drug susceptibility testing is
done, and contacts are tested.
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Based on the results of the exam, a TB Class designation is given:
• No TB Class is for those who had an normal CXR, or for children, had a negative TST.
• Those who are Class A had an abnormal CXR, and upon collection of sputum were found
to have active TB. A Class A arrival to Minnesota is very rare, perhaps once every 5 years
or so. These persons must be treated for active TB before travel, otherwise they must
apply for a waiver to travel before their treatment is complete.
• Class B1 TB, Pulmonary – CXR was abnormal suggestive of TB with negative sputum
smears and cultures; this includes previously treated TB.
• Class B1 TB, Extrapulmonary – the person had evidence of extrapulmonary TB – this is
also very rare.
• Class B2 TB – those who were TST or IGRA positive and had a normal CXR.
• Class B3 TB – are recent contacts of a known infectious TB case. Arrivals can have a Class
B3 designation along with another TB Class.
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How does MDH find out about TB Class Arrivals to Minnesota?
CDC has an electronic database that serves as a notification system for all newly arriving
refugees and for all TB Class arrivals.
In that database, one can access a copy of the arrival’s overseas exam. It is also the
database where exam outcome information is entered for those with TB Class conditions.
All states use this database, as well as all of the CDC Quarantine Stations. Within the
database is the capacity to transfer records between states if it is found that an arrival has
moved.
The database is housed in and maintained by DGMQ.
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This shows an overview of the flow of information from the time of the overseas exam to
screening and entry of outcome data.
A person is screened overseas and must travel within 3-6 months. Most often they arrive
at an airport that has a DGMQ Quarantine Station, and the Quarantine Station officer
reviews their overseas exam and sends a copy of the exam for refugees and TB Class
arrivals to EDN. EDN uploads that information, where MDH accesses it and reviews it.
After review, a copy of the overseas exam is sent to the LPH nurse in the arriver’s county.
In the three counties with public TB clinics in Minnesota, the flow of information stops at
LPH, as these public clinics will do the TB evaluation. But for all the other counties, LPH
forwards the exam information to the provider, the provider returns the results of the exam
to LPH, who submits it to MDH. When MDH receives the exam results, that data is entered
into EDN.
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Now that overseas exam and the flow of information for TB Class arrivals have been
discussed, the next step after arrival to the U.S. is the Domestic TB Class Follow-up
Evaluation.
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In the U.S., there are resources to go a step further than the overseas exam in the
treatment and prevention of TB in this high-risk population.
The overseas exam only clears the person for travel to the U.S. It rules out active,
pulmonary, infectious TB at time of exam. It is not meant to be diagnostic of other TB
conditions.
So, the follow-up evaluation is a full TB evaluation – its purpose is to evaluate the person
for active pulmonary TB, extrapulmonary TB, and LTBI, and to treat these conditions, if
found.
MDH does not receive any funding to cover the cost of the follow-up exam, thus the exam
is highly recommended, but not required.
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CDC expects programs to set and report on these four indicators for Class B screening.
Minnesota sets its own program objectives and reports to CDC twice a year on its
performance. The objectives that are evaluated are:
For immigrants and refugees with CXRs read overseas as consistent with active TB
(otherwise known as Class B1):
• Percent whose evaluation was initiated within 30 days of notification
• Percent whose evaluation was completed within 90 days of notification
• Percent who began LTBI treatment if LTBI was diagnosed
• Percent who completed LTBI treatment if they started it.
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Minnesota is considered a national leader in Class B screening and does very well on the
objectives, as can be seen here from the 2011 data, the most recent year for which data is
complete. This is in large part due to MDH’s LPH partners!
CDC also uses the screening-specific data from the evaluations to monitor TB trends among
incoming populations to the U.S. as well as to inform and evaluate the effectiveness of the
panel physician TB screening.
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So what does the TB Class Follow-up Evaluation entail?
The recommendations are based on the TB Class, and vary slightly for each class. For the
most part, the follow-up evaluation consists of a routine screening for TB, with one
exception that will be pointed out.
Evaluating for signs and symptoms of TB disease is the first step for all.
The second step is to screen the arrival with either a TST or an IGRA, unless they have
either a) reliable documentation of a previous positive result or b) a reliable history of TB
disease.
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Normally a CXR is recommended based on a positive TST or IGRA result or the presence of
TB symptoms.
The difference for Class B1 arrivals is that they should always have a CXR regardless of their
TST or IGRA result or their treatment history because of their recent history of an abnormal
X-ray. Hopefully the arrival will have a copy of their overseas CXR with them on a CD for
comparison purposes.
For more detail about the recommended steps to the evaluation, please refer to the
detailed document available online. This is a good resource for providers to use if they are
not familiar with or do not routinely perform these evaluations.
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The IGRA is the preferred TB screening tool for this population.
IGRAs are preferred for persons born outside the U.S. because of their better specificity
compared to the TST.
IGRAs are specific to Mycobacterium tuberculosis, and they do not react with BCG.
This is important for foreign-born persons in the U.S., because prior to immigrating they
may have been exposed to non-TB mycobacteria. Many of them also come from countries
where BCG vaccination in children is common. The use of the IGRA can increase patient
confidence in the diagnosis – if they know they have had BCG vaccine, they often attribute
a positive TST result to that vaccination, and may be less likely to accept preventive
treatment.
Please note that the IGRA is not yet recommended for children under 5 years old – a TST
should still be used for very young children.
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The role of local public health in the TB Class follow-up process can be broken down into
three steps.
The first step is to help the arrival obtain a TB evaluation with a local provider. This process
will look a slightly different for refugees vs. immigrants.
Step two is to ensure that the results of the evaluation are submitted to MDH.
The third step is then to facilitate medical treatment for any TB-related condition that is
identified.
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For step one, helping the arrival obtain a TB evaluation, for refugees this step should be a
part of the full domestic refugee health exam. The LPH nurse should arrange for the
domestic refugee health exam according to the protocol in his or her county.
Make sure that the provider doing the exam knows that for a Class B1 arrival, the
recommendation is to do a CXR regardless of the IGRA or TST result, or treatment history.
After the appointment for the domestic refugee health exam has been arranged, the LPH
nurse should forward both the yellow TB follow-up evaluation form and the pink Refugee
Health Assessment form to the provider.
Please note that no additional yellow form is sent for Class B2 and B3 because the protocol
for these TB Classes are identical to recommended protocol for the TB portion of the
refugee health assessment.
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Immigrants do not have a VOLAG (resettlement agency) supporting them through their first
few months here. For these arrivals, LPH will need to be a bit more hands on in arranging
the TB evaluation.
For these arrivals, MDH asks that the LPH nurse attempt to contact the arrival and explain
the purpose of the exam. Hopefully the contact information provided on the overseas
paperwork will have a working phone number – otherwise MDH recommends that the LPH
nurse send a letter requesting they contact LPH. Additional efforts to contact the arrival are
at the discretion of the LPH agency’s resources.
Many immigrants will have also received a letter in the mail from the U.S. Department of
State explaining that they have a TB Class Condition, but they may not understand what it
means or the importance of follow-up.
If the LPH nurse is able to contact the arrival, ask if they have a preferred provider. If not,
assess their resources and facilitate setting up an appointment for a TB evaluation with a
provider in the area.
After an appointment has been arranged, forward overseas paperwork and yellow TB
Follow-up Evaluation form to the provider. It also may be helpful to forward copies of the
Recommended Protocol and instructions on how to fill out the worksheet if the provider
does not do these exams very often.
For Class B2 and Class B3 there will still be a yellow form, because those on immigrant visas
only receive a TB evaluation as opposed to a full refugee health exam.
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After the person has their appointment, the second step for the LPH nurse is to ensure that
the results of the evaluation are submitted to MDH.
For Class B1 refugees, it is important to return both the Refugee Health Assessment form
(aka pink form) AND the TB Class Follow-up Worksheet (aka yellow sheet) because the TB
Class Follow-up Worksheet asks for additional information not on the pink form.
29
Here is a screen shot of the TB portion of the Refugee Health Assessment form. One can
see that it asks for the basics of the TB evaluation without many additional details – the
mm of induration of the TST, the IGRA test chosen and the result, the basic CXR category,
diagnosis, and treatment start information.
30
This is a very-zoomed out version of the two-page TB Class Follow-up Worksheet. It is
typically printed and mailed on yellow paper.
This form has many differences from the pink form, mostly because it asks for additional
information.
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The first section of the exam is the TB screening tool section.
32
One can see here that unlike the pink form, this form asks for the dates of the TST and/or
IGRA.
Please note this does say QFT – the new version of this form that CDC is working on (to be
released in early 2014) will incorporate both FDA-approved IGRAs. For now please
interpret this to mean any IGRA. If using the T-spot, please indicate that in this section.
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The second section is the CXR information.
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This is much more detailed than the pink form.
It asks for:
• C8: The date of the CXR taken here in the U.S.
• C9 and C10: Detailed info on findings of domestic CXR
• C4, C5, C6: If the overseas CXR was available, and if so, what is the U.S. reading of
overseas CXR
• C11: A comparison between the overseas CXR and the domestic CXR
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The bottom of the first page asks about lab information, if applicable.
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Any acid-fast bacilli (AFB) smear and culture results should be recorded here if this testing
was necessary.
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The top of the second page is a review of overseas treatment.
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The most important parts of this section are:
1. C14: Was the patient treated overseas? Was the treatment documented on the
overseas forms, reported by the patient, or both?
2. C16: Did the patient complete treatment overseas?
3. C17: Does the provider have any concerns about the overseas course of treatment?
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For all arrivals, MDH asks that if the LPH does not fill out the yellow TB Class Follow-up
Worksheet with info from the provider, please review what the provider filled out for
accuracy and completeness.
There are detailed instructions on the web on how to fill out the worksheet; it is a
complicated form.
CDC requests the MDH collects this data, which they use for surveillance. All this data is
entered by MDH into the CDC EDN database. If any information is missing or unclear, LPH
or the provider may receive a follow-up call for clarification.
MDH asks that once filled out, the LPH nurse should return the worksheet to the MDH TB
Program, preferably by mail, but faxing is also acceptable.
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What happens if an evaluation is not able to be arranged or it was started but not finished?
MDH asks that the LPH nurse fill out as much data as was completed, indicate the reason
for an incomplete or no exam on the back of the form, and return the form to MDH.
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The third part of the role of LPH is to facilitate treatment for any TB-related condition that
is identified.
All cases of confirmed or suspected active TB disease should be reported to the MDH TB
Program.
If LTBI is diagnosed, inform the provider about MDH’s free TB Medications program and
consider encouraging referral to LPH for LTBI treatment and monitoring.
If MDH does not provide the medication, the provider will be contacted for treatment
outcome information.
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LPH nurses may encounter barriers when attempting to arrange for these evaluations and during the course of
an evaluation.
The main reason why immigrants do not receive an evaluation is because the contact information provided is
invalid. The Q-Station officer at MSP tries to make sure to talk to every Class B immigrant arrival, give them
MDH’s contact information, and impress upon them the importance of following up; however, the majority of
our arrivals come through Q-stations at larger U.S. airports before flying to MSP. For those immigrants that do
contact MDH, MDH staff can verify their address information, discuss the basics of what Class B means, and
provide them with their county’s contact information.
If an immigrant can be contacted, the next biggest barrier is often lack of insurance or a payment source. In
these situations, MDH asks that the LPH nurses be as creative as possible. Is there a low-cost/sliding fee scale
clinic within reasonable distance? Can LPH perhaps perform the TST and then refer for the CXR? For Class B2
arrivals who had a positive TST overseas and have their CXR on CD, if the CXR is less than 3 months old, that
can be used to rule out active TB so the child may only need a provider visit. If there are no options and the
arrival is unwilling to pay for the exam, they are allowed to refuse, but all involved should try to not have that
outcome if at all possible.
Other barriers for immigrants include frequent travel between the home country and the U.S.
Barriers for all arrivals include the stigma of TB. TB may also be one of many pressing health issues. Culture also
may play a role, as people have differing beliefs about the origin of illness and understanding of preventative
care. There may be trust issues with the U.S. health care system.
Transportation can often be a barrier for new arrivals, as can language – LPH may need to use interpreter
services such as language line to communicate with new arrivals.
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The MDH TB Class Arrivals page has several good resources for both LPH and providers
doing evaluations.
These include a recommended medical follow-up document, instructions for completing
the TB Class Follow-up Worksheet, as well as a link to the TB TIs.
MDH also has a new fact sheet.
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The new factsheet is now available on the MDH TB Program website, and it is a two-page
condensed version of this presentation. Here is a screen shot of the top of the first page.
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Other resources include the CDC’s Division of Global Migration and Quarantine website,
the MDH Refugee Health Program’s website, and if one is interested in learning more about
the TB Technical Instructions, the New Jersey Medical School/Rutgers Global TB Institute
has a good webinar available on their website.
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Thank you for taking the time to listen to this presentation. Here is the presenter’s contact
information. She is always happy to answer phone calls or emails with any questions
related to TB Class arrival follow-up.
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