Attachment C(1)13_237881-A PhysicPanelTool

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1991 vs. Culture and Directly Observed Therapy Tuberculosis Technical Instructions
Category

1991

•• Persons ≥15 years: PA;

CXR

<15 years: in specific
circumstances
•• Frontal and lateral views
in children

CDOT

•• Required for all applicants ≥15 years.
•• Applicants <15 years undergo CXR if they have a TST ≥10 mm or a positive IGRA

(when required based on estimated TB incidence rate in country of origin) or have
signs and symptoms suggestive of TB, or HIV infection. Frontal and lateral views in
children <10 years of age.

TST or IGRA

•• TST: not routine; used

•• All applicants 2–14 years of age living in countries with a WHO-estimated incidence

Tuberculosis
(TB) laboratory
screening

•• Persons ≥15 years with CXR

•• Persons with TB symptoms, abnormal physical examination, or CXR suggestive of TB

Initial patient
management prior
to laboratory results

•• Not applicable

•• Consider treatment for other lower respiratory infection (no fluoroquinolones) if

Management of
persons with
positive TST or IGRA

•• Not applicable

•• Applicants 2–14 years of age or contacts who have a TST ≥10 mm or a positive IGRA,

TB treatment and
management

•• TB treatment outdated,

•• Treating physicians should follow ATS/CDC/IDSA guidelines.
•• Directly observed therapy (DOT) should be implemented for treatment of

infrequently in specific
circumstances; IGRA: not used
and/ or symptoms suggestive
of active disease: AFB smears
x 3, or Children <15 years of
age who are contacts, have
history of TB disease, or signs
or symptoms): AFB smears x 3

and minimal guidance for
drug-resistant TB

rate ≥20 per 100,000. All applicants who are contacts of a known TB case.

disease, or who are HIV positive:
• Sputum for AFB smears x 3 and for TB cultures x 3, &
• Drug-susceptibility testing (DST) on positive cultures (for persons who cannot
produce sputum: specimen collection by other means such as induced sputum or
gastric aspirates).

applicable.

but who otherwise have a negative evaluation for TB, will be classified for U.S.
follow-up as Class 2 B2 TB, LTBI Evaluation, with TST results and treatment status
documented.

pulmonary and extrapulmonary TB.

•• For drug-resistant patients, refer also to written guidance from the Francis J. Curry

National Tuberculosis Center and California Department of Health Services, 2004:
Drug-Resistant Tuberculosis: A Survival Guide for Clinicians.
•• MDR TB expert consultations and CDC consultations recommended.
•• Treatment of drug-resistant and MDR TB should be done by or in close consultation
with experts in the management of such cases and in coordination with the Division
of Global Migration and Quarantine (DGMQ).
•• Identification of applicants with MDR TB should be reported to DGMQ.

Sources of TB drugs

•• Source not specified

•• Quality-assured drugs:
• WHO Global Drug Facility for first-line drugs and International Dispensary Association
and

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• WHO Green Light Committee for second-line drugs.
Laboratory
monitoring during
TB treatment

•• No monitoring after AFB

•• Drug susceptible, drug resistant (but not MDR) TB: two sputum specimens should

Laboratory
monitoring after TB
treatment

•• Not applicable

•• All applicants to have two sputum specimens collected and submitted for AFB

smear becomes negative

be collected and submitted for AFB microscopy and mycobacteria culture once a
month during therapy until cultures are negative for 2 consecutive months.
•• MDR TB: two sputum specimens should be collected and submitted for AFB
microscopy and mycobacteria culture once a month during therapy.
•• No drug-susceptibility testing results (culture negative): one sputum specimen
should be collected and submitted for AFB microscopy and mycobacteria culture
once a month during therapy.

microscopy and mycobacteria culture at the end of therapy. Applicants may not be
cleared unless results are negative.

National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

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Category
Management of
known TB contacts

1991

•• Not applicable

CDOT

•• All contacts should receive a TST or IGRA.
•• If the TST is ≥5 mm or IGRA is positive, the contact should be further evaluated with
medical history, physical examination, and CXR.

•• If the contact is not started on LTBI therapy, he or she should receive an evaluation

with medical history, physical examination, and CXR every 3 months until departure.

•• If the TST is <5 mm, or the IGRA is negative, and the contact is not placed on

prophylaxis, the TST or IGRA should be repeated every 3 months until
• ≥8 weeks after contact ends, the index case has negative sputum smears for 2
consecutive months, OR
• TST become ≥5 mm or IGRA becomes positive.
•• Children <4 years of age and applicants with impaired immunity who are contacts of
a known TB case (that is not isoniazid resistant) and who have a negative evaluation
for TB disease, should begin directly observed preventive therapy (DOPT) regardless
of TST or IGRA results.
•• Preventive therapy may be discontinued if TST is <5mm or IGRA is negative 8 weeks
after conclusion of exposure to the infectious case.
•• Contacts cleared for travel should receive a Class B3 TB, Contact Evaluation
classification.

Validity of
TB screening
examination

•• 12 months if normal; 6 months

Pre-departure
clearance
examination

•• Not applicable

Information transfer
to CDC and state
and local public
health departments

if Class A condition or Class B1
or B2 TB condition

• Paper: DS medical forms

travel with refugees
and immigrants and are
processed at port of entry
and CDC headquarters

•• 6 months if no TB classification or only Class B2 TB or Class B3 TB.
•• 3 months if Class B1 TB, Pulmonary or Class B1 TB, Extrapulmonary, or No TB Class and
B- Other, HIV infection.

•• Additional screening immediately prior to departure (pre-departure evaluation) may

be required.
• in the event of an outbreak of TB disease or
• in the setting of extremely elevated rates of TB disease.
•• CDC will inform panel physicians and Consulates when this additional screening is
required.
•• When required, pre-departure screening would occur within 3 weeks of departure
for all applicants with findings suggestive of TB disease on medical history, physical
examination, or CXR but with negative sputum smears and negative cultures.
•• Pre-departure screening would consist of medical history, physical exam, CXR, and at
least 3 sputum smears for AFB microscopy (cultures not required).

•• Paper: DS medical forms and additional information on TB treatment travel with

applicants and are processed at port of entry and CDC headquarters. DS forms from
initial medical examination for applicants diagnosed with Class A TB and undergoing
repeat medical examination after completing treatment should be included.
•• Electronic data transfer of DS medical forms, including TB screening, diagnosis and
treatment, when available.
•• Class A and B1 cases reported to U.S. Embassy upon detection.
•• Panel physicians are required to make 3 copies of all DS forms for all refugees and for
immigrants with Class A conditions or any Class B TB condition.

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