Update on the 2007 TB Technical Instructions Adriene Rister TB Control Coordinator Mainely TB: April 14, 2011
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 Source: U.S. Department of Homeland Security Refugee admissions: 61,498 (2008)
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)
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
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)
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
Estimated TB Incidence Rate, 2007 Estimated new TB cases (all forms) per 100 000 population No estimate 0 24 25 49 50 99 100 299 300 or more 1/3 of world infected 9.3 million cases of active TB 1.8 million deaths
TB Cases, United States, 1993 2008 TB rate: FB 20.6/100K US 2.1/100K
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
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 + = 34% Sensitivity AFB Smear Conclusion: 1991 protocol missed 66% of culture positive active TB cases *Maloney SM, et al. Arch Int Med 2006;166:234 40
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. highprevalence countries Domestic: Support timely and complete post-arrival follow-up of immigrants and refugees with overseas TB classifications
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)
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 2007 TB TI Drug susceptibility testing (DST) for all TB isolates Treatment to completion of therapy according to ATS/CDC/IDSA guidelines, delivered as DOT + + *countries with WHO estimated incidence rate 20 per 100,000
2007 TB TI Children 2, high incidence countries Physical exam, medical history If s/s, HIV+ TST/IGRA, CXR, sputum Children 15 in low incidence countries Physical exam, medical history If s/s, HIV+ TST/IGRA, CXR, sputum
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
Implementation of the 2007 TB TI Current Status Current status 27 countries 53% of immigrants >50% of refugees
Implementation of the 2007 TB TI 2010 Implementation South Korea Ghana Panel physician training India: January 13-15 Ghana: March 16-18 Dominican Republic: May 3-5 Summer/Fall Spring Nepal Spring ACET/NTCA Vietnam India Summer/Fall Guatemala Summer/Fall Thailand Nigeria Summer/Fall Spring Malaysia Indonesia Summer/Fall Spring
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
How do the 2007 technical instructions impact U.S. Follow Up Requirements?
2007 TI: Tuberculosis Classification 2007 TI Class A Definition Diagnosed with TB disease. Require waiver for admission into the U.S. Medical Evaluation in Maine Immediate evaluation for the treatment of TB disease by TB Consultant. Follow TB Case/Suspect policy & procedure Ensure TB follow up worksheet returned to TBC
2007 TI: Tuberculosis Classification 2007 TI Class B1 Definition Medical history, PE or CXR suggestive of pulmonary TB Smear negative Culture negative Completed treatment or No treatment Medical Evaluation in Maine Review disease and treatment history Administered TST if no documentation Obtain CXR and compare to overseas CXR if available Collect sputa x3 if patient symptomatic Refer to provider for medical evaluation, TB Consultant preferred Ensure TB follow up worksheet returned to TBC
2007 TI: Tuberculosis Classification 2007 TI Class B2 Definition TST is 10 mm CXR normal No evidence of active TB LTBI Medical Evaluation in Maine Review medical history Evaluate for s/s Obtain CXR Refer to provider for medical evaluation Ensure TB follow up worksheet returned to TBC
2007 TI: Tuberculosis Classification 2007 TI Class B3 Definition Identified as a contact to a known TB case Medical Evaluation in Maine Review medical history Evaluate for s/s Administer TST or IGRA If TST 5mm or IGRA+, obtain CXR and refer for medical evaluation Ensure TB follow up worksheet returned to TBC
National TB Objective: #11 Evaluation of Immigrants and Refugees Those with abnormal CXR initiate medical evaluation within 30 days Those with abnormal CXR complete medical evaluation within 90 days Increase the proportion who start treatment for LTBI Increase the proportion who complete treatment for LTBI
2007 TB Technical Instructions Available at: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/tub erculosis panel technical instructions.html
Acknowledgements Thank you to: Sharmila Shetty, MD from the Immigrant, Refugee & Migrant Health Branch Division of Global Migration and Quarantine, Centers for Disease Control and Prevention for use of slides in this presentation (slides 2 13, 15 18, and 25)