Immigrant and Refugee Tuberculosis Class A/B Notification Surveillance Paul Gacek, MPH, CPH CDC/CSTE Epidemiology Fellow Connecticut State Department of Public Health Centers for Disease Control and Prevention Council of State and Territorial Epidemiologists

Overview • Review the Importance of CDC DGMQ TB Class A/B notification program • Review the new 2007 TB Technical Instructions • Disseminate the results of Connecticut's TB Class-A/B arrivers surveillance system

The Importance of the TB Class A/B Notification Surveillances System • 15% of recent class-B arrivals screened under the 1991 TIs have been diagnosed with active and infectious TB disease • TB disease among persons with a B1 classification is 4 times higher than among persons with a B2 classification • TB disease among persons with a B1 classification is 20 times higher than among close contacts of persons with TB disease

Objectives of the TB Class A/B Notification Surveillances System 1. Detect active pulmonary TB disease at an earlier stage in recent foreign-born arrivers 2. Rapid identification of individuals with latent TB infection (LTBI) 3. LTBI therapy to prevent future disease

Overseas Medical Examination •

Health Service Act, Section 325, "Examination of Aliens" (42 U.S.C. 252)

•

Immigration and Nationality Act, Section 212(g)

Overseas Medical Evaluation • Overseas medical examinations are performed by ~400 panel physicians selected by Department of State consular officials • CDC’s Division of Global Migration and Quarantine provides technical instructions to panel physicians

1991 vs. 2007 Technical Instructions of TB Classification: Class A 1991 TI

2007 TI

Infectious Active TB Disease

Infectious Active TB Disease

Positive sputum smear

Positive sputum smear or culture Sensitivity testing of positive cultures

Treatment required

Treatment required by DOT

Can request a waiver once smear negative

Less likely to see a waiver

1991 vs. 2007 Technical Instructions of TB Classification: Class B1 1991 TI

2007 TI

Clinically active TB

TB Suspect

1. Not infectious 2. CXR Abnormal 3. Smear Negative

Pulmonary TB Disease • Exam or CXR suggest TB • Negative sputum smears and cultures

Extrapulmonary TB Disease • Evidence of extrapulmonary TB

1991 vs. 2007 Technical Instructions of TB Classification: Class B2 1991 TI

2007 TI

Not clinically active TB

Latent TB Infection

• • •

1. TST >10mm (>5mm if HIV+) 2. Normal CXR 3. No clinical findings of TB disease

Not infectious Abnormal CXR No sputum smears required

1991 vs. 2007 Technical Instructions of TB Classification: Class B3 1991 TI Not used in recent years

2007 TI • A contact not started on preventive treatment

•Currently on preventive treatment •Completed preventive treatment

Medical Examination Requirements 1991 TI

2007 TI

Validity

6 months if B1 12 months if B2/B3

3 months if B1 6 months if B2/B3

TST

Not done

2-14 yrs if TB case rate > 20; known contacts

CXR

> 15 yrs

> 15 yrs; 5mm

Pregnancy

No CXR

CXR required

Overseas Medical Evaluation How long is a Overseas Medical Exam Valid? 1 Year

6 Months Medical Examination with no TB classification or B2/ B3 classification

3 Months Medical Examination with B1 Pulmonary or B1 Extrapulmonary +HIV

2007 CDC DGMQ TI

US Entry Medical Examination with no TB classification or B2/ B3 classification

Medical Examination with B1 Pulmonary or B1 Extrapulmonary +HIV

1991 CDC DGMQ TI

Where the 2007 Technical Instructions for TB Screening and Treatment have been Implemented

A Glimpse of Connecticut's TB Class-A/B Arrivers Surveillance System Overseas Medical Examination

Report to CDC Division of Global Migration and Quarantine (DGMQ)

US Entry

DGMQ Report Received by the State TB Control Program

Report to Local Health Department

Report to the Immigrants Sponsor

U.S Follow-up Medical Examination

Report to the Refugees Voluntary Resettlement Agency

TB Class-B Arrivers Surveillance Data Connecticut, 2007-2008 80% 70% 60% 50% 40% 30% 20% 10% 0% Medical Evaluation

TB Treatment

LTBI Surveillance

TB Class-B Arrivers Surveillance Data Connecticut, 2007-2008 80% 70% 60% 50% 40% 30% 20% 10% 0% Medical Evaluation

LTBI Surveillance

TB Treatment

HD Record Review

TB Class-B Arrivers Surveillance Data Connecticut, 2007-2008 80% 70% 60% 50% 40% 30% 20% 10% 0% Medical Evaluation

Surveillance Database

TB Treatment

HD Record Review

Follow-up with local HD

Time for the TBCP to Receive Notification of a New TB Class-B Arrivers Connecticut, 2007-2008

Notification Type US Mail Notification Electronic Disease Notification

Days to Notification 14 days (Range 0–75) 26 days (Range 1-77)

Classification of TB Class-B arrivers in Connecticut, 2007-2008 TB Class 1991 TI

2007 TI

Combined

B2 B1

68 (45.4%) 58 (54.5%)

40 (58.1%) 23 (41.9%)

103 (56.0%) 81 (44.0%)

Total

126 (68.5%)

63 (31.5%)

184 (100%)

Active TB Cases Detected Among TB Class-B arrivers in Connecticut, 2007-2008 TB Class 1991 TI B2 B1

3 (4.8%)

2007 TI 1 (2.5%)

Combined 4 (4.9%)

Time for TB Class-B arrivers to receive a U.S. Follow-up Medical Examination, Connecticut, 2007-2008 U.S. Entry TBCP Notification

Percentage Evaluated

0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 0-15

16-30

31-45

46-60 Time in Day

61-75

76-90

>91

An Example of a Class-B1 Arriver Identified with Active TB Disease • Class-B1 • Immigrant from the Philippines • Female, 25 years old Overseas Medical Examination • CXR: Noncavitary consistent with TB • 3 negative sputum smears

An Example of a Class-B1 Arriver Identified with Active TB Disease • Time from overseas medical examination to U.S. entry: 175 days

An Example of a Class-B1 Arriver Identified with Active TB Disease • Time from U.S. Entry to U.S. follow-up medical examination: 23 days

An Example of a Class-B1 Arriver Identified with Active TB Disease Results of the Follow-up medical examination: • Abnormal CXR, Noncavitary disease consistent with TB disease • 3 negative sputum smears • A positive sputum culture • DOT was appropriately administered

Recommendations Towards Eliminating TB in B-Arrivers •

Ensure that refugees with a TB B classification receive a follow-up medical examination within 30 days of US entry

•

Prioritize scheduling a follow-up medical examination for pulmonary TB B1

•

Recommend that those with a TB B classification start and complete LTBI therapy

Acknowledgments Lynn Sosa Mark Lobato Tom Condren Maureen Williams Margaret Tate Danielle Orcutt Tricia Christensen Linda Luther Connecticut Local Health Departments