CDC Update on the 2007 TB Technical Instructions

Sharmila Shetty, MDImmigrant, Refugee & Migrant Health BranchDivision of Global Migration and QuarantineCenters for Disease Control and Prevention

Summary

• Overview of Immigrant, Refugee, Migrant Health Branch

• Epidemiology and trends of TB in the US• Changes in 2007 TB Technical Instructions (TI)

Source: U.S. Department of Homeland Security Refugee admissions: 61,498 (2008)

Annual Estimate of Migrants Entering the U.S.

Total: ~60 million

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

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 infected9.3 million cases of active TB1.8 million deaths

TB Cases, United States, 1993-2008

TB rate:FB 20.6/100KUS 2.1/100K

MDR TB Cases, United States 1993-2007

XDR TB (’00-’06): 76%XDR TB (’00-’06): 76%

Simplified TB Screening AlgorithmCDC 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+

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

*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

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

TB in US-bound Hmong Refugees

# of Refugees Location Cases Identified N Rate/100,000

9482 Wat Tham Krabok

US

24

48

126

506

*Screened with 1991 TB TI

TB Cases

TB in US-bound Hmong Refugees

# of Refugees Location Cases Identified N Rate/100,000

9482 Wat Tham Krabok

US

24

48

126

506

•TB culture added to screening algorithm5801 Wat Tham Krabok

US

24

5

420

86

TB Cases

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

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 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

Saint Luke’s Extension Clinic, PhilippinesFY 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)

121

75

95

291

306

93

102

505

4

0 50 100 150 200 250 300 350 400 450 500 550

Smear – / No CultureDone

Smear – / Culture –

Smear – / Culture +

Smear + / Culture –

Smear + / Culture +

Number of Applicantswith Pulmonary TB

2007 Technical Instruction

1991 Technical Instruction

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 status27 countries53% of immigrants>50% of refugees

Implementation of the 2007 TB TI-2010 Implementation

GuatemalaSummer/Fall

IndiaSummer/Fall

GhanaSummer/Fall Nepal

Spring

ThailandSpring

South KoreaSpring

MalaysiaSpring

NigeriaSummer/Fall

IndonesiaSummer/Fall

Panel physician trainingIndia: January 13-15Ghana: March 16-18Dominican Republic: May 3-5

ACET/NTCAVietnam

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

2007 TB Technical Instructions

Available at:

http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/tuberculosis-panel-technical-instructions.html

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

Thank you!!

Sputum smears x 3

InfectiousClass A

NoninfectiousClass 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

Sputum smears x 3

InfectiousClass A

NoninfectiousClass 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 ≥20/100,0002-14 years of age:TST ≥10 mm or Positive IGRA

3 cured

DOT

or

HIV

Signs and symptoms

2007 Technical Instructions:Classifications

Class 1991 Technical

Instructions

2007 Technical Instructions

No classification Normal evaluation Normal evaluation

Class A Tuberculosis disease Tuberculosis disease

Class B1- Pulmonary

Abnormal CXR, sputum smears negative

Abnormal CXR, sputum smears and cultures negative

Class B1 – Extrapulmonary

Extrapulmonary tuberculosis

Extrapulmonary tuberculosis

Class B2 Inactive tuberculosis on CXR

LTBI evaluation

Class B3 Old or healed tuberculosis

Contact evaluation

Waivers for Medical ConditionsBasic 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

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)

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