Information for civil surgeons

The Centers for Disease Control and Prevention (CDC) recently released the revised Tuberculosis (TB) Technical Instructions for Civil Surgeons that describe the responsibilities of civil surgeons for testing and referral to local health departments.

As of October 1, 2018, civil surgeons are required to report all persons diagnosed with latent tuberculosis infection (LTBI), as part of medical screening to apply for U.S. permanent resident status, to the local health department where the applicant resides. This coincides with the new requirement to use a TB blood test, an interferon-gamma release assay (IGRA), instead of a tuberculin skin test (TST) for TB screening of applicants 2 years of age and older.

Civil surgeons are also required to refer to the local health department all applicants with CXR findings suggestive of TB disease, all applicants with symptoms or signs of TB disease, all applicants with known HIV infection, and all applicants with extrapulmonary TB for further evaluation and management.

Summary of testing required

All applicants 2 years of age and older must have an IGRA performed (a QuantiFERON or T-SPOT.TB test). A TST cannot be used as a substitute for an IGRA. Applicants with written documentation of a previous positive IGRA result do not need a repeat IGRA (applicants with written documentation of a prior TST still need to have an IGRA performed).
Applicants under 2 years of age with symptoms or signs of TB disease or HIV infection must have a TST or IGRA and a 2-view CXR (AP/PA and lateral) performed. A TST is considered positive if it is 10 mm or greater (5 mm or greater if the applicant is a contact to a person with TB disease or is immunosuppressed).

Note regarding indeterminate tests: Although indeterminate tests provide no information about the likelihood of TB infection, for the purposes of the status adjustment medical evaluation, the test does not need to be repeated and a CXR does not need to be performed in order to complete the I-693 form and give to the applicant. The applicant should, however, be advised to have a repeat test performed, as it is not known whether or not they have LTBI.

A CXR must be performed for all of the following applicants with:
- Positive IGRA (including applicants with a history of a positive IGRA)
- Symptoms or signs of TB disease, regardless of the IGRA result
- Known HIV infection, regardless of the IGRA result
- Extrapulmonary TB, regardless of the IGRA result
CXR views required:
- Applicant younger than 10 years of age: 2-view CXR must be performed (AP/PA and lateral).
- Applicant 10 years of age or older: only a 1-view CXR (PA) must be performed.

When to report applicants to the local public health department

Reporting to the local public health department is required for:

All applicants with CXR findings suggestive of TB disease
All applicants with symptoms or signs of TB disease
All applicants with known HIV infection
All applicants with a positive IGRA

Note: Applicants who have documentation of previous diagnosis and completion of treatment for LTBI, and who have a negative CXR, no symptoms or signs of TB disease, and no known HIV infection do not need to be reported. They should be classified as “No Class A or Class B TB.”

I-693 completion

Applicants requiring referral to the health department for evaluation for TB disease (all applicants with CXR findings suggestive of TB disease, all applicants with signs or symptoms of TB disease, and all applicants with known HIV infection):

The civil surgeon must not classify, issue medical clearance for TB, or sign the I-693 form until the applicant returns from the local health department with documentation of the results of his or her TB disease evaluation. Applicants diagnosed with TB disease by the health department will need to return to the civil surgeon after treatment so they can be reclassified and cleared, and the I-693 form can be completed.

Applicants classified as class B2 TB, LTBI requiring reporting to the health department (positive IGRA, no signs or symptoms of TB disease, negative CXR, and no known HIV infection):

The I-693 form can be completed and given to the applicant.

How to report and refer applicants to the County of Santa Clara Public Health Department

Applicants requiring evaluation for TB disease (all applicants with CXR findings suggestive of TB disease, all applicants with symptoms or signs of TB disease, and all applicants with known HIV infection) need to be reported to the County of Santa Clara Public Health Department TB Program by completing a CMR form, and they also need to be referred to the Santa Clara Valley Medical Center TB Clinic for clinical evaluation and management. Most patients, including uninsured patients, can be seen at the Santa Clara Valley Medical Center TB Clinic, but if they are insured and the Santa Clara Valley Medical Center TB Clinic is out of their network, then the County of Santa Clara Public Health department will assist to arrange for an evaluation by an in-network provider. Please fax all of the following information to the TB Program at (408) 885-2331. You can reach the TB Program via the TB Provider Line: (408) 885-2440.

To report applicants with CXR findings suggestive of TB disease, all applicants with symptoms or signs, and all applicants with known HIV infection to the County of Santa Clara Public Health Department TB Program:

Fax the CMR form, indicating the disease being reported as “Tuberculosis.”
Fax the supplemental information needed:
- I-693 form and include whether the applicant has any symptoms or signs of TB, known HIV infection, the approximate date of U.S. arrival and the reason for referral.
- Do not sign the I-693 form until an infectious disease providers has evaluated the patient.

Notes:

Applicants who have documentation of previous diagnosis and completion of treatment for LTBI, and who have a negative CXR, no symptoms or signs of TB disease, and no known HIV infection do not need to be reported. They should be classified as "No Class A or Class B TB."
Report applicants to the jurisdiction of their residency.
- To refer the applicant to the Santa Clara Valley Medical Center TB Clinic for clinical evaluation and management, please fax the SCC Referral Package along with supporting documents to the Santa Clara County Health and Hospital System Authorization Center at (408)793-1892.
  - Santa Clara County Referral Package
- Educate the applicant about the necessity for follow-up evaluation performed in collaboration with the local health department. Applicants should be told that the civil surgeon’s medical examination cannot be completed until the results of the follow-up evaluation are available.

Applicants with class B2 TB, LTBI (positive IGRA, no signs or symptoms of TB disease, negative CXR, and no known HIV infection) need to be reported to the TB Program by completing the CMR form. Please fax all of the following information to the TB Program at (408) 885-2331. You can reach the SCCPHD TB Program via the TB Provider Line: (408) 885-2440.

Fax the CMR form, indicating the disease being reported as “Latent Tuberculosis Infection – Civil Surgeon.”
- Please indicate whether you plan to treat the applicant for LTBI, whether you are referring the applicant to another physician for LTBI treatment (please provide the name and contact information of the physician), if the applicant needs to be linked to care, or indicate the reason that the applicant does not need to be treated.
- If you decide to treat the applicant for LTBI, you can find information about treatment regimens for LTBI at sccphd.org/tb, including short-course regimens (12-dose weekly isoniazid/rifapentine and rifampin daily for four months) which are preferred (in persons for whom there is no contraindication) due to their higher treatment completion rates as compared with 9 months of daily isoniazid.
Fax supplemental information needed: IGRA result, CXR report.
Inform the applicant of their LTBI diagnosis, that this must be reported to the health department, and that treatment is important to prevent the development of TB disease in the future, but that this is not required to complete the status adjustment process.

Clinical consultation for TB disease or LTBI

During business hours, please call the TB Provider line at (408) 885-2440. After business hours, please call County of Santa Clara Communications and ask for the Health Officer On-Call at (408) 998-3438.

Thank you for helping us protect the health of residents in Santa Clara County.

Tuberculosis (TB) Prevention and Control Program

County of Santa Clara Public Health Department
976 Lenzen Ave., Suite 1700
San Jose, CA 95126

Phone: (408) 792-1381
Fax: (408) 885-2331