Questions and Answers: 2009 Update to the Tuberculosis Screening Required for Adjustment of Status

These Questions and Answers only provide information about the assessment by the civil surgeon to determine whether an applicant has been infected with TB and address the most recent updates to the Tuberculin (TB) Component of the Technical Instructions for the Medical Examination of Aliens in the United States.

Background

On November 1, 2009, the Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC) updated the Tuberculosis Component of the Technical Instructions for the Medical Examination of Aliens in the United States (May 2008)  (available on CDC's website at www.cdc.gov/ncidod/dq/civil.htm). This update makes the traditional Tuberculin Skin Test (TST), and as of November 1, 2009, the QuantiFERON®-TB Gold (QFT-G) Test, the QuantiFERON®- TB Gold in Tube (QFT-G IT) test, and the T-Spot TB test available for TB testing. USCIS anticipated this change and made the necessary amendments to Form I-693, Report of Medical Examination and Vaccination Record.

The civil surgeon is required to comply with the Technical Instructions for the Medical Examination of Aliens in the United States (Technical Instructions), and any updates, issued by the CDC. The update to the TB Component of the Technical Instructions is effective and applies to the completion of any medical assessment made on or after November 1, 2009. The update supplements the Tuberculosis Component of the Technical Instructions for the Medical Examination of Aliens (May 2008) (TB Component of the Technical Instructions); it does NOT replace it.

The screening for TB is one part of the medical examination only; the civil surgeon has to screen an applicant for other conditions that render an applicant inadmissible to the United States. These conditions include other communicable diseases of public health significance, as defined in the Department of Health and Human Service's (HHS) regulations at 42 CFR part 34; mental and physical disorders with associated harmful behaviors; and drug abuse or drug addiction. The civil surgeon also has to assess whether the individual has received vaccinations against vaccine preventable diseases, and administer appropriate vaccines, as required by HHS.

More information on immigration medical exams and civil surgeons is available on our website at www.uscis.gov.  For more information about the medical examination, please visit Immigration Medical Examinations. For more information about civil surgeons, please visit Designated Civil Surgeons.
 

Questions and Answers

Q. What is Tuberculosis?
A. Tuberculosis (TB) is a disease caused by bacteria called Myobacterium tuberculosis. The bacteria usually attack the lungs. But TB bacteria can attack any part of the body, such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal. TB disease was once the leading cause of death in the United States.

TB is spread through the air from one person to another. The bacteria are put into the air when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected.

However, not everyone infected with TB bacteria becomes sick. People who are infected but not sick have what is called latent TB infection. People who have latent TB infection do not feel sick, do not have any symptoms, and cannot spread TB to others. However, some people with latent TB infection go on to get TB disease. People with active TB disease can be treated if they seek medical help. Most people with latent TB infection can take medicine so that they will not develop active TB disease. For more information on TB infection, visit www.cdc.gov.

Q. Why are TB and TB control an issue in the United States?
A. In the early 1900s, TB disease killed one out of every seven people living in the United States and Europe. Starting in the 1940s, scientists discovered the first of several medicines now used to treat TB. As a result, TB disease slowly began to decrease in the United States. But in the 1970s and early 1980s, the country let its guard down and TB control efforts were neglected. This contributed to an increase in the number of TB cases between 1985 and 1992. However, with increased funding and attention to the TB problem, there has been a steady decline in the number of persons with TB disease since 1993.

TB continues to be a problem. For example, while the number of TB cases is still declining, the speed of decline has slowed since 2003. Multidrug-resistant TB (MDR TB) remains a concern, and extensively drug-resistant TB (XDR TB) has become an important issue. Finally, racial and ethnic minority populations and foreign-born individuals continue to account for a large number of TB cases in the United States. This is why the initial screening for TB and the appropriate treatment of TB for individuals coming to the United States and living here permanently is an important tool to help eradicate the disease in the United States and worldwide.

For more information on TB, please consult CDC's website at www.cdc.gov.

Q. Why am I, as an applicant for adjustment of status, screened for TB?     
A. When passing immigration laws, Congress wanted to ensure that immigrants with significant health conditions do not endanger the health of the United States public. It put laws in place (section 212(a)(1)(A) of the Immigration and Nationality Act) to guard against certain significant health conditions being spread or introduced to the US.

Therefore, every immigrant, including an adjustment of status applicant, has to be screened for health-related grounds of inadmissibility, such as communicable diseases of public health significance. Adjustment of status applicants are screened by going to a civil surgeon (a physician that is designated by USCIS) and having a medical examination which includes a screening for communicable diseases of public health significance (such as TB) and other physical or mental conditions. The civil surgeon also assesses vaccination status and administers required vaccines. If the civil surgeon encounters an individual with a significant health-related condition, the civil surgeon will be able, for most conditions, to prescribe the necessary treatment so that the inadmissibility no longer exists and the danger to the public is eliminated or diminished.

Q. Are all adjustment of status applicants screened for TB?
A. Under the May 2008 TB Component of the Technical Instructions for the Medical Examination of Aliens in the United States, and its updates, all applicants for adjustment of status are screened for TB, unless they are too young. Initial screening tests are required for all applicants ages 2 years or older. Children under the age of 2 must be tested if there is evidence of contact with a person known to have TB or if there is another reason to suspect TB. There are three exceptions to initial screening requirements, as detailed below. However, testing has to be conducted even if an applicant is pregnant or has been previously vaccinated with the Bacille Calmette-Guérin (BCG) vaccine.

Before November 1, 2009, screening for TB had to be done through the administration of a tuberculin skin test (TST). As of November 1, 2009, the civil surgeon may use an interferon gamma release assay (IGRA) in place of TST testing. If evidence of TB infection is found, a chest x-ray is required.

For more information, please visit the CDC's website at http://www.cdc.gov/ncidod/dq/civil.htm.

Q.  What is a tuberculin skin test (TST)?
A. The tuberculin skin test (TST) is the administration of a tuberculin solution in between the different levels of your skin. The Technical Instructions require a Mantoux tuberculin skin test, which is an intradermal injection of the tuberculin solution.  After the administration of the test by the civil surgeon’s staff, you will need to return to the civil surgeon's office within 48 to 72 hours to have the result read. Generally, if the reaction is 4 mm or less, you will not need any further tests for TB. If the reaction is 5mm or greater, you are required to have a chest x-ray as a means of additional screening for TB.

There are certain exceptions that do not require you to undergo another TST if you had one previously. If possible, you should bring written documentation of any previous TB screening to your appointment with the civil surgeon so that the civil surgeon is able to determine whether you are required to have another one.

Q. What is initial testing with interferon gamma release assay (in place of TST)?
A. To fulfill the requirement of the initial TB testing, civil surgeons may, as of November 1, 2009, use interferon gamma release assay (IGRA), which are blood tests. The IGRAs that are currently acceptable to CDC are: the QuantiFERON ® TB Gold Test, the QuantiFERON® TB Gold in Tube Test, and the T-Spot ® TB Test.  CDC may add additional tests. If it does, it will publish the inclusion of any test on its website at http://www.cdc.gov/ncidod/dq/civil.htm.

If you choose an IGRA (in place of a TST), the civil surgeon will take a blood sample from you during the medical examination. The blood is used to perform the TB initial screening test. Unlike with the TST, you will not have to return to the civil surgeon's office to have the test result read.

The results of the IGRA test are generally available within 24 hours of your office visit. If the result is negative, you will probably not need any further testing for TB. If the result is positive, you will be required to have a chest x-ray as a means of additional screening for TB. You may not have a TST or other initial screening test; the administration of more than one initial screening test is a violation of the Technical Instructions.

There are certain exceptions to the IGRA testing requirement. For the civil surgeon to make the best determination of what is required, you should bring, at the time of your appointment with the civil surgeon, written documentation of any IGRA testing you previously had.
 
Q. Do I need both the TST and an IGRA test?
A. No. Only one of the tests is required as an initial screening method to determine whether you are infected with TB. Also, only one initial screening method is allowed, according to the update to the TB Component, as published on CDC's website at http://cdc.gov/ncidod/dq/civil.htm.
 
Q. Can I choose a particular test?
A. In general, any of the initial testing methods permitted is suitable for use in most persons. The TST is widely available. The QuantiFERON-TB Gold Test, QuantiFERON® TB Gold in Tube Test and the T-Spot TB test are not currently as widely available in the United States as the TST. If one or more of the tests would not be suitable for you, or is not available, the civil surgeon will inform you and not perform that particular test.  Otherwise, you may discuss the options with the civil surgeon.

Q. Which initial testing method is better, the TST or the IGRA blood tests?
A. Each of these tests has been approved by the federal Food and Drug Administration (FDA) as suitable methods for initial testing for TB. While the TST may be inconvenient due to the need of a follow up visit, the IGRA tests have availability and cost limitations. Once the civil surgeon has informed you of your options, you can make a decision. 

Q. Does a civil surgeon have to offer all three tests to me?
A. No. The civil surgeon is only required to offer one initial testing method.

The ability to perform the IGRA blood tests varies in different parts of the United States. In order to perform the blood tests correctly, the civil surgeon must ensure that the test is timely initiated and processed. The civil surgeon may not have the necessary equipment or a laboratory nearby to perform the test correctly. This may be one of the reasons that a civil surgeon chooses to use the traditional TST as an initial TB testing method.

If the civil surgeon does not offer the test that you prefer, you can try to find a civil surgeon who does.

Q. Who pays for the initial TB test?
A. As is the case with all the tests that are needed for the proper completion of the medical examination requirement, the applicant is responsible for paying the appropriate fee for the test. You will have to pay this fee directly to the civil surgeon, as agreed upon with the civil surgeon. Some of the initial TB tests are much more expensive than others. Prior to the administration of the test, you should ask about the price of the test.

Q. What happens if I choose a TST and the TST is "positive"? Can I choose another, alternative test instead of a chest X-ray?
A. No. According to the update to the TB Component of the Technical Instructions, (available at http://www.cdc.gov/ncidod/dq/civil.htm) a civil surgeon may only administer one of the initial TB tests. If that test is positive, a chest x-ray is required.

Q: What happens if I choose an IGRA test and the result is indeterminate or borderline/equivocal? Do I need to repeat the IGRA test?
A. No. The civil surgeon should treat an indeterminate or borderline/equivocal result as a negative result. 

Q. When can a civil surgeon start to use the IGRA tests in place of the TST?
A. With the publication of the Update to the TB Component of the Technical Instructions for the Medical Examination of Aliens in the United States (available at http://www.cdc.gov/ncidod/dq/civil.htm) any initial testing for TB may be done by either using the TST or the IGRA as initial TB testing method. That is, for medical examinations conducted on or after November 1, 2009, the civil surgeon may use any of these methods. However, if the IGRA method is used, the civil surgeon must record the results of the IGRA test on the newest version of the Form I-693, Report of Medical Examination and Vaccination Record (edition October 14, 2009). Older versions of Form I-693 cannot be used for recording the IGRA results.

If a Form I-693 is completed prior to November 1, 2009 by using other methods than the TST, the form will be rejected.

Q. Are there any exceptions to the initial TB testing requirement?
A. Yes. Under the May 2008 TB Component of the Technical Instructions for the Medical Examination of Aliens in the United States, and its update, an applicant may not be required to undergo the initial TB screening testing with a TST or IGRA under the following circumstances:

• Applicants providing written documentation (with a health care provider's signature) of a TST reaction of 5 mm or greater of induration. For this TST exception to apply, the written documentation must include:
  1) The date of the test;
  2) The millimeters of induration;
  3) The type of PPD used;
  4) The testing health care provider's name, signature, and office information.

A verbal history from an applicant of a positive TST reaction is not acceptable.

• Applicants who have a history of a severe reaction with blistering to a prior TST.

• Applicants providing written documentation (with the health care provider's signature) of a prior positive IGRA. If more than one IGRA has previously been performed, the most recent result should be used by the civil surgeon. The written documentation must include:
  1) The date of the test;
  2) The type of IGRA performed;
  3) The test results including units of measurement;
  4) The testing health care provider's name, signature, and office information.

A verbal history from the applicant of a positive IGRA result is not acceptable.

If one of these exceptions applies, the civil surgeon is directed to annotate the Form I-693 accordingly and to have the applicant undergo a chest x-ray.

Q. When is a chest x-ray required?
A. Every applicant is required to undergo a chest x-ray if one of the following applies:

• The applicant has a TST reaction of 5mm or greater of induration (including pregnant or  possibly pregnant individuals)
• The applicant has a positive IGRA result (including pregnant or possibly pregnant individuals)
• The applicant was not required to undergo the TST or IGRA testing because of the exceptions  specified in the TB Component of the Technical Instructions for the Medical Examination of  Aliens in the United States (May 2008), and its update, applied to the applicant
• The applicant has signs or symptoms of TB (regardless of the initial testing result)
• The applicant is immunosuppressed (regardless of the initial testing result)

Q. If a chest x-ray is required, will USCIS accept Form I-693 without the full and formal chest x-ray report?
A. No. If a chest x-ray is required, the TB Component of the Technical Instructions for the Medical Examination of Aliens in the United States (May 2008), and its update require the civil surgeon to submit a full and formal chest x-ray report. This report should be as follows:

The chest x-ray should be interpreted by a radiologist or other qualified physician who is trained and experienced in reading chest radiographs demonstrating TB or other diseases of the lungs. After interpreting the results, the radiologist or other qualified physician should create and sign the full and formal report on official hospital or medical office letterhead. USCIS will accept the original or a copy of the report. USCIS cannot accept any preliminary or incomplete evaluation, whether handwritten or not, that does not describe the full evaluation or findings. In most cases, the civil surgeon will have to wait a day or two before this report has been sent by the reviewing medical office and cannot not sign off on the Form I-693 until this report has been received.

The instructions of Form I-693 direct the civil surgeon to the applicant a copy of the results of any testing conducted in relation to Form I-693 and a copy of the Form I-693, as submitted to USCIS.

Q.  Will USCIS accept a Form I-693 if the civil surgeon performed a chest x-ray without the initial TB test (either TST or IGRA)?
A. No. USCIS will not accept a Form I-693 if the civil surgeon performed a chest x-ray without the initial TB screening test (either TST or IGRA) and if the civil surgeon failed to provide a valid exception to the TST or IGRA initial screening requirement.

Q: I am pregnant (or possibly pregnant) and I have a positive initial screening result.  Do I still need a chest x-ray or will USCIS accept Form I-693 without an x-ray?
A. USCIS will not accept a Form I-693 if not completed in accordance with the Technical Instructions for the Examination of Aliens in the United States (Technical Instructions), including the TB Component of the Technical Instructions for the Examination of Aliens in the United States (May 2008), and its update.

If you are pregnant (or possibly pregnant) and your initial TB test reveals that you are infected with TB, you are required to undergo a chest x-ray, pursuant to the TB Component of the Technical Instructions for the Medical Examination of Aliens in the United States (May 2008) and its update.

However, you may choose to defer the chest x-ray until later in pregnancy or after delivery but the civil surgeon cannot sign the medical examination form until the radiograph is performed and interpreted, and treatment of Class A pulmonary TB disease, if needed, is completed.

Therefore, if you choose to defer the chest x-ray, the civil surgeon cannot sign the Form I-693.
 
Q. What happens, if the civil surgeon determines that I have an abnormal chest x-ray suggestive of TB?
A. If the chest x-ray suggests TB disease, the civil surgeon will tell you in detail what steps you have to take. According to CDC's directive, the civil surgeon is required to refer you to the local health department's TB control program for further evaluation. If it is determined that you have active TB (Class A TB) the civil surgeon cannot complete your Form I-693 until you received and completed treatment for TB (usually about 6 months). That is, he cannot sign Form I-693 and cannot give you the completed Form I-693 in a sealed envelope until you no longer have Class A TB and until any follow up assessment has been completed.

Q. I have an abnormal chest x-ray, and the referral to the local health department determines that I don't have Class A TB but a Class B TB condition. Am I cleared for immigration purposes and can the civil surgeon immediately sign Form I-693 and give it to me in a sealed envelope?
A. Yes, you can be cleared by the civil surgeon (for TB purposes), and the civil surgeon can sign the I-693 form (provided there are not any other medical conditions that would prevent the signing of the Form I-693).

Q. What if my skin test is positive and my chest x-ray is normal?
A. If you are diagnosed with Class B, Latent TB infection, the civil surgeon may recommend you go to the health department for further assessment and preventative treatment. However, it is only recommended (not required) that you get assessed by the local health department. The civil surgeon can immediately sign Form I-693 and give it to you in a sealed envelope provided that all other examinations are up-to-date, and you can be medically cleared for immigration purposes prior to the referral to the health department TB control program.

Q: Where can I find more information about TB and how it affects the completion of Form I-693?
A. If you have questions about TB, please consult CDC's website at www.cdc.gov.

If you want to look at the Technical Instructions for the Medical Examination of Aliens in the United States, including the TB Component of these Technical Instructions, please visit CDC's website at www.cdc.gov or click on the following link: www.cdc.gov/ncidod/dq/civil.htm.

If you have any questions about the civil surgeon program or the completion of Form I-693, or the adjustment of status application, please visit USCIS' website at www.uscis.gov or call the USCIS Contact Center at 1-800-375-5283 (TTY 1-800-767-1833).