Download CDC Presentation - International Panel Physicians Association

US First Timers
Zachary White, MPH
Drew L. Posey, MD, MPH
Medical Assessment and Policy Team
Immigrant, Refugee, and Migrant Health Branch
Tuesday, March 30, 2017
Panel Physicians Training Summit
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine
Learning Objectives
1.
Understand the roles and responsibilities of the panel
physician
2.
Apply CDC technical instructions to successfully examine
immigrants and refugees
3.
Identify common mistakes to avoid and achieve best
practice at the panel site
Background
 Each year, approximately 400,000 immigrants and 50,000
refugees enter the United States
 CDC’s Division of Global Migration and Quarantine
(DGMQ) has regulatory authority to stipulate the
requirements of the overseas medical examination via
Technical Instructions
 The Bureau of Population, Refugees, and Migration
(BPRM) is the US Department of State bureau responsible
for refugee resettlement
 BPRM has contracted with the International Organization
for Migration (IOM) to perform the medical screening for
approximately 80% of the refugees
 Panel physicians are using Cultures and Directly Observed
Therapy Technical Instructions for Tuberculosis (TB TIs)
Question 1
Have you diagnosed a tuberculosis case at your panel site?
A.
B.
Yes
No
Share Experiences as a New Panel Physician


Successes?
Problems?
Case Example





Ten-year-old child screened May 4, 2016
According to the child’s guardian, he was diagnosed with TB
in November 2015 and received treatment that ended April
2016
The guardian does not have record of the treatment
medications
The following information was gathered during the exam:
The child has suffered from fever, night sweats, cough for 5
days, and weight loss, and was hospitalized
The TST result was 0mm
Case Example

Additional Information Obtained from Guardian:
•
•
•
•
•
Mother died from TB in 2013 but was HIV negative
No additional information about the father and other relatives
The child was hospitalized for first 3 months of treatment
The guardian gave the rest of TB medication
The child is suffering from acute respiratory infection
Given this information, what are your next
steps?
Question 2
After reviewing the information, does this child need
a Chest Radiograph (CXR)?
A.
B.
C.
Yes
No
Not enough information
Actual Case – DS-3030
Actual DS-3026
Question 3
Which of the following on the DS-3026 should be considered as
“signs and symptoms” for TB?
A.
B.
C.
D.
E.
F.
Cough
Fever
Night sweats
Weight loss
None of the above
All of the above
Question 4
Should this child receive sputum smears and cultures?
A.
B.
Yes
No
DS-2054
Important Resource

http://www.cdc.gov/immigrantrefugeehealth/exams/ti/pan
el/technical-instructions-panel-physicians.html
TB Screening Algorithm
Cultures and Directly Observed Therapy TB
Technical Instructions
If TB rate
≥20/100,000 or
2-14 years of age:
TST ≥10 mm or
positive IGRA
Valid for travel
within 3 months
HIV or
TB signs or
symptoms
Sputum smears and cultures (3)
All (-)
Noninfectious
Class B1
One or more (+)
Infectious
Class A
DOT until
cured
Class A
waiver
Importance of the Physical Exam


Always follow TB algorithm
Thorough physical exam and clinical judgment of panel
physician are essential
• If the applicant has signs and symptoms of tuberculosis disease,
perform a CXR.
• Applicants with CXR findings suggestive of tuberculosis, signs and
symptoms of tuberculosis, or HIV infection should provide three
sputum specimens for microscopy for acid-fast bacilli (AFB), as well
as culture for mycobacteria and confirmation of the
Mycobacterium species, at least to the M. tuberculosis complex
level.
CXR of Applicant
Question 5
Who should complete and sign the DS-3030?
A.
B.
C.
D.
Panel physician
Radiologist
Either the panel physician or radiologist
Any staff member at the panel site can complete the DS3030
Chest X-ray

Are there any concerns regarding the chest x-ray?

Should the child have been given a chest x-ray overseas?

What are the findings suggestive of tuberculosis, if any?

Should this applicant have received smears and cultures
based on the chest x-ray and/or medical history?
Stateside Follow-up of Inadmissible Conditions





CDC has regulatory responsibility to provide information
to receiving health departments (HD) of arriving aliens
with a notifiable condition
Electronic Disease Notification System (EDN)
Replaces paper-based Immigrant and Migrant
Populations (IMP) system
Provides HD access to recorded DS Form information and
all scanned overseas DS Forms
Provide HD with an electronic system to record and
evaluate outcome of domestic follow-up evaluations
EDN
Overseas
U.S.
Overseas
Screening
Overseas
Forms
Quarantine Stations
EDN-IOM Interface
EDN – DATA ENTRY
Data Entry Center
CDC HQ - Atlanta
EDN – WEB
Local/State
Health Departments
Health Department Report
Teaching Points

Always refer to the CDC technical instructions

Panel physicians should use clinical judgment to perform
thorough examinations

Remember to collect in-depth medical history to determine
the classification of an individual
Questions?
[email protected]
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected]
Web: www.cdc.gov
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine