Wisconsin Department of Health Services

Lorna Will, RN Wisconsin Tuberculosis and Refugee Health Program

B1, B2 and B3 Tuberculosis Classifications and Wisconsin

P-01707 (12/2016)

Learning Objectives

Understand what tuberculosis (TB) statuses are and how they are determined

Identify reasons why follow-up is important Describe the TB status notification process Differentiate between the TB statuses

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Topics

Overseas Screening Process TB Classifications TB Status Notifications and Process Follow-Up and Domestic Screening

Recommendations

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Refugees, asylees, and those immigrating as permanent residents are required to undergo screening.

Non-immigrants such as temporary workers, students, and visitors for either business or pleasure are excluded from screening requirements.

Not Required Required

Who is Screened Overseas

Source: Curry International Tuberculosis Center, 2008 4

Pre-Immigration Screening

Screening of refugees and immigrants is required by law Non-immigrants currently not required to receive

screening Screening done by “panel physicians,” overseas

physicians working under an agreement with the local U.S. embassy or consulate

Standards for screening set by the CDC in technical instructions (TI), most recently TI 2007

Sources: Curry International Tuberculosis Center, 2008; CDC, 2014b 5

TI 2007 Screening Protocol

Countries with < 20 cases of TB per 100,000 No screening is necessary for individuals aged 2-14

years. Individuals aged 15 years or older need screening.

– Medical history, physical exam, and chest x-ray (CXR) – If suggestive of TB or HIV infection, three sputums – If indicated, assign appropriate TB classification

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TI 2007 Screening Protocol

Countries with ≥ 20 cases of TB per 100,000 Individuals aged 2–14 years

– Medical history, physical exam, and Mantoux tuberculin skin test (TST) or Interferon-Gamma Release Assays (IGRA)

– If TST greater than 10mm or IGRA positive, take CXR and consider sputum collection

– If indicated, assign appropriate TB classification

Individuals aged 15 years or older – Medical history, physical exam, and CXR – If suggestive of TB or HIV infection, three sputa – If indicated, assign appropriate TB classification

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Topics

Overseas Screening Process TB Classifications TB Status Notifications and Process Follow-Up and Domestic Screening

Recommendations

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Tuberculosis Classifications

Screening will put individuals into one of the following categories: no classification, A, B1, B2, or B3.

TB classifications give information on whether an individual has active disease, evidence of disease, suspected latent TB infection (LTBI), or is a contact to a recent known case of TB.

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No TB Classification

Applicants with normal tuberculosis screening examinations

Do not require follow-up examinations upon arrival to the United States, except for refugees

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A TB Classification

The individual has active TB disease. Evaluate the individual by performing a CXR,

sputum collection and clinical assessment. Continue or revise treatment. Directly Observed Therapy (DOT) is standard

of care for persons with active TB disease. None have entered Wisconsin from 2012 to

2016. 11

B1 TB Classification

Split into two (non-exclusive) subcategories – Pulmonary: medical history, physical exam, or

chest x-ray suggestive of TB, but with negative sputum smears and cultures; or previous diagnosis of pulmonary TB with documented completion of directly observed treatment

– Extrapulmonary: evidence of extrapulmonary TB Consider suspect TB until evaluated in U.S. Most common classification: 385 B1

individuals entered Wisconsin 2012–2014

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B2 TB Classification

Has greater than 10mm of induration on a Tuberculin Skin Test (TST) or a positive Interferon-Gamma Release Assays test (IGRA), but otherwise has a negative evaluation for TB disease

Considered to have LTBI Not as common as B1 classification: 167 B2

individuals entered Wisconsin from 2012 to 2014

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B3 TB Classification

Recent contact of a known TB case Treat like a contact to a domestic TB case Not very common: 6 B3 individuals entered

Wisconsin from 2012 to 2014

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Arrival of TB Classifications

B1 Classification is the most common

B2 is the second most common

B3 is rare, a few cases per year B1

69%

B2 30%

B3 1%

Wisconsin B Notifications 2012–2014

B1B2B3

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HIV and B1 Status

In 2010, HIV testing was removed from the immigration medical examination.

If an immigrant self-reports as having HIV, additional TB screening tests will be done.

An HIV positive individual will receive a B1, Pulmonary classification regardless of normal CXR or absence of signs and symptoms.

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Topics

Overseas Screening Process TB Classifications TB Status Notifications and Process Follow-Up and Domestic Screening

Recommendations

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TB Status Notifications

The CDC electronically notifies the Wisconsin (WI) TB Program within two weeks of immigrant or refugee arrival.

Once the notification is received the WI TB Program creates a WEDSS case and uploads the immigration paperwork.

The WI TB Program then faxes the information to the local health department (LHD). 18

TB Status Follow-Up

The LHD evaluates the client for TB and LTBI and treats if needed.

The LHD completes the TB Worksheet. The information on the TB Worksheet is then

entered into WEDSS by the LHD and returned to the state TB Program, which closes the case, and the TB Worksheet is submitted to the CDC electronically. 19

Follow-Up is Important

Overseas screening focuses on determining infectiousness for travel and finding abnormal CXRs, not ruling out infection.

U.S. screening focuses on appropriate follow-up to rule out active TB diagnosed in pre-immigration screening as well as identifying and treating LTBI to prevent future activation.

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Follow-Up is Beneficial to Refugees and Immigrants

Timely TB follow-up and treatment may simplify immigration status adjustment procedure in the future.

Immigrant may be required to undergo TB screening as part of their pre-employment testing when starting a new job in certain industries.

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Follow-Up is Beneficial to Refugees and Immigrants, Continued

LTBI may become active TB disease. It is particularly important for individuals from

countries where TB disease is endemic and Multi-Drug Resistant TB (MDR TB) is common.

Dispensary may cover cost of screening and treatment if immigrant has no insurance (or is under-insured) and sponsor is not able to cover the cost (case-by-case basis). 22

Topics

TB Status Notifications and Process Overseas Screening Process TB Classifications Follow-Up and Domestic Screening Recommendations

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LHD TB Screening for Notification of Class B1 TB

A person in this class is considered a TB suspect until they have completed follow up with the LHD.

Evaluate the individual – Give IGRA unless a documented positive test is

available. – Perform a CXR, regardless of CXR performed overseas. – Evaluate for signs and symptoms of TB. – Collect sputa for smear and culture as needed to

determine TB diagnosis. 24

LHD TB Screening for Notification of Class B2 TB

A person in this class is considered to have LTBI

Evaluate the individual – Perform IGRA. – Perform a CXR, regardless of CXR performed

overseas. – Standard of practice is to offer treatment for LTBI;

both a CXR and medical evaluation should be completed before initiation of LTBI treatment.

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LHD TB Screening for Notification of Class B3 TB

Evaluate the individual as a contact Administer IGRA unless there is a

documented previous positive IGRA. Administer CXR for all individuals with

positive TST or IGRA, or with signs or symptoms of TB.

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Continuing Follow-Up for Clients with TB Status

Once the diagnosis or disposition is determined, treat the client as is indicated.

Regardless of outcome, complete the electronic TB Worksheet in WEDSS and inform WI TB Program that screening has been completed.

If treatment is initiated, notify WI TB Program when treatment is completed.

The WI TB Program will notify the CDC and close the B1 or B2 service in WEDSS.

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Timeline for Follow-Up

U.S. Evaluation Timeline (time from arrival) Initial U.S. Medical Evaluation 30 days U.S. Review of Overseas CXR 30 days Domestic CXR and Comparison 30 days U.S. Microscopy/Bacteriology Less than 12 weeks U.S. Review of Overseas Treatment 30 days Evaluation Disposition Disposition 90 days Diagnosis 90 days U.S. Treatment U.S. Treatment Initiated 90 days U.S. Treatment Completed Less than 9 months 28

DHS Contacts for Questions on TB Notifications

Medical and Screening Questions – TB Main Line, 608-261-6319

Process, Paperwork, or General Questions – Savitri Tsering, Refugee Health Coordinator,

608-267-3733 – Maggie Northrop, RIHU Office Associate,

608-266-7473

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For More Information

Technical Instructions on Screening Overseas: CDC

TB Worksheet Guidance: CDC (pdf) Domestic TB Screening Guidelines: CDC TB Classification Follow-Up

Recommendations: WI TB Program

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References

Centers for Disease Control and Prevention. (2009). CDC Immigration requirements: Technical instructions for tuberculosis screening and treatment. Washington, DC.

Centers for Disease Control and Prevention. (2014a). EDN tuberculosis follow-up guide. Washington, DC.

Centers for Disease Control and Prevention. (2014b). Medical Examination of Immigrants and Refugees. Retrieved from http://www.cdc.gov/immigrantrefugeehealth/exams/medical-examination.html

Curry International Tuberculosis Center. (2008). B Notifications Template. Retrieved from http://www.currytbcenter.ucsf.edu/ sites/default/files/04bnot0808.doc

Wisconsin Department of Health Services. (2014). Tuberculosis (TB) follow-up recommendations for arrivals with a TB class condition (DHS publication no. P-00619). Madison, WI

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