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Class B TB Notifications

The Department of Public Health (DPH) Refugee and Immigrant Health Program (RIHP) conducts certain TB control activities as part of the broader mission of the Tuberculosis (TB) Control Program at DPH.

 

The RIHP collaborates with sponsors, health care providers, and Local Health Departments and Districts (LHDs) to ensure that evaluations, diagnoses, and treatment for TB and latent TB infection (LTBI) are obtained.

 

Refugee or immigrant entrants who arrive to Connecticut with an overseas TB classification should undergo a U.S.-based TB evaluation soon after U.S. entry.

 

 

What is a TB Class B designation?

The United States Department of State requires all refugees and immigrants coming to the U.S. to have a pre-immigration medical exam overseas to rule out diseases of public health significance, one of which is active TB disease.

  • Adults ages 15 years or older are required to have a chest X-ray (CXR);
  • Children ages 2–15 years old are required to have an interferon gamma (IFN-γ) release assay (IGRA) test (e.g., QuantiFERON-TB Gold Plus or T-SPOT.TB); and
  • Children ages 6 months–2 years old should be given a tuberculin skin test (TST).

If the pre-immigration TB exam is negative, no further follow-up is needed upon arrival in the U.S., and there is no TB Class indicated.

 

If, during the pre-immigration exam, active TB disease is diagnosed, full treatment must be completed  overseas before the individual is cleared to travel to the U.S.

 

If the pre-immigration TB exam has positive findings other than active TB disease, a TB Class B

designation is given according to exam results. Class B designations are:

  1. Class B1: The individual had an abnormal CXR with evidence of TB, or the individual has a history of treatment for TB disease, or the individual has a known HIV+ diagnosis.
  2. Class B2: The individual has been referred for a latent TB infection (LTBI) follow-up evaluation in the U.S. These are typically children whose TST or IGRA result was positive and CXR was normal.
  3. Class B3: The individual is a recent contact of a TB case-patient. An individual can have this designation along with another TB Class designation.

 

The pre-immigration exam is not intended to diagnose or treat extrapulmonary TB, non-infectious pulmonary TB, or LTBI.

 

Why do TB Class B entrants need a follow-up evaluation in the U.S.?

 

The Centers for Disease Control and Prevention (CDC) strongly recommends that immigrants and refugees with overseas TB Class B designations receive a full TB evaluation soon after arriving in the U.S.

 

The purpose of this is to evaluate the person for active TB disease, extrapulmonary TB, and LTBI, and to treat these conditions, if found. Quite often, many months have passed between the original overseas medical exam and actual U.S. entry. It is important for individual and community health to ensure that a domestic evaluation for TB is conducted after entry to the U.S.

 

This TB Class B follow-up evaluation should be done within 30 days after arrival in the U.S.

 

 

What is the LHD’s role regarding TB Class B entrants to their jurisdiction?

 

When the RIHP receives notification from the CDC that a TB Class B person has entered CT, the RIHP sends a “TB Class B Notification packet” containing a CDC-generated EDN TB Follow-up Worksheet and overseas examination documents to both the LHD jurisdiction (i.e., the town where the entrant lives), and to the sponsor of the entrant.

 

LHDs are responsible for: 1) arranging a TB evaluation with a local TB Clinic or other provider for the new  entrant to the U.S., 2) ensuring that the results of the evaluation are submitted to the RIHP, and 3) facilitating medical treatment for any TB-related conditions that are identified.

 

Importantly, this process is slightly different for refugees and immigrants.

 

  • For refugee entrants, TB screening should normally be part of the full domestic refugee health assessment (RHA) that a refugee receives soon after arrival. Usually, the RHAs are arranged by the refugee resettlement agencies who are the refugee’s sponsor of record. RHA providers are given guidance for TB and other evaluations.
  • For refugees who are also TB Class B1 entrants, the sponsoring refugee agency should already have the TB Class B Notification packet, and should give it to the provider conducting the RHA. The provider should return both the three-page EDN TB Follow-up Worksheet and the RHA form after the full completion of the RHA and TB evaluations.
  • For immigrant entrants with TB Class B designations, LHDs play a more direct role in the Class B1/B2/B3 evaluation process than for refugees. This is because immigrants do not have the support of a resettlement agency and may not have health insurance.
  • While this process may vary by LHD based on capacity, below are the general steps:
  1. Attempt to contact the immigrant or sponsor listed on their paperwork (phone or letter if no/incorrect phone number). Explain the purpose of the exam and its importance. Many immigrants will have received a letter about their TB Class B designation upon arrival, but may not fully understand the need for the evaluation or how to obtain it.
  2. Assess the immigrant’s resources, and facilitate setting up an appointment for a TB  evaluation with a nearby TB clinic. NOTE: Uninsured immigrants are best directed to TB clinics as they will not be billed for any tests or services.
  3. TB Class B immigrants with insurance should feel free to go to a provider of their choice. However, the TB clinics in the state are very experienced with TB Class B evaluations and should be considered by insured immigrants as well.
  4. Once an appointment has been arranged, ensure that the sponsor or immigrant brings their copy of the TB Class B Notification packet with them to the provider (a cover letter in the sponsor’s packet indicates they should do this). It may also be helpful to forward a copy of EDN TB Follow-up Worksheet: Summary, Medical Recommendations, & Instructions for Completion. The provider is responsible for sending the EDN TB Follow-up Worksheet to the RIHP.
  5. LHDs are not expected to help immigrants establish primary care – only to facilitate TB evaluations with local providers and TB clinics.
  6. LHDs may call DPH at 860-509-7722 to ask if the RIHP has received the EDN TB Follow-up Worksheet for a person in their jurisdiction.

This EDN evaluation, while strongly recommended, is optional; immigrants and refugees are allowed to refuse.

 

What type of medical follow-up is recommended for TB Class B entrants?

 

Recommendations for providers who perform the evaluation are based on the type of TB

Class designation (i.e., B1, B2, or B3).

 

For further information about TB evaluation protocols, please consult

https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/tuberculosis-guidelines.html

 

 

What if the immigrant or refugee cannot be located, or has moved?

 

If the LHD is unable to initiate a TB evaluation for the entrant, please indicate the reason (e.g., not located, lost to follow-up, refused, returned to country of origin) on the back of the EDN TB Follow-up Worksheet and return the form to the RIHP.

 

If the person has moved, please note the full new address on the back of the EDN TB Follow-Up Worksheet, and return it to the RIHP. The RIHP will change the jurisdiction to the new state so the person may be evaluated there.

 

 

EDN TB Follow-up Worksheet: Medical Recommendations, Completion Instructions

CDC TB Follow-Up Worksheet (Class B Entrants)

CDC Tuberculosis Guidelines for Newly Arrived Refugees