Refugee Health Screening Guidance
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Domestic Refugee Health Screening Guidance
Tuberculosis (TB) Screening
Last updated: July 2022
Minnesota TB infection screening recommendations
- Screen all refugees for signs or symptoms of TB disease (pulmonary or extra-pulmonary) and history of contacts with active TB.
- For all TB classes, review all available TB assessment and/or treatment documentation on the overseas medical records.
- Verify if the arrival has a TB classification. If so, refer to specific guidance for TB evaluation components: Recommended Medical Follow-up for TB Class B Arrivals (PDF). Note that MDH recommends:
- Accepting any documented positive IGRA results documented on overseas records.
- Domestically retesting those with a documented negative IGRA result, due to possibility of recent exposure or seroconversion.
- For arrivals without a TB classification:
- Administer a TB test for each arrival unless the person has a reliable history of previous treatment for TB. IGRA (i.e., QFT® or T-SPOT®) is the recommended test for patients age 2 years and above. TSTs are preferred on patients below 2 years of age regardless of BCG history. MDH recommends repeating an initial negative TST in an infant after the child reaches six months of age.
- The TB lab work should be done regardless of TST results on overseas documents or negative IGRA result on overseas document.
- If IGRA or TST is positive, proceed with assessment for active or latent tuberculosis, including CXR. Note that the assessment, including the CXR, should be done by the domestically. An overseas CXR can ONLY be used if ALL of the following criteria are met:
- The patient had repeated CXRs overseas showing improvement or stability with the most recent CXR in the series obtained in the previous 3 months.
- The patient is HIV negative.
- The patient has no signs or symptoms compatible with active TB disease.
- Do additional diagnostic tests (e.g., sputa for AFB, other imaging), as indicated, to determine diagnosis.
- Establish a diagnosis (i.e., LTBI or active TB disease).
- If active TB is suspected or diagnosed, report to MDH by calling 651-201-5414 within one working day.
- Do not wait for culture confirmation.
- Children or immunocompromised persons with active TB disease may have atypical clinical and radiologic presentations. Young children with TB rarely produce sputum and usually are unable to expectorate voluntarily. Young children with positive TST or IGRA results should be promptly evaluated, because they can rapidly progress to active TB disease.
- Persons with suspected pulmonary or laryngeal TB disease should be triaged and evaluated quickly. They should be given tissues and instructed to cover their cough. The patient should be instructed to wear a simple surgical mask whenever outside of their private living quarters, especially during transport, in clinical settings, or while waiting in any public space.
Microlearning series: Tuberculosis
This video (under 5 minutes) is meant to serve as a summary of tuberculosis screening guidance and resources for providers completing the refugee health screening and all those serving new arrivals.
- IGRA testing is recommended for use in anyone ≥2 years of age. TSTs are preferred for patients age <2 years.
- A TST administered prior to 6 months of age may yield a false negative result. TSTs may be used for children under six months of age, however, a negative TST result in a child of this age is unreliable. A positive TST at any age is considered valid. MDH recommends repeating an initial negative TST in an infant after the child reaches six months of age. Contact MDH TB Program with questions, 651-201-5414.
- For most refugees and immigrants, TST is positive if > 10mm induration.
- Use the > 5mm TST cutoff for: persons with an HIV diagnosis, all recent close contacts to an infectious TB case, arrivals with Class B1 TB or fibrotic changes on CXR, organ transplant recipients, or otherwise significantly immunocompromised individuals.
- Children younger than 5 years of age should have both posterior-anterior and lateral radiographs when chest x-rays are indicated. All other persons should receive posterior-anterior radiographs; additional radiographs should be performed at the physician’s discretion.
- A pregnant woman with a positive IGRA should have a shielded chest X-ray. If she is asymptomatic, the chest X-ray may be delayed until after the first trimester.
- TB screening should be performed on all refugees. Clinicians should assess for extra-pulmonary as well as pulmonary disease, as well as latent TB infection.
- Diagnosis and treatment of TB disease and latent TB infection (LTBI) is a critical benefit of the refugee health screening for individuals, families, and communities. Providers should work with their local health departments regarding options for consultation, medication, and patient case management. Treating active and latent TB when diagnosed offers exponential public health protection.
- Since incomplete therapy confers little benefit, an individualized treatment plan should be developed to increase the patient’s chances of successfully completing therapy. The plan may include patient education, incentives and enablers, transportation and social service support, referrals to local public health nursing services for treatment monitoring, and coordinating TB treatment with the services of other providers.
- Persons receiving LTBI therapy should have monthly visits throughout therapy to monitor for tolerance, adherence, and signs and symptoms of active TB disease.
- TB medications are available at no cost to the patient from MDH. Clinicians may request medications for their patients at Tuberculosis Medications Program.
- TB remains a stigmatizing disease in many cultures. Assuring confidentiality, explaining LTBI (asymptomatic, not contagious, curable), and emphasizing the benefits to a patient’s community for complete treatment may encourage refugees to pursue treatment.
Background and epidemiology
TB remains a significant disease globally and within Minnesota. In 2007, the overseas screening protocol for active tuberculosis was significantly enhanced, integrating sputa with smears and cultures for those with CXR that might be consistent with TB (the full technical instruction available below in the resources section). Most recently, IGRA tests have been integrated in TB screening for those ages 2 – 14 in countries with high prevalence. Any cases of active TB receive complete directly observed treatment (DOT), with documentation provided in overseas records when they travel.
Cases of active TB in recent arrivals are extremely uncommon. The Refugee Health Screening remains a critical opportunity to diagnose and treat cases of LTBI. According to the Centers for Disease Control and Prevention, without prophylaxis approximately 5 -10 percent of persons with LTBI will develop active TB disease at some point in their lifetime. The risk is higher for children, newly infected persons, and those with certain medical conditions. Completing therapy for LTBI can reduce the likelihood of developing TB disease by up to 90 percent.
Non-U.S.-born persons and racial/ethnic minorities bear a disproportionate burden of TB disease in the United States. The rate of TB among non-U.S.-born persons in the United States is generally 15 times higher than among U.S.-born persons. On average, patients born outside the U.S. make up 80-90% of new TB cases reported in Minnesota. Although the number of cases of TB disease reported nationally has decreased annually since the early 1990s, the incidence of TB in Minnesota increased throughout much of the 1990s and peaked at 239 TB cases (4.9 cases per 100,000 population) in 2001. Following a second peak of 238 cases (4.6 per 100,000 population) in 2007, Minnesota has reported a median number of 151 new cases per year.
Multidrug resistance, or resistance to at least two of the most effective TB medications, isoniazid and rifampin, has remained steady over the past several years nationally, but has seen an increase in Minnesota since 2016 due to an ongoing outbreak of such cases. Treatment for MDR TB is longer, more costly, and potentially leads to more side effects.
Visit TB Statistics for the latest data and reports on tuberculosis cases in Minnesota.
Prevalence of Tuberculosis (TB) Infection among Primary Refugees to Minnesota, 2009-2019
|Region of Origin||Received RHA*||Screened for TB**||TB (latent or active)***|
|East Asia/Pacific||38||38 (100%)||12 (32%)|
|Eastern Europe||778||737 (95%)||99 (13%)|
|Latin America/Caribbean||223||211 (95%)||15 (4%)|
|North Africa/Middle East||1,368||1,345 (98%)||144 (11%)|
|South/Southeast Asia||8,531||8,430 (99%)||1,349 (16%)|
|Sub-Saharan Africa||9,129||8,888 (97%)||2,724 (31%)|
|Total||20,067||19,949 (98%)||4,343 (22%)|
*Refugee Health Assessment (RHA): health screening done in U.S., usually within 90 days of U.S. arrival
**% among those who received RHA
***% among those screened for TB
All refugee arrivals are screened for active tuberculosis (TB) prior to U.S. arrival, and treated prior to departure to the U.S., if found to have active disease. Because of this overseas screening, active TB disease is identified very infrequently at the refugee health assessment (RHA).
Among the 20,067 primary arrivals to Minnesota from 2009-2019 who received a RHA, 98% were screened for tuberculosis (TB) infection. Twenty-two percent were identified as having latent or active TB infection. The vast majority of these were latent TB infection, which is not infectious and cannot be spread to others. People with LTBI can be treated to get rid of the TB bacteria entirely. Refugees diagnosed with LTBI at the RHA were referred for treatment, with the majority of individuals successfully completing it. Cases of confirmed or suspected TB disease are also reported to appropriate authorities for monitoring and further public health intervention, such as contact investigation.
- Tuberculosis (TB)
The MDH TB Program offers TB medication services, consultation and education, case management, and tracking immigrants and refugees with TB Class conditions. Refer to the "For Health Care Professionals" section. 651-201-5414 or 877-676-5414 (toll-free).
- Refugee and Immigrant TB Class Arrivals
All immigrants and refugees are required to have a medical examination before entering the United States. Those with TB-related findings that need medical follow-up after arrival in the U.S. are given a TB class designation and MDH is notified.
- Recommended Medical Follow-up for TB Class B Arrivals (PDF)
MDH document designed to provide clinicians with a description of the TB Class B arrival notifications for refugees and immigrants, and general clinical recommendations for domestic TB screening appropriate for each class.
- Instructions for Completing the TB Follow-up Worksheet (PDF)
MDH document that provides guidance to clinicians who provide domestic examinations and who document the findings on the TB Follow-up Worksheet (PDF).
- TB Class B Arrivals: The Role of Local Public Health (LPH)
Describes the role of LPH and action steps for ensuring follow-up evaluation for immigrants and refugees who have recently arrived to the U.S. with a TB Class designation.
- Refugee and Immigrant TB Class Arrivals
- CDC: Tuberculosis (TB)
Division of Tuberculosis Elimination
- CDC: Latent Tuberculosis Infection: A Guide for Primary Health Care Providers
- CDC: Core Curriculum on Tuberculosis: What the Clinician Should Know
Interactive and print versions of a CDC Division of Tuberculosis Elimination course that provides basic information about TB for clinicians.
- CDC: Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium Tuberculosis Infection - United States, 2010
MMWR, June 25, 2010; 59(RR05); 1-25
- Hennepin County Public Health Clinic
The tuberculosis control program accepts clients by referral. The clinic does not provide routine screening for work or school. 612-543-5555, option 4.
- Ramsey County: Tuberculosis Clinic
Tuberculosis control program: 651-266-1343.
- Olmsted County: Clinics & Testing Services
Tuberculosis (TB) Control: TB screening, case follow-up, and clinic services. 507-328-7500.
- Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis
Payam Nahid, Susan E. Dorman, Narges Alipanah, Pennan M. Barry, Jan L. Brozek, Adithya Cattamanchi, Lelia H. Chaisson, Richard E. Chaisson, Charles L. Daley, Malgosia Grzemska, Julie M. Higashi, Christine S. Ho, Philip C. Hopewell, Salmaan A. Keshavjee, Christian Lienhardt, Richard Menzies, Cynthia Merrifield, Masahiro Narita, Rick O'Brien, Charles A. Peloquin, Ann Raftery, Jussi Saukkonen, H. Simon Schaaf, Giovanni Sotgiu, Jeffrey R. Starke, Giovanni Battista Migliori, Andrew Vernon, Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis, Clinical Infectious Diseases, Volume 63, Issue 7, 1 October 2016, Pages e147–e195, https://doi.org/10.1093/cid/ciw376
- Committee on Infectious Diseases; American Academy of Pediatrics; David W. Kimberlin, MD, FAAP; Michael T. Brady, MD, FAAP; Mary Anne Jackson, MD, FAAP; Sarah S. Long, MD, FAAP “Tuberculosis ” in Red Book 2018.
- CDC: Diagnostic Standards and Classification of Tuberculosis in Adults and Children (PDF)
Official statement of the American Thoracic Society and the Centers for Disease Control and Prevention.