Tuberculosis Testing and Follow-Up Practices Among Civil Surgeons in California and New England

BACKGROUND:  Foreign citizens applying to adjust their U.S. residency status to Permanent Resident Alien must undergo a medical examination performed by a civil surgeon designated by U.S. Citizenship and Immigration Services. Since 2005, more than 400,000 persons annually have successfully adjusted their status. The medical examination includes testing for tuberculosis (TB) in accordance with Technical Instructions (TI) for Civil Surgeons provided by the Centers for Disease Control and Prevention (CDC). However, civil surgeons receive little or no formal TI training. Given the large number of applicants, incorrect interpretation of the TIs might lead to missed or improperly managed TB cases. The purpose of this evaluation is to describe the knowledge and practices with regard to TB testing and follow-up evaluation among civil surgeons in California and six New England states (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont).

METHODS:  A survey with 31 questions was mailed to all civil surgeons in California (974) and New England (143). The survey asked about respondent‘s medical training and experience, their testing and follow-up practices, and also included scenario based questions. After one month, the survey was re-mailed and phone calls were made to non-responders. Data were analyzed using SAS v. 9.2.

RESULTS:  Of the 706 (63%) civil surgeons who completed the survey, 85% had read the TIs. In the past year these civil surgeons performed a median of 35 exams. Sixty-two percent of these respondents understood that a chest radiograph (CXR) is required for applicants with TB symptoms; only 35% understood that a CXR is required for all immunosuppressed applicants. Fourteen percent of responders had diagnosed active TB among applicants during the last 3 years, with a median of 1 case each. Twelve percent of responders who suspected active TB disease would neither report nor refer the applicant to the public health department, as required by the TIs. Sixty-five percent of respondents indicated that an abbreviated pocket guide for the TIs would be helpful for screening applicants.

CONCLUSIONS: The results of this survey suggest that gaps in CDC TI testing knowledge and practice exist among civil surgeons, and that TB cases could have been missed or improperly managed. Educational and quality assurance efforts, such as more frequent trainings and review of the results of medical examinations, might help to ensure proper TI implementation and improve the TB screening performed by civil surgeons. Increased communication between local health departments and civil surgeons could help maximize prevention efforts.