Civil Surgeons and the Adjustment of Status Medical Examination Civil Surgeon Training

1. Civil Surgeons and the  Adjustment of Status Medical ExaminationCivil Surgeon Training Mary Naughton, MD, MPH Division of Global Migration and Quarantine (DGMQ) Centers for Disease Control and Prevention (CDC) February 26, 2010

2. Topics Background Role of CDC/DGMQ Role of the Civil Surgeon 2008 TB Technical Instructions (TI) 2009 Vaccination TI HIV: New Final Rule Mental Health Conditions (Alcohol Abuse) Substance Abuse

3. Migrants Entering U.S., 2005*

4. 2008 Legal Permanent Residents Total number: 1,107,126 New Arrivals: 466,558 Adjustment of Status: 640,568

5. DGMQ/Partners� Roles DGMQ Defines communicable diseases of public health significance (inadmissible & others) Promulgates regulations for health-related inadmissible conditions Prepares & distributes TI Partners Division of TB Elimination (CDC/DHHS) US Citizenship and Immigration Services (USCIS/DHS)

6. Medical Grounds of Inadmissibility Medical grounds of inadmissibility under the Section 212(a)(1) of the Immigration and Nationality Act: Communicable disease of public health significance (Class A) Failure to show proof of required vaccinations Physical or mental disability with associated harmful behavior (Class A) Drug abuse or addiction (Class A)

7. Medical Examination of Aliens (42 CFR 34) - Regulation Inadmissible communicable diseases of public health significance Tuberculosis, active Hansen�s disease, infectious (multibacillary) Syphilis, untreated Untreated chancroid, gonorrhea, granuloma inguinale, and lymphogranuloma venereum CFR= Code of Federal RegulationsCFR= Code of Federal Regulations

8. Interim Final Rule (IFR) �Communicable Disease of Public Health Significance� On October 6, 2008, HHS/CDC published an Interim Final Rule (IFR) regarding communicable disease regulations Title: Medical Examination of Aliens � Revisions to Medical Screening Process IFR pertains only to examinations performed outside of the United states (not civil surgeon exams)

9. IFR: �Communicable Disease of Public Health Significance�(Overseas Exam) Current list (previous to October 6, 2008) + Quarantinable diseases (Presidential Order) Pandemic flu, SARS, viral hemorrhagic fevers, cholera, diphtheria, infectious TB, plague, smallpox, yellow fever + Communicable diseases that are public health emergencies of international concern reported to World Health Organization Cholera, poliomyelitis due to wild-type poliovirus, viral hemorrhagic fevers (Ebola) and others

10. Who are Civil Surgeons? Physicians who are designated by local offices of the Bureau of U.S. Citizenship and Immigration Services (USCIS) to perform medical exams on certain groups of aliens in the U.S. Aliens are persons who are not U.S. citizens or nationals Civil surgeon program is administered by USCIS DGMQ writes the TI for the civil surgeon medical examination DGMQ does not have oversight authority of civil surgeons

11. Aliens Examined by Civil Surgeons Adjustment of Status Applicants Non-immigrants (students, workers) Parolees Refugees requiring vaccinations only Refugees with Class A conditions Asylees Others

12. Role of the Civil Surgeon �Civil surgeons must ensure that the person appearing for the medical examination is the person actually applying for immigration benefits.� Follow procedures of USCIS Follow CDC TI and Updates Report results of medical examination and required tests

13. Purpose of Medical Examination Determine whether the alien Has a physical or mental disorder that renders him or her ineligible for adjustment of status (Class A) Has a physical or mental disorder that may interfere with the alien�s ability to care for himself or herself, or to attend school or work, or that may require extensive medical treatment or institutionalization in the future (Class B) In practical terms, Immigrant medical exam focuses on public health issues Infectious diseases Conditions harmful to self, others, property TB of high concern due to degree of transmissibility In practical terms, Immigrant medical exam focuses on public health issues Infectious diseases Conditions harmful to self, others, property TB of high concern due to degree of transmissibility

14. Review of Systems Targeted to Class A/B conditions Symptoms Cardiovascular Pulmonary Neuropsychiatric Specific inadmissible infectious diseases Active TB, untreated syphilis, Hansen�s disease Untreated Chancroid, Gonorrhea, Granuloma Inguinale, or Lymphogranuloma Venereum

15. Physical Examination Physical evaluation at a minimum must include: Eyes and ears Nose and throat Heart and lungs Abdomen Lymph nodes External genitalia (visual and palpation) Extremities Skin

16. Physical Examination, Cont�d. Mental status examination at a minimum must include an assessment of: Intelligence Thought Cognition (comprehension) Judgment Affect (and mood) Behavior

17. Physical Examination, Cont�d. Testing: All diagnostic tests required to: Diagnose communicable diseases of public health significance Confirm any other Class A or B condition

18. Management of Illnesses Not Related to Immigrant Medical Examination Acute illness precluding Class A/B determination: Applicant to seek care from physician of choice Civil surgeon to re-examine when illness resolved Non-acute illness: Civil surgeon to advise applicant of need for, and type of, further evaluation or treatment

19. Referral for Further Evaluation Civil surgeon must refer applicant for medical or mental health evaluation if: Unable to make a definitive diagnosis Unable to determine Class A vs. B designation After referral completed, civil surgeon: Completes and forwards I-693 form to USCIS Includes report of consulting physician or specialist with I-693 form

20. What the Medical Examination is Not A thorough review of applicant�s health A routine medical examination An opportunity for applicant to receive treatment for chronic conditions that are not inadmissible An opportunity for the civil surgeon to determine eligibility for adjustment of status (USCIS decides)

21. Estimated TB Incidence Rates, 2006Number of Immigrant and Refugee Arrivals, 2006

22. U.S. TB Statistics, 1992-2008 Year 1992 2008 Rate* 10.5 4.2 Cases 26,673 12,898 * Rate per 100,000 persons Tb disease�smear or culture positive or much less commonly a clinical or radiographic diagnosis Latent TB infection�TST positive and CXR clear Among foreign-born persons in the United States, both the number and rate of TB cases declined in 2008. A total of 7,541 TB cases were reported among foreign-born persons (58.8% of all cases in persons with known origin), a 2.8% decrease from the 7,757 cases reported in 2007. The TB rate among foreign-born persons in 2008 was 20.2 per 100,000 population, which was a 2.6% decline since 2007 In 2008, four countries accounted for approximately half (50.1%) of foreign-born TB cases: Mexico (1,742), the Philippines (855), India (598), and Vietnam (580). Tb disease�smear or culture positive or much less commonly a clinical or radiographic diagnosis Latent TB infection�TST positive and CXR clear Among foreign-born persons in the United States, both the number and rate of TB cases declined in 2008. A total of 7,541 TB cases were reported among foreign-born persons (58.8% of all cases in persons with known origin), a 2.8% decrease from the 7,757 cases reported in 2007. The TB rate among foreign-born persons in 2008 was 20.2 per 100,000 population, which was a 2.6% decline since 2007 In 2008, four countries accounted for approximately half (50.1%) of foreign-born TB cases: Mexico (1,742), the Philippines (855), India (598), and Vietnam (580).

23. TB Cases, United States, 1993-2008 1992: 27% of cases were FB 2008: 59 % FB rate 10 x higher than US born rate Both the FB number of cases and rate of disease decreased in 2008 1992: 27% of cases were FB 2008: 59 % FB rate 10 x higher than US born rate Both the FB number of cases and rate of disease decreased in 2008

24. Current Civil Surgeon TB TI May 1, 2008: New TB TI November 1, 2009: Update re option of using Interferon Gamma Release Assay (IGRA) in place of tuberculin skin test (TST) CDC/DGMQ website contains: TI and updates Frequently asked questions (FAQs) USCIS website contains: I-693 form and instructions FAQs I-693 form is the USCIS medical form that the civil surgeon completes and returns to USCISI-693 form is the USCIS medical form that the civil surgeon completes and returns to USCIS

25. Required Pulmonary TB Work-Up Cell-mediated immunity testing for applicants 2 years of age and older TST or IGRA CXR if TST = 5 mm or positive IGRA Sputum smears and cultures if Chest radiograph suggestive of TB Signs or symptoms of TB Immunosuppresssion (e.g., HIV infection, 15 mg prednisone for one month or greater, or equivalent, hx of organ transplant)

26. Required Pulmonary TB Work-Up, Cont�d. Drug susceptibility testing if culture positive Proper DGMQ classification of TB (not ATS) Directly observed therapy (DOT) throughout treatment for Class A TB (smear or culture positive)

27. TB History and Physical Exam Medical history Hospitalizations, respiratory illnesses CXRs & treatment records Review of systems Cough > 3 weeks, hemoptysis, fever, night sweats, weight loss Physical examination Chest examination for TB Lymph nodes Hepatomegaly, splenomegaly Neck stiffness

28. TB Skin Test (TST) Test everyone > 2 years of age Use Mantoux technique Trained HCW to administer and read (no self-reading) Perform CXR if induration > 5 mm MPD = multi-puncture device; amount of tuberculin injected intradermally cannot be precisely controlledMPD = multi-puncture device; amount of tuberculin injected intradermally cannot be precisely controlled

29. IGRA Blood tests Measure a component of cell-mediated immune reactivity to Mycobacterium tuberculosis in fresh whole blood Types QuantiFERON-TB Gold� QuantiFERON-TB Gold� In Tube (QFT-GIT) T-SPOT � Perform CXR if IGRA positive

30. Cell-Mediated Immunity TestsSpecial Notes May defer in these circumstances: Documentation of prior TST result of > 5mm, signed by health-care provider Oral history of severe reaction with blistering to prior TST Documentation of prior positive IGRA (most recent result), signed by health-care provider In above circumstances, perform CXR Do not perform another type of cell-mediated immunity test to achieve negative result IGRAs�Interferon gamma release assays: Quantiferon Gold and T-spotIGRAs�Interferon gamma release assays: Quantiferon Gold and T-spot

31. Cell-Mediated Immunity TestsSpecial Notes, Cont�d. Prior BCG vaccination Does not change testing requirement Does not change action based on test results Indeterminate or borderline/equivocal IGRA result = negative result If test negative but applicant has TB signs or symptoms or is immunosuppressed, CXR is required

32. CXR Required for all applicants with TST > 5mm induration or positive IGRA Required for applicants with TST < 5 mm (including 0 mm) or negative IGRA with: Signs or symptoms of TB Immunosuppression

33. Pregnancy and Radiation 2008 TB TI CXR required before exam can be completed CXR can be performed during or after pregnancy Safety of fetus must be considered Birth defects Childhood cancer

34. Pregnancy and Radiation, Cont�d. Requirements if CXR performed during pregnancy Applicant must be advised of risk Applicant must consent to radiation Applicant should sign radiation consent form* Technologist should apply double layer wrap-around lead shield to protect pregnancy during exposure* *Advise that record contain consent form and technologist clearly document double lead shielding

35. CXR Interpretation CXR interpreter: Review previous CXRs Describe abnormalities by location, appearance, and change over time Determine if suggestive of pulmonary TB

36. �CXR should be interpreted by a radiologist or other qualified physician who is trained and experienced in reading chest radiographs demonstrating TB or other diseases of the lung�* 

38. Why Refer to HD? TB significant public health problem, especially in foreign-born TB patients uncommon in private practice TB diagnosis and treatment issues have increased in complexity Directly observed therapy needed for TB disease HD conducts TB disease contact and source investigations TB relatively uncommon RCA = Immigration Reform and Control Act of 1986. TB relatively uncommon RCA = Immigration Reform and Control Act of 1986.

39. TB Classifications in 2008 TI* Class A Pulmonary TB Disease Class B1 Pulmonary TB Class B1 Extrapulmonary TB Class B2 Pulmonary TB Class B, Latent TB Infection Class B, Other Chest Condition (Non-TB)

40. Required vs. Recommended Referral to HD TB Control Program Required referral CXR suggestive of TB disease (active or inactive) Will eventually be classified as Class A TB, Class B1 Pulmonary, or Class B2 Pulmonary Signs or symptoms of TB, regardless of TST/IGRA result or CXR finding Recommended referral Class B, Latent TB Infection Needing Evaluation for Treatment Table on page 15.Table on page 15.

41. *Chest radiograph performed if TST = 5mm induration. TST performed on all applicants = 2 years of age or if applicant symptomatic or immunosuppressed. Figure 1 on p. 18. Process for Classifying TB and Other Chest Conditions. This classification system is designed to assist state and local health department TB Control Programs to prioritize their efforts to most effectively diagnose and treat applicants with TB conditions. *Chest radiograph performed if TST = 5mm induration. TST performed on all applicants = 2 years of age or if applicant symptomatic or immunosuppressed. Figure 1 on p. 18. Process for Classifying TB and Other Chest Conditions. This classification system is designed to assist state and local health department TB Control Programs to prioritize their efforts to most effectively diagnose and treat applicants with TB conditions.

42. Sputum Collection Container Container Clean, unused Ten-fifty mL capacity Wide mouth Screw top

44. Table 2 on p.19. TB Classifications and Summary of Appropriate Related Actions. For the first four conditions, classification cannot be determined until evaluation of applicant by the Health Department TB Control Program has been completed. 1 After evaluation by civil surgeon (and referral to Health Department TB Control Program, if required) is completed. See Appendix D 2 Refer to health department TB Control Program for work-up of suspicious chest radiograph 3 After written confirmation of complete TB treatment on I-693 form, classification is changed in this special circumstance to B2 4 Make required referral to health department TB Control Program for further evaluation and, if needed, initiation of CDC/ATS/IDSA-recommended drug regimen for extrapulmonary TB 5 If health department TB Control Program decides to perform sputum smears and cultures, categorize as Class A or B1 depending on results 6 After discuss resources with health department TB Control Program 7 See text Table 2 on p.19. TB Classifications and Summary of Appropriate Related Actions. For the first four conditions, classification cannot be determined until evaluation of applicant by the Health Department TB Control Program has been completed. 1 After evaluation by civil surgeon (and referral to Health Department TB Control Program, if required) is completed. See Appendix D 2 Refer to health department TB Control Program for work-up of suspicious chest radiograph 3 After written confirmation of complete TB treatment on I-693 form, classification is changed in this special circumstance to B2 4 Make required referral to health department TB Control Program for further evaluation and, if needed, initiation of CDC/ATS/IDSA-recommended drug regimen for extrapulmonary TB 5 If health department TB Control Program decides to perform sputum smears and cultures, categorize as Class A or B1 depending on results 6 After discuss resources with health department TB Control Program 7 See text

45. Conclusion: Class A (Inadmissible) Abnormal CXR suggestive of pulmonary TB Referred to HD Sputum smear and/or culture positive OR CXR negative but symptomatic with smear and/or culture positive Treatment must be completed before I-693 form signed

46. Conclusion: Class B1 TB Class B1 Pulmonary TB Abnormal CXR suggestive of active TB Referred to HD Sputum smears and cultures negative x 3 Class B1 Extrapulmonary TB No pulmonary component Referred to health department for evaluation Neither B1 Class is inadmissible

47. Following Required Referral to HD Applicant returns to civil surgeon with HD evaluation results If smear or culture positive (Class A), must complete treatment before clearance If smear and culture negative, CS can complete and sign I-693 (cleared regarding TB portion of exam)

48. Conclusion: Class B2 Pulmonary TB If smears and cultures performed, is Class B1If smears and cultures performed, is Class B1

49. Conclusion: Latent TB Infection Needing Evaluation for Treatment New TB Classification Recommended referral for LTBI evaluation receives increased emphasis in new TI Referral does not defer medical clearance LTBI Rx does not defer medical clearance Most common criteria: TST = 10mm Applicant from country with high TB prevalence Applicant in U.S. < 5 years

50. Conclusion: Latent TB Infection, Cont�d. Emphasis placed on clear communication between civil surgeon and health department Other recommended referral categories*: Also use 10 mm cut-off if applicant doesn�t meet previous criteria but: Has other conditions such as diabetes mellitus Is a child < 4 years of age Use 5 mm cut-off if applicant is: Immunosuppressed S/P organ transplantation Recent contact to a case of TB disease

51. Other TB Classifications No Class A or Class B TB TST < 10 mm and CXR normal Applicant has no criteria for 5 mm TST cut-off for LTBI Other Chest Condition, non-TB

52. FOR TB CLASSIFICATIONS: ONLY CLASS A TB (SMEAR AND/OR CULTURE POSITIVE) IS INADMISSIBLE AND REQUIRES THE CIVIL SURGEON TO DEFER SIGNING THE I-693 FORM UNTIL TREATMENT IS COMPLETE

53. Vaccination Requirements

54. Role of Civil Surgeon Know 2009 Vaccination TI Age-appropriate vaccines Contraindications and precautions Review previous vaccination records to determine required vaccines Self-reported doses of vaccines NOT acceptable

55. Prior to December 14, 2009Required Vaccinations According to the Immigration and Nationality Act, immigrants were required to receive all vaccinations that the Advisory Committee for Immunization Practices (ACIP) recommended for persons living in the U.S

56. 2009 Vaccination Criteria The vaccine must be an age-appropriate vaccine recommended by the ACIP for the general U.S. population, AND At least one of the following: The vaccine must protect against a disease that has the potential to cause an outbreak The vaccine must protect against a disease that has been eliminated in the U.S. or is in the process of elimination in the U.S. [1] For purposes of this Notice, �outbreak� means the occurrence of more cases of disease than could be anticipated in a given area or among a specific group of people over a particular period of time. [1] �Elimination� is the reduction to zero of the incidence of infection caused by a specific agent in a defined geographic area as a result of deliberate efforts; continued measures to prevent re-establishment of transmission are required. [1] For purposes of this Notice, �outbreak� means the occurrence of more cases of disease than could be anticipated in a given area or among a specific group of people over a particular period of time. [1] �Elimination� is the reduction to zero of the incidence of infection caused by a specific agent in a defined geographic area as a result of deliberate efforts; continued measures to prevent re-establishment of transmission are required.

57. Results? Because they do not meet the newly adopted criteria, human papillomavirus (HPV) and herpes zoster vaccines are not required as a condition of admission into the U.S. *Note � the new vaccination criteria do not apply to the statutorily listed vaccinations for mumps, measles, rubella, polio, tetanus and diphtheria toxoids, pertussis, Haemophilus influenzae type B, and hepatitis B

58. Required Age-Appropriate Vaccines Diphtheria, tetanus, pertussis Polio Measles, mumps, rubella Rotavirus Haemophilus influenzae type B Hepatitis A Hepatitis B Meningococcal Varicella Pneumococcal Influenza

59. Classification of Vaccines Live attenuated Measles, mumps, rubella Oral polio Rotavirus Inactivated Diphtheria, tetanus, pertussis Polio Haemophilus influenzae type B Hepatitis A Varicella Intranasal influenza Hepatitis B Meningococcal Pneumococcal Influenza

60. Vaccine Administration Area

61. Vaccine Contraindications Any vaccine: Severe allergic reaction Live attenuated vaccines: Pregnancy* and severely immunocompromised conditions Oral poliovirus MMR** Pertussis: Encephalopathy within 7 days of pertussis vaccination *For details see http://www.cdc.gov/vaccines/pubs/preg-guide.htm **Should avoid becoming pregnant for 4 weeks after vaccination

62. Not Contraindications to Vaccine Administration Mild to moderate local reactions to previous dose of vaccine Mild acute illness (e.g., low-grade fever, upper respiratory infection, diarrhea) Recovering from illness Antimicrobial therapy Tuberculin skin test* *All vaccines can be given on the same day as a TST or any time after TST is applied. If MMR, varicella or live attenuated (intranasal) influenza vaccine is given before TST, at least 4 weeks is recommended before giving TST.

63. Not Contraindications to Vaccine Administration, Cont�d. Pregnant or immunosuppressed persons in the household* Breastfeeding Preterm birth Family history of adverse events *Exception: Live attenuated influenza vaccine (LAIV) should not be administered to persons who have contact with severely immunosupressed persons who are isolated because of immunosuppression. LAIV may be administered to contacts of persons with lesser degrees of immunosuppression.

64. Vaccine Precautions Any vaccine Moderate or severe acute illness (e.g., high-grade fever) Td/Tdap, meningococcal and influenza vaccines Prior Guillain-Barr� syndrome Rotavirus vaccine Prior intussusception Rhesus-based vaccine associated with intussusception in 1999 no longer on market

65. Vaccine Precautions, Cont�d. DTP/DTap vaccine Any of the following after a previous dose of DTP/DTap vaccine Fever of 40.5oC (105oF) or higher within 48 hours Persistent crying for >3 hours within 48 hours Convulsions w/ or w/o fever within 3 days If a vaccine is not administered due to a precaution, mark �contraindicated� on the I-693 form

66. Vaccines: Practical Issues Only one dose of vaccine series is required OK to give simultaneous vaccines Multiple body sites No mixing in same syringe unless licensed for such use I-693 form Every row should have at least one check mark Physician should not sign until after vaccines are administered Almost every applicant will require a blanket waiver I-693 form not yet updated to remove HPV and herpes zoster vaccines!

67. Storage Refrigerator for Vaccines

68. Waivers Blanket waiver categories (no application) Not age appropriate Contraindicated Insufficient time interval Not fall (flu) season (influenza vaccine only) Individual waiver categories (requires application) Religious conviction Moral conviction

69. Spacing of Live* Vaccines If live vaccines are not given simultaneously, they must be spaced apart by at least 4 weeks May arise is applicant has recently been vaccinated elsewhere If time period less than 4 weeks, mark �insufficient time interval� on I-693 form * Parenteral vaccine or live attenuated intranasal influenza vaccine

70. Applicant Education and Record Educate applicant about need to complete vaccine series Provide copy of vaccination page of I-693 form to each applicant FRN April-MayFRN April-May

71. HIV: New Final Rule On November 4, 2009, HHS published a Final Rule that Removed HIV from the list of inadmissible conditions for immigration purposes Removed HIV from the scope of the immigrant medical examination

72. HIV: New Final Rule Effective January 4, 2010 HIV is no longer a medically inadmissible (Class A) condition for U.S. applicants HHS/CDC no longer requires HIV testing of persons undergoing an immigration medical examination overseas (e.g., immigrants, refugees ) or of persons applying to adjust immigration status in the U.S. HIV waivers are no longer required for HIV-infected persons to enter the U.S.

73. These changes for HIV do not affect testing for other inadmissible conditions such as tuberculosis or syphilis

74. As with all other medical conditions, civil surgeons may advise applicants for whom HIV testing is clinically indicated, about HIV testing Such applicants may include those with Signs or symptoms of HIV infection Tuberculosis disease What Does The HIV Change Mean for the Civil Surgeon?

75. Consent for HIV Testing Consent for HIV testing should include that the applicant understands They do not have to be tested for HIV If they would like to be tested for HIV, the test does not have to be done by a civil surgeon If a civil surgeon performs test, the civil surgeon must include the test results on the I-693 form

76. HIV Infection Present If HIV infection is disclosed by the applicant or confirmed by civil surgeon testing, the civil surgeon should record on the I-693 form as a Class B Other condition* *I-693 Form not yet updated to remove HIV testing section

77. TB Testing for Applicants Known to be HIV-Infected Per 2008 TB TI, a CXR is required regardless of TST/IGRA result or TB sign/symptom status If CXR suggestive of TB, smears and cultures are required If TB smears and cultures negative, designate as Class B1 for TB Class B Other for HIV Infection If sputum smears or cultures positive, designate as Class A for TB Class B Other for HIV Infection

78. Link to Guidance for HIV for Panel Physicians and Civil Surgeons http://www.cdc.gov/immigrantrefugeehealth/exams/ti/hiv-guidance-panel-civil.html

79. Mental Health ConditionsIncluding Alcohol Abuse

80. Definitions Mental disorder Currently accepted psychiatric disorder, according to the current Diagnostic and Statistical Manual Published by the American Psychiatric Association Harmful behavior (for this examination) Dangerous action or series of actions that has Resulted in psychological or physical injury to the alien or another person OR Threatened the health or safety of the alien or another person OR Resulted in property damage

81. Classifications Determined by 1991 Technical Instructions Class A Current evidence of mental disorder and Associated harmful behavior or history of harmful behavior judged likely to recur Class B Current evidence of mental disorder and No currently associated harmful behavior and no history of harmful behavior that is judged likely to recur

82. Major Mental Health Diagnostic Categories Mental retardation Dementias Disorders Psychotic Delusional Mood Dissociative Anxiety-related Somatoform Disorders Personality Adult anti-social Conduct Adjustment Sexual Impulse Control

83. Mental Health Evaluation Refer to 1991 Technical Instructions Review medical history for Hospitalization or institutionalization for psychiatric illness History of harmful behavior Diagnosis of mental disorder with which harmful behavior may be associated or in which harmful behavior is an element of the diagnostic criteria

84. Mental Health Evaluation, Cont�d. Review other records, if available Police Military School Employment Interview applicant Psychiatric illnesses History of associated harmful behavior Interview applicant�s family when appropriate

85. Mental Health Evaluation, Cont�d. Perform physical exam, including mental status examination Intelligence Thinking Cognition (comprehension) Judgment Affect (mood) Behavior

86. Diagnosis and Classification Evaluation should determine: Diagnosis If Class A or B (harmful behavior?) Technical Instructions require civil surgeon to refer to specialist if civil surgeon unable to make diagnosis or classification (fraud prevention) CDC consultant psychiatrist conducts review of cases on regular basis or as needed A request for an advisory opinion of diagnosis and classification may be made through USCIS to CDC

87. Alcohol Abuse(Mental Disorder) Alcohol Abuse Not evaluated as Substance Abuse Evaluated as Mental Disorder with Associated Harmful Behavior Need both: Mental disorder diagnosis Associated harmful behavior (current or history judged likely to recur) If civil surgeon unable to make diagnosis of alcohol abuse, the civil surgeon must refer to specialist

88. Alcohol Abuse(Mental Disorder) If civil surgeon�refers to specialist Civil surgeon should provide the reason (s) for referral Civil surgeon should�indicate that the evaluation should address: (1)�the�determination of a mental disorder diagnosis (alcohol abuse) and� (2)�whether there is current or a history of associated harmful behavior to self, others, or property, and if there is a�history of harmful behavior,�is�it�judged likely to recur There are no specific forms for the specialist�s report Specialist�s report�must be included with the�I-693 form, provided to USCIS

89. Alcohol Abuse(Mental Disorder) Need BOTH mental disorder diagnosis and associated harmful behavior to be Class A May request CDC to review medical exam documents and provide an advisory opinion

90. Substance Abuse and Addiction

91. Substance Abuse and Addiction Civil surgeon responsibility Interview and examine applicant Review records Determine if there is current or past nonmedical use of a psychoactive substance If yes, determine whether substance is listed in Section 202 of the Controlled Substances Act (CSA) Determine whether Class A or Class B Technical Instructions require civil surgeon to refer to specialist if civil surgeon unable to determine diagnosis or classification (fraud prevention)

92. Drug Classes in Section 202 of the CSA (Not All-Inclusive) Amphetamines and Related Substances Cannabinoids Cocaine and related substances Hallucinogens Opioids and related substances Phencyclidine (PCP) and related substances Sedative, hypnotic, or anxiolytic substances (tranquilizers)

93. Definitions Psychoactive abuse/dependence includes 2 groups Nonmedical users of any drug currently listed in Section 202 of the CSA Illegal in U.S. Click on Appendix A of the 1991 Technical Instructions at http://www.cdc.gov/ncidod/dq/panel_1991.htm No associated harmful behavior required Abusers of drugs not listed in Section 202 of the CSA Determination of Class A or B status Same as for a mental health or physical condition. There must be current associated harmful behavior, or a history of harmful behavior judged likely to recur.

94. Definitions, Cont�d. Remission (Class B) No nonmedical use of a drug listed in Section 202 of the CSA for 3 or more years No nonmedical use of a drug NOT listed in Section 202 of the CSA for 2 or more years Nonmedical use Considered to be more than experimentation with substance Experimentation = single use Consult specialist if needed

95. Substance Abuse and AddictionNotes Evaluation should determine: Diagnosis Classification (A or B) CDC consultant psychiatrist conducts review of cases on regular basis or as needed A request for an advisory opinion of diagnosis and classification may be made through USCIS to IRMH/CDC consultant psychiatrist NO WAIVER AVAILABLE for immigrant applicants Substance Abuse/Addiction is separate from Alcohol Abuse

96. CDC Links Civil Surgeon Technical Instructions and Updates http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html 1991 General TI 2008 TB TI and FAQ 2009 Vaccination TI HIV Guidance http://www.cdc.gov/immigrantrefugeehealth/exams/ti/hiv-guidance-panel-civil.html

97. CDC Contacts Phone - 800-CDC-INFO (800-232-4636) Fax 404-639-4441 �Attention Civil Surgeon Technical Instructions� E-mail cdcqap@cdc.gov Identify as Civil Surgeon practice

98. Thank youQuestions?