b. Examination of visa applicants.--Sputum specimens are not acceptable unless raised in the presence of the examiner. Negative results shall be followed by examination of specimens properly obtained by tracheal or gastric lavage. If such are impossible to obtain, laryngeal swab specimens properly obtained 5 may be used. The best generally available test, however, is the examination of fasting gastric contents, preferably obtained prior to the applicant's arising from bed. It shall be tested by animal inoculation. Where proper laboratory animals are not available, bacterial culture shall be used. At least three specimens taken one day apart shall be examined before a negative result is accepted. 11. Tuberculin test.--The intracutaneous (Mantoux) test is preferred. This test is performed by injecting intracutaneously 0.0001 milligram of freshly prepared purified protein derivative or 0.1 milligram of old tuberculin in 0.1 cc. of solution. A positive reaction is interpreted as one showing more than 5 millimeters of definite induration in 48 to 72 hours after injection. The test shall be performed in accordance with the current Diagnostic Standards of the National Tuberculosis Association. Care shall be exercised to perform the test, and interpret the results, correctly. When there is doubt as to the reading of the test, or as to the validity of negative results, the test shall be repeated. A delay of 8 weeks would allow time for allergy to develop in persons who are in the latent stage. Other causes of negative results in persons with tuberculous infection are malnutrition, exanthemata, and overwhelming tuberculous infection. Special Conditions (See paragraph 20 regarding modification of procedures in the United States.) 12. Reversible collapse therapy (pneumothorax, pneumoperitoneum, temporary phrenic nerve interruption, and extrapleural pneumothorax.)--Applicants who have received reversible collapse therapy must have had at least one year's observation following maximum reexpansion of the involved lung or lungs." This observation shall consist of quarterly X-ray examinations, demonstrating (a) appearance consistent with inactive disease, (b) complete radiological stability, and (c) no evidence of pleural effusion. 5 By a method satisfactory to the tuberculosis consultant. 6 Unless in the opinion of the tuberculosis consultant this period can be shortened. 13. Permanent collapse therapy. --Where permanent collapse therapy has been employed (thoracoplasty, extrapleural plombage, etc.), the same minimum observation period applies as in the reversible collapse therapy cases, provided that the period shall not commence until at least one year after the completion of surgery. 6 In class B cases the date and nature of the operation shall be stated. 14. Pulmonary resection.--Because of the changing indications for and extent of resections for pulmonary tuberculosis, fixed rules cannot be established. Generally speaking the minimum postoperative observation period shall be:" Pneumonectomy Segmental or wedge resection.. 24 months 12 months 6 months All such cases shall be referred to the area tuberculosis consultant who shall, whenever possible, examine the applicant personally. In areas that are not served by a tuberculosis consultant such cases shall be referred to Washington headquarters.7 15. Pleural effusion. a. All idiopathic pleural effusions in tuberculin positive aliens must be considered tuberculous. When an alien has had an idiopathic pleural effusion or an effusion of proved tuberculous etiology, a class A notification for "Tuberculosis--pleurisy with effusion" shall be issued unless the alien can present sufficient X-ray and laboratory examination data to meet the requirements for a class B notification stated in paragraph "b" below. He may be reexamined at 3-month intervals. b. A class B notification may be issued for "Pleurisy with effusion, healed" (as well as pulmonary fibrosis if present) when it has been demonstrated that for at least 2 years all fluid has been absent, there has been no change in the size or distribution of the pleural density, the lesion has remained healed, and all laboratory tests on gastric contents have been negative. c. Any parenchymal lesion in the lung must be evaluated as it would in the absence of pleural effusion. d. The examiner need not delay issuing a class B notification in cases which in his opinion have only pleural thickening or adhesions as manifestations of old pleural disease. "Unless in the opinion of the tuberculosis consultant this period can be shortened. 7 For address see footnote 2. 16. Pregnancy.--In the case of pregnancy, determination of the status of tuberculosis shall not be made until at least one year after termination of the pregnancy. (The criteria in par. 9 for inactive disease shall be met.) 8 Extrapulmonary Tuberculosis 17. When the examiner finds definite evidence of extrapulmonary tuberculosis, he shall issue a class A notification. This notification cannot be removed until there has been no evidence of activity for at least 2 years as indicated by the following: 8 a. Lack of drainage. b. No demonstrable abscess or effusion. c. No meningeal signs. d. No renal involvement. e. No miliary manifestations. f. Negative bacteriological findings in all reasonably available fluids or tissues. g. Where applicable, no evidence of activity revealed by X-ray examination. Information in Medical Reports, Regarding Observation 18. In issuing a class B notification for an alien who has been under observation after deferral or after issuance of a class A notification, the examiner shall include on form FS-398: a. A brief review of the X-ray findings tracing the progress of the condition through the series of films, with a detailed reading of the latest film, and a statement of the time since all lesions have appeared to be healed and unchanged. b. Dates and details of any laboratory tests for tuberculosis. (Preceding is based on section 34.4 (b) (2) of regulations.) Examination in the United States 19. When an arriving alien's medical report shows that a notification of a class B condition was issued abroad, and there is no evidence to warrant further study of the case, a corresponding class B certificate shall be issued at the time of medical inspection. 8 Unless in the opinion of the tuberculosis consultant this period can be shortened. 20. When an alien is held for medical examination on arrival, the instructions in preceding sections of this chapter shall be followed as a guide. However, since aliens cannot be detained for long periods of time, the diagnosis of a doubtful lesion or the decision as to whether a tuberculous lesion is inactive must be made on the basis of available evidence based on such tests as may be indicated provided that these can be completed promptly, and any other medical data available. When a class A certificate is issued for pulmonary tuberculosis, the diagnosis shall not be followed by such terms as "probably active" or "activity doubtful." (The alien need not be hospitalized or detained in isolation pending a report on examination or testing procedures, unless the responsible medical officer deems such detention necessary to protect the health of the alien or of others.) Special Reports 21. For visa applicants.--When the medical examiner discovers a known or suspected case of active tuberculosis, he shall report it to the health authority if required to do so by law. 22. In the United States.--Form PHS-2538, Report of Alien with Pulmonary Fibrosis, is completed in duplicate when a certificate is issued for pulmonary fibrosis. The original is sent to the health department of the State where the alien will reside; the copy is filed at the station. Medical Officers in Charge of quarantine stations issue the form when applicable for aliens certified by a quarantine officer and for those certified after issuance of a medical hold. Hospitals and Outpatient Clinics issue the form for aliens referred to them direct by the Immigration Service--i.e., without initial inspection by a quarantine officer. (Applies to all categories of aliens--those arriving at ports, applying for adjustment of status, etc. However, do not issue unless the alien is admitted by the Immigration Service and plans to stay at one address for several months.) Admission of Certain Aliens with Tuberculosis 23. Immigrants, under Section 212(f), Immigration and Nationality Act. a. Law. Section 212(f) of the Immigration and Nationality Act (as amended effective September 26, 1961, by Public Law 87301) states: Any alien afflicted with tuberculosis in any form who (A) is the spouse or the unmarried son or daughter, or the minor unmarried lawfully adopted child, of a United States citizen, or of an alien lawfully admitted for permanent residence, or of an alien who has been issued an immigrant visa, or (B) has a son or daughter who is a United States citizen, or an alien lawfully admitted for permanent residence or an alien who has been issued an immigrant visa, shall, if otherwise admissible, be issued a visa and admitted to the United States for permanent residence in accordance with such terms, conditions, and controls, if any, including the giving of a bond, as the Attorney General, in his discretion after consultation with the Surgeon General of the United States Public Health Service, may by regulations prescribe. b. Immigration Service Provisions. The following instructions (prepared in cooperation with the Division of Foreign Quarantine) appear on Immigration Service form I-601, "Application for Waiver of Grounds of Excludability," available at all Immigration Service offices and United States consular offices: As conditions for the issuance of a visa and for admission of an alien under Section 212(f) of the Immigration and Nationality Act, as amended September 26, 1961, the ALIEN SHALL SUBMIT: 1. A statement by a State, territorial, or local health department, or by a recognized hospital or other institution engaged in the treatment of tuberculosis. (Unless the United States Public Health Service has established that the hospital or other institution is satisfactory for the treatment of tuberculosis, a statement made by such an institution must bear an endorsement by a health department affirming its recognition of the institution for that purpose.) The statement must include: A. Name and address of the hospital or institution where the alien will be treated. B. Affirmation that upon arrival at such hospital or institution the alien will be placed in inpatient or outpatient status as determined by the responsible local physician. C. Affirmation that (1) financial arrangements for the alien's care have been made by a sponsor or other responsible individual; or (2) the alien has established eligibility under the Dependents Medical Care Act of June 7, 1956 (70 Stat. 250; 37 U.S.C. 401). D. Agreement to supply any treatment and observation required for proper management of the alien's condition, in conformity with accepted local standards of medical practice. |