CDC mulls pilot project to skin-test applicants seeking permanent residency
CDC mulls pilot project to skin-test applicants seeking permanent residency
Vietnam, Mexico eyed as possible sites for pilot
Within the year, TB experts at the Division of TB Elimination (DTBE) at the Centers for Disease Control and Prevention (CDC) in Atlanta say they may launch a pilot program to test recommendations from an Institute of Medicine (IOM) report released last May. The IOM report proposes adding TB skin testing to the medical exam for applicants for permanent residency status. It also proposes making candidates for treatment of latent TB infection (LTBI) complete a course of prescribed therapy before receiving their green cards.
Vietnam, which supplies the United States with about 14,000 immigrants each year, is being strongly considered as the site for the pilot project, says Ken Castro, MD, head of the DTBE at CDC. That probably means TB control programs here in the United States that would be engaged most in the pilot will be on the West Coast because the majority of Vietnamese immigrants declare their intent to settle there, says Susan Cookson, MD, head of the CDC’s Division of Quarantine.
The changes the IOM report proposes also would apply to persons legally emigrating from Mexico because that nation is the source of so much TB among the foreign-born here, and it would apply to those coming from countries where the rate of skin-test positivity is higher than the global median of 35%.
Enacting the two changes would prevent about 2,000 TB cases a year, says Larry Geiter, PhD, head of the IOM committee that produced the report.
The problem is that the proposed policy changes may not be possible without making a change in the law, according to a document written by Immigration and Naturalization Service (INS) officials in Washington, DC, in response to the IOM report. The INS document, which was prepared for public affairs use, poses the issue this way: "Does INS have the authority to make successful completion of follow-up treatment/preventive therapy a condition for issuing the I-551 Permanent Resident Card?"
The reply that follows seems clear: "Under existing law, INS has no authority to pose such a condition on aliens approved for adjustment of status or admitted as lawful permanent residents. Once an individual is admitted to the United States on the immigrant visa issued by the U.S. consular officer abroad, he/she enjoys all the rights and privileges of a lawful permanent resident. Consequently the INS has no legal authority to withhold issuance of the Permanent Resident Card which is the evidence of that lawful status."
Making therapy completion a condition
Admittedly, the situation lends itself to confusion. The U.S. Public Health Service (PHS) is the medical authority to which the INS defers. If, for example, the PHS decides to add skin testing for TB to the overseas medical exam, there’s no problem there, most experts agree.
The rub is how to make completion of therapy for latent TB infection a condition for achieving permanent residency status. As it stands now, an application for permanent residency status in the United States is denied if the applicant has an "excludable" medical condition — for example, infectious TB.
But when applicants not deemed medically excludable are allowed to enter the United States, they arrive already equipped with permanent residency status, the INS argument goes. So even though the PHS could change the definition of "excludable," it cannot, under existing law, attach a temporary status to what’s already a permanent condition.
For the same reason, withholding an immigrant’s green card until treatment for LTBI is completed may not be tenable. A green card merely furnishes formal proof of an already permanent condition; that status cannot, under ordinary circumstances, be modified, waived, or revoked.
If that’s the case, Geiter replies, "and if we decide this program’s going to be implemented, then we’ll have to make the necessary legislative changes." Besides, he adds, Class A waivers do appear to provide the kind of mechanism that could be used to withhold permanent status until a condition — in this case, completion of treatment for LTBI — has been met. Class A waivers permit people with active TB who’ve been rendered noninfectious to enter the United States with the provision that they finish treatment for TB here. "So, clearly there is a category of immigrant who gets here but can be deported for failure to adhere to an agreed-upon treatment," he says. "We think there are ways to enforce such a restriction."
Vietnam or Mexico: Both would work well
Pending a review of the legal ramifications, Castro says Vietnam may be a good place to start testing the two IOM proposals. After Mexico and the Philippines, Vietnam is responsible for the most TB cases among the foreign-born here. At the same time, it’s blessed with a strong and capable public health system, adds Castro. "The infrastructure is certainly there [in Vietnam]," he adds. "If these [IOM] recommendations will work anywhere, this would be the place."
Cookson agrees Vietnam might be a good place to try a pilot, but Mexico might be an even better choice, she adds. Like Vietnam and, for that matter, the Philippines, Mexico has just one "panel city," where medical exams are performed on immigration applicants. That would make it easier to train the panel physicians — the professionals appointed by embassies and consulates of the U.S. Department of State — how to plant and read skin tests, she notes.
But Mexico’s biggest advantage over Vietnam is that it’s so close. Its panel city, Ciudad Juarez, stands right across the border from El Paso. Panel physicians there are U.S.-trained, and they often consult with the El Paso health department, says Cookson.
Weighing costs to immigrants, U.S. programs
Certainly, adding a skin-test requirement to the entry exam will increase costs to applicants. Those costs already amount to thousands of dollars for a typical family: about $100 for the medical exam, which now includes a chest X-ray, but not tuberculin skin testing; $110 for an immigration petition; $260 for an application; and $65 for processing once an application is approved. For applicants who don’t live in the panel city, there is also the cost of lodging and food.
Adding a skin-test component presumably would increase the cost of a medical exam and, because applicants would have to return within 48 to 72 hours to have their skin test read, would substantially increase the cost of food and lodging, says Cookson.
On the other hand, making applicants with positive skin tests complete treatment for LTBI results in a definite gain, both for the individuals and for the community, says Ronald Bayer, PhD, a medical ethicist from Columbia University in New York City who sat on the IOM reporting committee. "It’s comparable to requiring people to get vaccinated," says Bayer. "The benefits are substantial; the medical risks are very small."
Certainly, mandating completion of treatment for LTBI for so many more people stateside will take more money, and the money will be found, says Castro.
"This definitely won’t be one of those unfunded mandates," he says. "That would be the worst thing you could do — tell people in TB control they’ve got to do a lot more work but not give them any extra resources, or a single extra body, to do it."
Local TB control programs would need at least an extra $23 million to fund the additional work, the IOM report estimates. The DTBE is working up its own cost estimate as well, Castro adds.
It also helps that there’s a new short-course regimen for prophylaxis, Castro notes, although he cautions that widespread use of the two-month course of rifampin and pyrazinamide may turn up some problems that haven’t come to light so far.
The skin-test reagent used by the panel physicians who do the overseas medical exam probably won’t be the familiar American-made reagents, experts agree. Instead, RT-23, made by Serumstatum Institute in Amsterdam, probably would be the agent of choice, says Elsa Villarino, MD, MPH, chief of the therapeutic and diagnostic studies section of the DTBE. The product is inexpensive compared with American brands. Fortunately, it is biologically equivalent and is applied and read in the same way as skin-test reagents made in this country. Like U.S.-made products, RT-23 requires refrigeration and needs to be checked periodically to make sure the expiration date hasn’t passed.
Along with putting extra people through a course of preventive therapy here in the United States, the most daunting logistical part of implementing the IOM recommendations probably will be getting the panel physicians trained to administer the test.
Worldwide, there are 600 panel physicians working in 200 countries. The CDC’s Division of Quarantine, which provides oversight, is seeking a means for "cost recovery" to expand and improve the existing program, Cookson notes.
Given the current limits on funding available for panel-physician oversight, it might be worthwhile to consider another setting in which TB skin testing is already being done. Each year, about 450,000 individuals who are foreign-born but already living in the United States apply to change their status to permanent residency. That’s about the same number as apply overseas for the same status. Part of the change-of-status exam, which is performed by civil surgeons, already includes TB skin testing. A program to improve the administration, reading, and reporting of those skin test results is needed, says Cookson.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.