Chapter 6: Communicable Diseases of Public Health Significance

A. Communicable Disease​s​

Applicants who have communicable diseases of public health significance are inadmissible.​ [1] See INA 212(a)(1)(A)(i). HHS has designated the following conditions as communicable diseases of public health significance that apply to immigration medical examinations conducted in the United States:​ [2] See 42 CFR 34.2(b).

Chancroid​

Gonorrhea​

Granuloma ​inguinale​

Leprosy, infectious​

Lymphogranuloma​venereum​

Syphilis, infectious stage ​

Tuberculosis (TB), Active—Only a Class ​A​ TB diagnosis renders an applicant inadmissible to the United States. Under current CDC guidelines, Class ​A​ TB means TB that is clinically active and communicable. ​

1. Additional Communicable Diseases for Applicants Abroad​

HHS regulations also list two additional general categories of communicable diseases of public health significance.​ [3] See 42 CFR 34.2(b)(2) and 42 CFR 34.2(b)(3). Currently, these provisions only apply to applicants outside the United States who have to be examined by panel physicians:​ [4] An officer will not encounter such annotations on Form I-693, but may on the DS-2053/DS-2054.

Communicable diseases that may make a person subject to quarantine, as listed in a Presidential Executive Order, as provided under Section 361(b) of the Public Health Service Act.​ [5] The current revised list of quarantinable communicable diseases is available at http://www.cdc.gov and http://www.archives.gov/federal-register.

Communicable diseases that may pose a public health emergency of international concern if they meet one or more of the factors listed in ​42 CFR 34.3(d)​and for which the Director of the CDC has determined that (A) a threat exists for importation into the United States, and (B) such disease may potentially affect the health of the American public. The determination will be made consistent with criteria established in Annex 2 of the revised International Health Regulations. HHS/CDC's determinations will be announced by notice in the ​Federal Register​.​

2. Human Immunodeficiency Virus (HIV) ​

As of January 4, 2010, HIV infection is no longer defined as a communicable disease of public health significance according to HHS regulations.​ [6] See Pub. L. 110-293 and 42 CFR 34.2(b) as amended by 74 FR 56547 (November 2, 2009). Therefore, HIV infection does​not​make the applicant inadmissible on health-related grounds for any immigration benefit adjudicated on or after January 4, 2010, even if the applicant filed the immigration benefit application before January 4, 2010. ​

The officer should disregard a diagnosis of HIV infection when determining whether an applicant is inadmissible on health-related grounds. ​The officer should administratively close any HIV waiver application filed before January 4, 2010. ​

B. Parts of ​Form I-693​ Addressing Communicable Diseases​

1. Tuberculosis ​

An initial screening test, either a Tuberculin Skin Test (TST) or an Interferon Gamma Release Assay (IGRA), is required for all applicants 2 years of age or older. According to the Technical Instructions, applicants under 2 years of age are required to undergo an initial screening test if there is evidence of contact with an applicant known to have TB or there is another reason to suspect TB. For more information, please see the TB Component of the Technical Instructions. ​

The “testing age” is the applicant’s age on the date the civil surgeon completed the medical examination by signing the form, not the age at the time of the adjudicatio​n. An officer should not send a Request for Evidence​(​RFE​)​ for testing if the applicant was properly exempt from the testing requirement due to age at the time of the medical examination. The officer, however, may always require testing if evidence indicates the applicant may have been exposed to TB since the examination.​

The initial screening test results must be recorded. If the initial screening test was not administered, the exceptions should be clearly annotated in the remarks portion after the “not administered” box in the testing section. The officer should be aware that anyone who previously received the ​Bacille​Calmette-Guérin​ vaccine​ [7] Often referred to as the “BCG” vaccine. BCG vaccine is a tuberculosis vaccination that is administered in many countries outside of the United States, especially those with a high TB rate. For more information, please see CDC’s website at www.cdc.gov. must still undergo an initial TB screening test. These applicants are not exempt from the initial screening test. ​

The civil surgeon must also annotate the “Initial Screening Test Result and Chest X-Ray Determination” section. If the section indicates that the applicant is medically cleared relating to TB, then no further TB tests are required. In this case, the X-ray section should be left blank.​

If a chest X-ray is required, the chest X-ray section must be completed. ​If the chest X-ray is suggestive of active TB disease, the applicant must be referred to the health department for further assessment and possible treatment.​ [8] Under the new Technical Instructions, among other assessments, sputum cultures are required for applicants with chest X-ray findings suggestive of active TB diseases. Drug susceptibility testing is required for positive cultures results. These tests can take months to complete. Also, a referral to the health department and the TB treatment can take months. Officers, applicants, and their representatives should be aware that it can take a long time, and that the civil surgeon is not permitted to sign the Form I-693 until after follow-up assessments and treatment have been completed. The civil surgeon cannot sign off on the ​Form I-693​ until any required steps relating to TB have been completed.​

Under the Technical Instructions, a pregnant applicant can defer the chest X-ray until after pregnancy but the civil surgeon may not submit​ the form ​until the chest X-ray has been performed, interpreted, and the appropriate follow-up, if required under the Technical Instructions, is completed. If the officer receives an incomplete medical examination for a pregnant applicant, the officer should return the original​ form​ to the applicant for corrective action according to established local procedures. ​

Class ​A​ TB ​requires​ a referral to the TB Control Program of the Health Department for evaluation and the completion of TB treatment before the civil surgeon can sign off on the​ form​. In this case, the referral evaluation section must be completed and evidence of treatment must accompany the form. If not, the officer should RFE for corrective action.​

All Class B TB (other than Class B, latent TB) ​requires​ a referral to the Health Department for follow-up assessment before the civil surgeon can sign off on the​ form​. In this case, the referral evaluation section must be completed. If not, the officer should RFE for corrective action.​

For applicants identified with Class B, latent TB, a referral to the Health Department is only ​recommended​ under the Technical Instructions. A referral is ​not required​ and that section does not have to be completed in this case. Therefore, the officer may accept ​Form I-693​ without the referral evaluation section being completed and should not RFE.​

Determining whether a referral is required is detailed in the TB Technical Instructions.​ [9] Available online at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/tuberculosis-civil-technical-instructions.html.

2. Syphilis and Other ​Communicable Diseases​

Serological testing for syphilis is required for applicants 15 years of age or older. Applicants under 15 years may be tested by the civil surgeon if illness is suspected. The testing age is the age on the date the civil surgeon completed the medical examination and signed the form, not the age at the time of the adjudication of the adjustment application. ​

The civil surgeon must complete all “Findings” boxes for all categories. The civil surgeon may add explanatory remarks; however, the officer should not RFE simply because there are no remarks. Note that versions of ​Form I-693​ prior to the October 14, 2009 version may not have had boxes for “No Class A or B Condition” for some of these entries. In this case, the adjudicator should accept the finding reflected in the Summary Findings section of​ the form ​for the admissibility determination. ​