CDC Immigration Requirements: Technical Instructions for Gonorrhea for Civil Surgeons

Please note:  On March 15, 2017, the Gonorrhea TI were updated to reflect that laboratory reports do not need to be included with the I-693. 

Please note: August 1, 2016 is the date which civil surgeons should have started gonorrhea testing. The Gonorrhea TI were updated on November 23, 2016 which is reflected below.

Preface

The medical screening for gonorrhea among aliens applying for adjustment of status, hereafter referred to as applicants, is an essential component of the immigration-related medical evaluation. Because gonorrhea must be appropriately diagnosed and treated, these Technical Instructions provide a method for recording findings from the medical examination and instructing civil surgeons on classifying applicants.

The instructions in this document supersede all previous Technical Instructions, Updates to the Technical Instructions, memoranda and letters to civil surgeons, and memoranda and letters to international refugee resettlement organizations. These instructions are to be followed for gonorrhea screening and treatment among all applicants, and are effective as of November 23rd, 2016.

Visit the Technical Instructions for Civil Surgeons webpage for more information about the medical examination for applicants for U.S. immigration.

Key Concepts

Gonorrhea Screening

Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae. It is one of the most commonly reported communicable diseases in the United States. Persons with gonorrhea will most often present with urethral or cervical discharge and painful urination. However, it is most often asymptomatic in both men and women, especially if the infection is in the pharynx, cervix, or rectum. Left undetected and untreated in women, gonorrhea may ultimately cause complications such as pelvic inflammatory disease (PID), tubal scarring, ectopic pregnancy, and infertility.

It is important that gonorrhea be correctly diagnosed among applicants for adjustment of status. Correct diagnosis of gonorrhea will ensure that affected applicants receive appropriate treatment, long-term sequelae are minimized, and further spread of the disease is reduced.

Medical History

Obtaining the medical history should include inquiring about any genitourinary symptoms. Men with gonorrhea may report dysuria with penile discharge, while women who are symptomatic may experience vaginal mucopurulent discharge, pelvic pain, or dyspareunia.

Physical Examination

The physical examination must include checking for signs consistent with gonorrhea in applicants ≥15 years of age (and applicants younger than the age of 15 years if there is a history of gonorrhea or reason to suspect infection with gonorrhea). Other manifestations of gonorrhea that should be evaluated include pharyngeal discharge, rash, ocular symptoms, and abdominal and pelvic tenderness.  However, a genital examination is not required.

Laboratory Testing

A nucleic acid amplification test (NAAT) should be performed for screening. NAAT allows testing to be performed on specimens such as urine (from men and women), endocervical or vaginal swabs (women), or urethral swabs (men).  Civil surgeons should use tests that have regulatory approval and closely follow the instructions on the product inserts to ensure the correct specimen is used for the laboratory test, as collection methods and specimen types vary.

CDC encourages civil surgeons to use the least-invasive test for screening. Given these options, the least-invasive tests are the urine NAAT (men or women) or self-collected vaginal swab (women). CDC encourages civil surgeons to use these tests.  For self-collected vaginal swab NAAT tests, civil surgeons should use test kits that can also indicate if human DNA is present.

In symptomatic men, a Gram stain on urethral secretions, which demonstrates polymorphonuclear leukocytes with intracellular Gram-negative diplococci, can be considered diagnostic. However, a negative Gram stain cannot be used to rule out infection in asymptomatic men. In addition, a Gram stain is not diagnostic on endocervical, pharyngeal, or rectal specimens or in women.

Many gonorrhea tests automatically test for Chlamydia trachomatis. Although chlamydia is not listed in the diseases of public health significance in 42 Code of Federal Regulations (CFR) part 34, civil surgeons may use tests kits that screen for both gonorrhea and chlamydia if gonorrhea stand-alone test kits are unavailable; when combined test kits are used, applicants should be informed. Applicants who test positive for chlamydia only should be offered treatment in accordance with the CDC’s Sexually Transmitted Diseases (STD) Treatment Guidelines. If an applicant is tested for chlamydia, the results should be documented on the Form I-693 in the section, “Other Medical Conditions.”  If an applicant is diagnosed and treated for chlamydia, this should also be documented on the Form I-693 in the section, “Other Medical Conditions.” Applicants diagnosed and successfully treated for chlamydia should have chlamydia listed in the “Other Medical Conditions” section of the Form I-693.

All applicants diagnosed with gonorrhea should be advised to be tested for other STDs, including chlamydia, syphilis, and HIV. The consent for HIV testing should include the following:

• Applicants understand they do not have to be tested for HIV.
• Applicants understand that if they would like to be tested for HIV, they do not have to be tested for HIV by a civil surgeon.
• Applicants understand that civil surgeons must include the test results on the paperwork they complete.

If the applicant consents, civil surgeons should perform HIV testing consistent with current standards of care, including pre-test and post-test counselling for the HIV test.

Gonorrhea Screening Results

Gonorrhea Treatment

Civil surgeons must treat gonorrhea according to CDC’s STD Treatment Guidelines, which are periodically updated, before the medical report form is completed and signed.

Treatment should be provided onsite and be directly observed. Civil surgeons should recommend that sex partners of infected applicants also be treated.

Evaluation Post-treatment

A test of cure immediately at the conclusion of therapy is not needed prior to completion of the medical examination following treatment for uncomplicated urogenital or rectal gonorrhea that is treated with any of the recommended or alternative regimens. However, any applicant diagnosed with pharyngeal gonorrhea who is treated with an alternative regimen must have a NAAT or culture test performed 14 days after treatment prior to completion of the medical examination, and the test should be performed by the civil surgeon. If the NAAT is used and is positive, the applicant should have confirmatory culture with drug-susceptibility testing before re-treatment.

In cases of suspected or documented treatment failure, manifested by symptoms that persist after treatment, civil surgeons should perform both culture and drug-susceptibility testing because non-culture tests cannot provide drug-susceptibility results. Culture cultures requires endocervical swabs (women) or urethral swabs (men).  Additionally, gonococcal cultures require demanding nutritional and environmental growth requirements. Optimal recovery rates are achieved when specimens are inoculated directly and when the growth medium is incubated with an increased CO₂ environment.

Any additional testing or treatment should be documented on the Form I-693 in the section, “Other Medical Conditions.”

Because a high prevalence of N. gonorrhea infection has been detected among persons previously treated for gonorrhea, all applicants treated for gonorrhea should be counseled that they should be retested 3 months after treatment. However, this post-treatment evaluation does not prevent completion of the medical exam for status adjustment.

Documentation

For applicants requiring gonorrhea treatment prior to U.S. immigration, the civil surgeon is required to document the following:

• Laboratory test used to make the diagnosis
• Drug regimen received (including doses, dosage units, and administration routes of all medications), start date, completion date, and any periods of interruption.
• Clinical course observed, such as clinical improvement or lack of improvement during and after treatment, including resolution of symptoms and signs, as well as any drug reactions.

Glossary of Abbreviations

Acronym	Full Phrase
CDC	Centers for Disease Control and Prevention, United States
DGMQ	Division of Global Migration and Quarantine
DHS	Department of Homeland Security
DOS	Department of State
HIV	Human immunodeficiency virus
NAAT	Nucleic acid amplification test
STD	Sexually transmitted disease
USCIS	United States Citizenship and Immigration Services