CDC Immigration Requirements: Technical Instructions For Hansen’s Disease (Leprosy) For Civil Surgeons

Preface

The medical screening for Hansen’s disease among persons applying for adjustment of status to permanent resident and other persons required by law to have a medical examination, hereafter referred to as applicants, is an essential component of the medical evaluation. Because Hansen’s disease may be challenging to diagnose and treat, these instructions are designed to detect and treat Hansen’s disease among applicants and to reduce the risk of spread of Hansen’s disease among the US population after immigration.

The instructions in this document supersede all previous Technical Instructions, Updates to the Technical Instructions, memoranda and letters to panel physicians, and memoranda and letters to international refugee resettlement organizations. These instructions are to be followed for Hansen’s disease screening and treatment among all applicants and are effective as of January 1, 2013

Visit the Technical Instructions for Civil Surgeons web page for other information about the medical examination for applicants for U.S. immigration.

Key Concepts

Hansen’s Disease Screening

Hansen’s disease is an infectious, chronic bacterial disease that primarily affects the skin and peripheral nerves. Specific skin lesions (see Physical Examination) are characteristic of the disease.

Medical History

Obtaining the medical history must include inquiring about 1) past and present diagnoses of Hansen’s disease, 2) history of skin lesions unresponsive to treatment, and 3) family history of skin lesions or known Hansen’s disease.

Physical Examination

The physical exam must include a search for signs and lesions consistent with Hansen’s disease. These would include any of the following:

• Any anesthetic skin patches, with or without visible lesions
• Localized skin lesions
  • Raised, flat, or nodular
  • Light or pigmented
• Sensory loss in lesion or on fingers or toes (use monofilament or cotton wisp to evaluate)
• Painless wounds or burns
• Thickened peripheral nerves (ulnar, radial, peroneal)
• Loss of eyebrows
• Thickening of earlobes
• Atrophied hand muscles
• Lagophthalmos (inability to fully close the upper eyelid)
• Perforated nasal septum
• Acid-fact bacilli in lesion

Laboratory Testing

Further testing should be done as necessary by a clinician experienced in the evaluation of Hansen’s disease to confirm the diagnosis and guide treatment. Skin biopsy specimens may be sent to the United States National Hansen’s Disease Program (NHDP) for evaluation; there is no charge for this service, but shipping must be arranged and is not covered by the NHDP. No serologic tests are available for routine diagnosis. Clinicians should contact the NHDP (1-800-642-2477) for advice on diagnosis if Hansen’s disease is suspected; information is also on the NHDP website.

Referrals

Suspected Hansen’s disease cases must be referred to a Hansen’s disease clinic or a designated Hansen’s disease clinical provider for evaluation. Civil surgeons can contact the NHDP directly at 1-800-642-2477 to or visit their online list of Hansen’s disease clinics to find a recommended clinical provider in the appropriate geographic area. Among other services, the NHDP provides the following: clinical consultations, pathology evaluations, medications, and educational materials. The applicant must return to the civil surgeon with a copy of the Hansen’s disease evaluation before the medical exam can be completed.

Hansen’s Disease Screening Results

It is important that Hansen’s disease be correctly diagnosed among applicants for adjustment of status. Correct diagnosis of Hansen’s disease will ensure that affected applicants receive correct treatment, disability is minimized, and applicants are able to obtain appropriate follow-up care by specialists in the United States.

Cases diagnosed in the United States should have histopathologic classification by skin biopsy by a healthcare provider experienced in Hansen’s disease diagnosis and treatment to confirm the type of Hansen’s disease (using the Ridley-Jopling categorization scheme used in the United States) and to guide appropriate treatment.

1. Mid-borderline (BB), borderline lepromatous (BL), and lepromatous (LL)
   • These Ridley-Jopling categories of Hansen’s disease correspond to the WHO category of multibacillary (MB) disease assigned overseas to individuals with 6 or more lesions.
   • Report untreated BB, BL, or LL disease as a Class A condition on the Medical Examination for Immigrant or Refugee Applicant Form (I-693).
   • Report treated or partially-treated BB, BL, or LL disease as Class B condition on the I-693 form.
   • Consider the applicant untreated unless he/she has had at least 7 days of recommended therapy which must include daily rifampin. Once the applicant has completed at least 7 days of therapy and appropriate treatment is considered underway, he/she should be reported as Class B for Hansen’s disease.
2. Indeterminate (I), tuberculoid (TT), and borderline tuberculoid (BT)
   • These Ridley-Jopling categories of Hansen’s disease correspond to the WHO category of paucibacillary (PB) disease assigned overseas to individuals with 1-5 lesions.
   • Report untreated I, TT, or BT disease as a Class A condition on the I-693 form.
   • Report treated or partially-treated I, TT, or BT disease as a Class B condition on the I-693 form.
   • Consider the applicant untreated unless he/she has had at least 7 days of recommended therapy which must include daily rifampin. Once the applicant has completed at least 7 days of therapy and appropriate treatment is considered underway, he/she should be reported as Class B for Hansen’s disease.

Hansen’s Disease Treatment

Applicants for change of status who are suspected of having Hansen’s disease should be referred to an appropriate Hansen’s disease healthcare provider in the United States for evaluation and treatment after consultation with the National Hansen’s Disease Program (NHDP). The NHDP can be reached at 1-800-642-2477 weekdays 9 am to 5:30 pm Eastern Time or via e-mail at nhdped@hrsa.gov.

• Affected applicants should be treated with U.S. treatment regimens under the auspices of or in consultation with the National Hansen’s Disease Program.
• Details of treatment must be noted on the I-693 form.
• Civil surgeons should give affected applicants printed information about Hansen’s disease [PDF – 2 pages] and the clinical services available to them through the National Hansen’s Disease Program.

Documentation

For applicants requiring Hansen’s disease treatment after arrival in the United States, the civil surgeon is required to document the following:

• Diagnosis including histopathological results and Ridley-Jopling classification by a Hansen’s disease specialist.
• Drug regimen received (including doses of all medications), start date, completion date (if applicable), and any periods of interruption.
• Clinical course such as clinical improvement or lack of improvement during treatment, including resolution of symptoms and signs and any reactions.

The original Report of Medical Examination and Vaccination Record (I-693), must be completed in entirety, signed, and placed in a sealed envelope for submission to the Department of Homeland Security (DHS), U.S. Citizenship and Immigration Services (USCIS) office. This includes assigning a classification on the I-693 if an applicant is Class A or Class B for Hansen’s disease.

For applicants who are referred to a specialist for further evaluation, the civil surgeon is required to retain a copy of the specialist’s report along with the I-693 form for their records.

For applicants who are referred for evaluation, the civil surgeon is required to complete Part 5 of the I-693 form. The civil surgeon should provide pertinent information regarding referral in the appropriate remarks section in Part 1 of the I-693 form.

A copy of any other documents provided for review regarding the diagnosis or classification of Hansen’s disease for an applicant should be retained by the civil surgeon.

The physician to whom the applicant was referred for evaluation is required to complete Part 6 of the I-693 form.

Hansen’s Disease Ambulatory Care Clinics in the United States

Civil surgeons should seek prompt consultation with the National Hansen’s Disease Program (NHDP) if Hansen’s disease is suspected in an applicant. The National Hansen’s Disease Program’s Clinical Center in Baton Rouge, Louisiana provides specialized Hansen’s disease care to persons from anywhere in the United States requiring such care. The NHDP also maintains an active physician referral list which includes more than 250 private physicians in all parts of the United States. If civil surgeons need the name of a Hansen’s disease physician in a particular geographic area, they should contact the NHDP at 1-800-642-2477 or visit the online list of clinical sites. Any physician or Hansen’s disease patient having a problem or question concerning Hansen’s disease may call 1-800-642-2477 weekdays 9 am to 5:30 pm Eastern Time (in Hawaii: 1-808-733-9831).

Glossary of Abbreviations

Acronym	Full Phrase
BB	Mid-borderline category of Ridley-Jopling categorization scheme
BL	Borderline lepromatous category of Ridley-Jopling categorization scheme
BT	Borderline tuberculoid category of Ridley-Jopling categorization scheme
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
I	Indeterminate category of Ridley-Jopling categorization scheme
LL	Lepromatous category of Ridley-Jopling categorization scheme
MB	Multibacillary
MDT	Multidrug therapy
NHDP	National Hansen’s Disease Program
PB	Paucibacillary
TT	Tuberculoid category of Ridley-Jopling categorization scheme
USCIS	United States Citizenship and Immigration Services
WHO	World Health Organization

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