CDC Immigration Requirements: Technical Instructions For Syphilis For Civil Surgeons

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

Preface

The medical screening for syphilis among persons applying for adjustment of status to permanent resident and others required by law to have a medical examination, hereafter referred to as applicants, is an essential component of the immigration-related medical evaluation. Because syphilis may be challenging to diagnose and treat, these instructions provide a method for recording findings from the medical examination and additional guidance for the civil surgeon in classifying applicants.

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 syphilis 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

Syphilis Screening

Syphilis is a sexually transmitted, systemic disease caused by Treponema pallidum. It has often been called “the great imitator” because of its wide variety of signs and symptoms, with different stages having different clinical manifestations. There are three infectious stages (primary, secondary, and early latent disease) and two noninfectious stages (late latent and tertiary disease). Untreated syphilis can progress and lead to long-term sequelae and death.

Medical History

Obtaining the medical history should include inquiring about any history of painless sores on the genitals, anus, or mouth or a rash on the body, especially on the palms or soles of the feet.

Physical Examination

The physical examination should include an evaluation for mouth sores (chancres) or rashes on the body, particularly on the palms of the hands or soles of the feet, that would indicate a syphilis infection. However, a genital examination is not required unless applicants have a medical history suggestive of syphilis, physical examination findings consistent with syphilis, or laboratory-confirmed syphilis; these applicants should also undergo an evaluation for genital, anal, and perianal sores to help determine the stage of syphilis.  Sores consistent with syphilis are typically small, painless, indurated, clean-based ulcers. Regional lymphadenopathy may be present in primary or secondary syphilis. Applicants should be evaluated for clinical signs of neurosyphilis (i.e., cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, loss of vibration sense, and auditory or ophthalmic abnormalities). Syphilis in children (either congenital or acquired) must be properly evaluated. Physical examination findings in congenital syphilis may include nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, skin rash, and pseudoparalysis of an extremity. In older children, signs of untreated congenital infection may include: interstitial keratitis (5-20 years of age), eighth cranial nerve deafness (10-40 years of age), Hutchinson teeth (peg-shaped, notched central incisors), anterior bowing of the shins, frontal bossing, mulberry molars, saddle nose, rhagades (linear scars around the mouth), and Clutton’s joints (symmetric, painless swelling of the knees).

Top of Page

Laboratory Testing

A nontreponemal test (e.g., Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR] or equivalent test) should first be used for screening. Positive results on screening tests should then be confirmed using a treponemal test (e.g., the T. pallidum passive particle agglutination [TP-PA] assay, the T. pallidum microhaemagglutination assay [MHA-TP], enzyme immunoassays (EIAs), or chemiluminescence immunoassays [CIAs]); testing must be performed in this order. If the confirmatory test is positive, nontreponemal serum titers should be performed and documented on the Medical Examination for Immigrant or Refugee Applicant Form (I-693). Syphilis tests must be performed at the time of the screening medical examination and at the civil surgeon’s designated laboratory. Tests performed elsewhere or prior to the civil surgeon’s examination of the applicant are not acceptable. Applicants with clinical signs of neurosyphilis should have a cerebral spinal fluid (CSF) analysis for VDRL, cell count, and protein. Applicants with evidence of auditory or ophthalmic abnormalities should additionally have otologic and ocular slit-lamp ophthalmologic examinations performed, respectively. Children with suspected syphilis infection should have a nontreponemal test performed, followed by a confirmatory treponemal test if positive. Older infants and children aged ≥1 month who are identified as having reactive serologic tests for syphilis should have maternal serology and records reviewed to assess whether they have congenital or acquired syphilis.  Any child at risk for congenital syphilis should receive a full evaluation, which may include CSF analysis, complete blood count and differential, and long-bone radiographs, depending upon previous documented evaluation. Dark field microscopic examination of suspicious lesions or body fluids (e.g., nasal discharge) also should be performed. Civil surgeons should refer to CDC’s Sexually Transmitted Diseases (STD) Treatment Guidelines for specific guidance on testing in children.

All applicants diagnosed with confirmed syphilis should also be advised to be tested for 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.

Syphilis Screening Results

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

The applicant must be treated using a standard treatment regimen (see Syphilis Treatment) before the medical report form is completed. All test results and treatment information, including medication, dose, and date(s) of treatment, must be recorded on the I-693 form.

Once the recommended treatment is completed, syphilis is no longer a Class A condition. After treatment, syphilis is a class B condition (whether with or without residual defect), and should be recorded as such on the I-693 form.

Syphilis Treatment

Treatment of syphilis should follow U.S. guidelines.

• Details of treatment must be provided in Part 1 of the I-693 form
• No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women. Therefore, infected applicants with neurosyphilis who are children or pregnant should be desensitized and treated with penicillin if appropriate facilities are available.
• Adult applicants treated for syphilis should be informed by civil surgeons that they will need follow-up care for clinical and serologic re-evaluation in 6 months (3 months if HIV positive and treated for primary or secondary syphilis). Children should receive follow-up care 2-3 months after treatment. This follow-up does not affect the examination validity period.

Documentation

The original Report of Medical Examination and Vaccination Record, must be completed in its entirety, signed, and placed in a sealed envelope for submission to the Department of Homeland Security (DHS), 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 syphilis.

For applicants requiring syphilis treatment after arrival in the United States, the civil surgeon is required to document the following:

• Stage of syphilis based on history and clinical findings
• Drug regimen received (including doses, dosage units, and administration routes of all medications), start date, completion date, and any periods of interruption.
• Clinical course such as clinical improvement or lack of improvement during and after treatment for primary or secondary syphilis, including resolution of symptoms and signs, and any drug reactions.

Top of Page

Glossary of Abbreviations

Acronym	Full Phrase
CDC	Centers for Disease Control and Prevention, United States
CIA	Chemiluminescence immunoassay
CSF	Cerebral spinal fluid
DGMQ	Division of Global Migration and Quarantine
DHS	Department of Homeland Security
DOS	Department of State
EIA	Enzyme immunoassay
FTA-ABS	Fluorescent treponemal antibody absorbed
HIV	Human immunodeficiency virus
MHA-TP	T. pallidum microhaemagglutination assay
RPR	Rapid plasma reagin
STD	Sexually transmitted disease
TP-PA	T. pallidum passive particle agglutination assay
USCIS	United States Citizenship and Immigration Services
VDRL	Venereal Disease Research Laboratory