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Immigrant and Refugee Health

CDC Immigration Requirements: Technical Instructions For Hansen’s Disease (Leprosy) For Panel Physicians

Preface

The medical screening for Hansen’s disease among aliens applying for immigrant or refugee status, as well as non-immigrants who are required to have an overseas 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 Panel Physicians web page for more information about the medical examination for applicants for U.S. immigration.

Key Concepts

  • Patients with multibacillary or paucibacillary Hansen’s disease are considered to be Class A. However, after 7 days of treatment, they may be re-classified as Class B.
  • Disease categorization is based on clinical evaluation and follows the World Health Organization categorization scheme.

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.

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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 examination 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 may be done as necessary to confirm the diagnosis but is not required for initiating treatment. If skin biopsies are taken, they should be sampled from the active margin of the lesion; skin biopsies should only be performed if qualified personnel are available for evaluation. No serologic tests are available for routine diagnosis.

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Hansen’s Disease Screening Results and Travel Clearance

  • The evaluation is complete when the required aspects of the medical examination have been completed and the applicant can be assigned a Hansen’s disease classification (Class A, Class B, or No Classification).
  • Travel clearances are valid for the same length of time as the applicant’s tuberculosis screening evaluation in the country of examination for applicants who have either No Classification for Hansen’s disease or Class B Hansen’s disease.

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

Disease categorization is done on a clinical basis and follows the World Health Organization (WHO) categorization scheme:

  1. Multibacillary (MB) formApplicants with 6 or more lesions have multibacillary disease.
    • Report untreated MB disease as a Class A condition on the Medical Examination for Immigrant or Refugee Applicant form (DS-2053 or DS-2054).
    • Report treated or partially-treated MB disease as a Class B condition on the DS-2053 or DS-2054 form.
    • Consider the applicant untreated unless he/she has had at least 7 days of recommended therapy per the WHO protocol. Once the applicant has completed at least 7 days of recommended therapy and appropriate treatment is considered underway, he/she should be reported as Class B for Hansen’s disease.
  2. Paucibacillary (PB) formApplicants with 1-5 lesions have paucibacillary disease.
    • Report untreated PB disease as a Class A condition on the DS-2053 or DS-2054 form.
    • Report treated or partially-treated PB disease as a Class B condition on the DS-2053 or DS-2054 form.
    • Consider the applicant untreated unless he/she has had at least 7 days of recommended therapy per the WHO protocol. Once the applicant has completed at least 7 days of recommended therapy and appropriate treatment is considered underway, he/she should be reported as Class B for Hansen’s disease.
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Hansen’s Disease Treatment

Panel physicians must treat applicants with World Health Organization treatment regimens.

  • Start applicant on appropriate treatment regimen.
  • Treat patients with only a single skin lesion with a full 6 months of treatment. Please note this differs from the guidance in the WHO treatment guidelines.
  • Document details of treatment on the Medical History and Physical Examination Worksheet (DS-3026) in the remarks section.
  • Instruct applicants with Hansen’s disease that it is important to complete therapy after arrival in the United States.
  • Give affected applicants printed information about Hansen’s disease [PDF -2 pages] and the clinical services available to them through the National Hansen Disease Program (NHDP).
  • Provide applicant with at least a 60-day supply of medication for use during travel (i.e., two WHO multidrug therapy [MDT] blister packs or equivalent) and to allow time to find appropriate care.
  • Panel physicians should advise applicants with Hansen’s disease to contact the NHDP upon arrival in the United States. 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.

Waivers

  • A provision allows applicants undergoing the first week of treatment for Hansen’s disease to apply for a Class A waiver; however, the waiver will become unnecessary after 7 days of treatment as the applicant will be re-classified as Class B for Hansen’s disease.

A provision allows applicants with a Class A physical disorder to petition for a Class A waiver. The Application for Waiver of Grounds of Inadmissibility Form (I-601 or I-602 for immigrants or refugees, respectively) must be completed. These waivers are submitted to the Department of Homeland Security (DHS), U.S. Citizenship and Immigration Services (USCIS) on an individual basis. DGMQ also reviews the waivers and supporting medical examination to provide an opinion regarding the case to the requesting entity (Department of State or DHS, USCIS). DGMQ’s review of the waiver and supporting medical examination documentation is to ensure that the applicant has been classified properly and that an appropriate U.S. health care provider is identified for the applicant. DHS, USCIS has the final authority to adjudicate the waiver request.

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Documentation

  • All medical documentation, including any laboratory reports, must be included with the required DS Forms.
  • Information recorded on the DS Forms must be typed and in English.
  • All required medical documentation must be sent by courier or other secure means to the U.S. Embassy for all Class A conditions. Applicants with Class A Hansen’s disease should be reported to the U.S. Embassy upon diagnosis.

Department of State Medical Examination for Immigrant or Refugee Applicant form (DS-2053 or DS-2054), Vaccination Documentation Worksheet (DS-3025), Medical History and Physical Examination Worksheet (DS-3026), and Chest X-ray and Classification Worksheet (DS- 3024 or DS-3030) must be completed in their entirety and included in the applicant’s travel packet. This includes assigning a classification on the Medical Examination for Immigrant or Refugee Applicant form if an applicant is Class A or Class B for Hansen’s disease. Incomplete documentation may result in refusal to grant a visa or designation of medical hold status at arrival to a U.S. port of entry.

For applicants requiring Hansen’s disease treatment prior to U.S. immigration, the panel physician is required to document the following:

  • 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 and after treatment, including resolution of symptoms and signs and any reactions.
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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
MB Multibacillary
MDT Multidrug therapy
NHDP National Hansen’s Disease Program
PB Paucibacillary
USCIS United States Citizenship and Immigration Services
WHO World Health Organization

Information for Affected Applicants

Panel physicians should give applicants with Hansen’s disease printed information [PDF – 2 pages] about Hansen’s disease and the services available to them through the NHDP.

Useful Web Links

Related Links

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