CDC Immigration Requirements: Technical Instructions For Syphilis For Panel Physicians

Preface

The medical screening for syphilis 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 immigration-related medical evaluation. Because syphilis must be appropriately diagnosed and treated, these Technical Instructions provide a method for recording findings from the medical examination and instruct panel physicians 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 Panel Physicians 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).

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. Syphilis tests must be performed at the time of the screening medical examination and at the laboratory stated in the panel physician agreement. Tests performed elsewhere or prior to the panel physician’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. Panel physicians 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 panel physician.
• Applicants understand that panel physicians must include the test results on the paperwork they complete.

If the applicant consents, panel physicians should perform HIV testing consistent with the standards of testing in their countries.

Syphilis Screening Results and Travel Clearance

It is important that syphilis be correctly diagnosed among applicants for U.S. immigration. 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 and signed.  All test results and treatment information, including medication, dose, including units (for example, international units or milligrams), date(s) of treatment, and route of administration must be recorded on the Medical Examination for Immigrant or Refugee Applicant form (DS-2053 or DS-2054).

Once the recommended treatment is completed, syphilis is no longer a Class A condition and the applicant may be medically cleared for travel to the United States.  After treatment, syphilis is a class B condition (whether with or without residual defect) and should be recorded as such on the Medical Examination for Immigrant or Refugee Applicant form. The validity period for the syphilis evaluation is the same as the validity period of the applicant’s tuberculosis screening evaluation in the country of examination.

Syphilis Treatment

Panel physicians must treat syphilis following CDC’s Sexually Transmitted Diseases (STD) Treatment Guidelines, which are periodically updated.

• Details of testing and treatment must be provided on the Medical Examination for Immigrant or Refugee Applicant form (DS-2053 or DS-2054).
• No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women. Therefore, children, pregnant women, and infected applicants with neurosyphilis should be desensitized and treated with penicillin if appropriate facilities are available.
• Adult applicants treated for syphilis should be informed by panel physicians 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.

Waivers

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. healthcare provider is identified for the applicant. DHS, USCIS has the final authority to adjudicate the waiver request.

Documentation

Department of State (DOS) forms Medical Examination for Immigrant or Refugee Applicant (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 and 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 syphilis. After completing treatment, the applicant’s classification should be changed to Class B for syphilis. Incomplete documentation may result in refusal to grant a visa or designation of medical hold status at arrival to U.S. ports of entry.

For applicants requiring syphilis treatment prior to U.S. immigration, the panel physician 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.

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