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 Adoption Advocate No. 16:  NCFA Position Statement on the Centers for Disease Control’s (CDC) 2007 Technical Instructions on Tuberculosis (TB) as They Relate to Internationally Adopted Children
Published August 2009 by Elisa Rosman, Ph.D. and Chuck Johnson

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Case Study 

           In a story that received national attention in August, 2009, an American couple, James Scruggs and Candace Litchford, traveled to China to adopt a four-year-old girl, Harper.  Upon arriving in China, they learned that Harper had been diagnosed with tuberculosis (TB) two months prior to being adopted.  At the time of Harper’s adoption, she had been on anti-TB medication for over a month, a sputum culture test performed eight weeks earlier was negative, and she had three negative sputum smear tests.  Unfortunately, the CDC would not accept the sputum culture because it did not meet CDC’s newly implemented requirements.  With results expected to take at least six weeks, the parents reluctantly returned to the United States without their daughter, in order to tend to pressing issues at home, including the care of their six-year-old son, who had remained in the States.   

          It is expected that real life examples such as this one will become common under the new CDC Technical Instructions described below.  Since international adoptions are legally completed by the time the visa process is initiated (and the requirement to meet the new TB screening procedures come into play), American parents will be forced to find alternate care and treatment in a foreign country for their newly adopted child or remain in-country with their child for up to one year until the child is cleared to come home to the United States.  It is also a distinct possibility that a child of U.S citizens, denied entry into the U.S. and forced to seek medical treatment elsewhere, will die.


NCFA’s Position

          The new CDC Technical Instructions (TIs) regarding TB should not be applied to children adopted by U.S. citizens internationally. The TIs, though having a commendable public health goal of reducing the spread of TB, have had the unintended consequences of hurting children who are adopted internationally by United States citizens. These children are being held to a medical standard that is not applied to biological children of U.S. citizens (born abroad or in the U.S.) or even to foreign tourists from these same countries. Given that children with TB are almost never contagious and that they will almost certainly receive medical care upon arriving in the United States, NCFA believes that internationally adopted children of U.S. citizens should be exempt from the new TIs or that there should be an expedited process implemented that takes into account the low health risk and the fact that these are the legal children of U.S. citizens.


Overview of tuberculosis (TB) in children

          According to the World Health Organization, over 250,000 children develop TB each year, usually as a result of being exposed to a sputum-positive adult. The diagnosis of TB in children is usually based on the clinical presentation of cough and weight loss, as well as a history of close contact with an adult TB patient.1 Children with TB are rarely, if ever, contagious. Quoted in the Washington Post, Lee B. Reichman, executive director of the Global Tuberculosis Institute at the New Jersey Medical School. said, “’Kids catch TB from adults. Adults don't catch TB from kids’”.2


Overview of 2007 Technical Instructions

          The Centers for Disease Control’s (CDC) Division of Global Migration and Quarantine is responsible for setting and implementing guidelines for TB testing for individuals who are immigrating to the United States. Before 2007, the most recent Technical Instructions were from 1991. The 1991 TIs called for skin tests, chest x-ray and three sputum smears from individuals who were thought to have TB. With the advent of the 2007 TIs, the CDC describes the changes as follows:

         “In 2007 CDC updated the TB Technical Instructions by adding—

  • Cultures [as compared to smears] for those thought to have TB.BOLD This test attempts to grow any TB bacteria that may be in the sputum sample. Once colonies (or groups) of bacteria form, they can be checked for TB. The culture makes TB testing more accurate.
  • Drug susceptibility testing (DST) on positive TB cultures. This will show which drugs are likely to kill the type of TB bacteria found.
  • A new process for TB treatment before U.S. arrival:
    • TB drugs are given as directly observed therapy (DOT), in which medical staff give patients their TB drugs in person.”3


          According to the CDC, these guidelines specifically impact children as follows: “To help detect TB in children, the 2007 TB Technical Instructions require that children aged 2 through 14 years undergo a TB skin test if they are medically screened in countries where the TB rate is 20 cases or more per 100,000 population. If the skin test is positive, a chest X-ray is required. If the chest X-ray suggests TB, cultures and three sputum smears are required. For a sputum smear, a small amount of mucus is collected from deep in the lungs (sputum), smeared on a slide, and viewed under a microscope to look for TB bacteria. A culture involves putting a sputum sample (i.e., a small amount of mucus from deep in the lungs) in a petri dish to see if TB bacteria grows.”4

          These guidelines are inherently problematic for children. Pediatric TB expert Dr. Jeffrey Starke explains that since children do not usually produce sputum, it is necessary to take a sample of stomach juices early in the morning on three consecutive days, a highly traumatic procedure for children.5 Furthermore, for children who are receiving treatment, it will be nearly impossible for an orphanage to take a chilto a U.S.-approved doctor to meet the Drequirement.


Impact on children who are adopted internationally by US citizens

          The new TIs are being implemented on a country-by-country basis, and they were implemented in Ethiopia and China on April 1 and July 1, respectively. Once the new TIs are implemented in a country, they apply to children between the ages of 2 and 14 adopted by United States citizens. In 2008, there were a total of 3,852 children adopted from China and 1,666 children adopted from Ethiopia. While the Office of Immigration Statistics does not break down the numbers enough to know exactly how many of those children were age two and over, they do report that 394 children from China and 456 children from Ethiopia were age five and over. They also report that 2,533 of the children adopted from China were age one to four years, with the corresponding number being 643 from Ethiopia. In those two groups, all of the children between ages two and four would have been impacted by the new regulations.6 Furthermore, especially for China, as the rate of non-special-need referrals declines, it is believed that the number of special needs children will increase, which will result in increased numbers of older children being adopted.

          “The new protocols require a series of tests for all immigrants, including adopted children 2 years of age or older (<14). The tests have a likelihood of delaying the issuance of the child’s visa by up to seven days. For certain children, there could be delays varying between eight (8) weeks and twelve (12) months or more, depending on the outcome of the testing.”7

           A key factor here is that the adoption is finalized prior to the beginning of testing. That is, these children who are undergoing the new testing are legally children of United States citizens but will be, in some cases, held in their countries of birth and, therefore, unable to access U.S. medical care even though they are non-contagious and not a threat to the public health. INDENTA second issue is that keeping these children in their countries of birth may result in more time in institutionalized care. These children are often malnourished and developmentally delayed to begin with, and being denied the ability to return to the United States with their new families will only further delay their development.


Medical Issues

          The medical community is clear that children under the age of 12 with the pediatric version of TB are not contagious. Children are only contagious if they have the adult form of TB, and that is determined by a chest x-ray, which can be read in 1-2 days, not only by a sputum culture, which takes 8 weeks. It is so rare for a child to be contagious that, if a child is found with TB, it is incumbent on public health professionals to then determine which adult spread the disease. There is also consensus in the medical community that individuals become non-infectious two weeks after beginning the appropriate antibiotic treatment. As for the concern that children might spread TB to other individuals on the flight home from their birth countries, there are virtually no recorded instances of anyone contracting active TB as a result of in-flight exposure and none from a child.8

          Furthermore, there is little concern that children who are adopted by U.S. citizens will not receive treatment upon entering the United States. Although a potential concern of the CDC for adult immigrants, to apply this standard to internationally adopted children is an extreme application of the standard and potentially harmful to these children and their families. As stated in an editorial in the San Jose Mercury News, “The CDC should exempt children who are adopted abroad by American parents. Any parent who is willing to go to the extraordinary effort and expense of adopting a child from Ethiopia or China is going to be willing to voluntarily test the child for TB and will surely provide any treatment that's needed.”9



          There is no doubt the spread of drug resistant TB is a global health concern and that reducing the spread is a laudable public health goal. However, in the case of the new TB Technical Instructions issued by the CDC, the inclusion of internationally adopted children is unwarranted, a fact supported by a large body of medical evidence. It may be that the CDC in implementing a global policy for immigrant visas never considered the impact the policy would have on internationally adopted children, but this policy is in effect and is detrimental to the physical and emotional well-being of children adopted by Americans.

         The Child Citizenship Act (CCA) of 2000 was enacted to provide automatic citizenship to the internationally adopted children of U.S. citizens. However, under CCA, citizenship does not attach until the child enters the United States. This would be rectified with the passage of the recently introduced Foreign Adopted Children Equality Act (FACE, H. R. 3110 and S.1359). By making internationally adopted children citizens at the time of their adoption, the FACE Act would make the new TIs inapplicable to internationally adopted children. Instead, internationally adopted children would receive the same screenings required of biological children born abroad to American citizens.

          While NCFA supports the passage of the FACE Act, immediate action is required in the interim for children and families such as Harper and her new family. First and foremost, NCFA calls upon the Centers for Disease Control to exempt the population of internationally adopted immigrant children from the 2007 tuberculosis TIs. If this is not possible, then an expedited process 9 Mercury News. (2009, August 11). Editorial: TB threat shouldn’t hold up adoptions from China. Mercury News. Retrieved from must be in place for these children and families. At this point, internationally adopted children and their families are the unintended victims of the TIs. It is incumbent upon the CDC to rectify that situation to allow children to come home with their families and get the medical care they need.

          If the CDC fails to rectify the problem, NCFA, along with numerous other adoption advocates, will call on Congress to consider more expedient legislative fixes including those that remove this population of children from the CDC’s new guidelines. This is not the first time that Congress has had to intervene and correct an ill-advised government regulation. In 1998, Congress amended the Immigration and Nationality Act to exempt internationally adopted children under the age of ten from harmful immunization requirements (P.L. 105-73).

          Whatever the solution, an innocent and vulnerable population of internationally adopted children and their families are depending on the swift action of the U.S. Government to create a process that allows them to come home and begin their new lives in America.

Action Steps

  • • Sign the on-line petition at: 
  • • Write to:  Centers for Disease Control and Prevention  Director Thomas R. Frieden, MD, MPH  1600 Clifton Rd. Atlanta, GA  30333 Urge him to exempt the internationally adopted children of U.S. citizens from the new TB regulations 



  • • Blog of the family’s struggle to bring Harper home:
  • • A copy of NCFA’s letter to Dr. Frieden is available at our website: 
  • • The Washington Post article about Harper and her family is available at:
  • • The Associated Press article about Harper and her family is available at:
  • • Interview with pediatric tuberculosis expert Dr. Jeffrey Starke:
  • • Editorial in San Jose Mercury:



1 World Health Organization. (2006). Tuberculosis factsheets: TB and children. Retrieved August 10, 2009 from   2 Cauvin, H.E. (August 11, 2009). Child’s TB complicates adoption by VA family. Washington Post. Retrieved from    3 CDC Global Migration and Quarantine. (2009). CDC global tuberculosis control activities for U.S. immigration. Atlanta, GA: Author. Retrieved August 10, 2009 from   4 CDC Global Migration and Quarantine. (2009). 2007 Tuberculosis Technical Instructions frequently asked questions. Atlanta, GA: Author. Retrieved August 10, 2009 from   5 Doheny, C. (August 14, 2009). Interview with pediatric tuberculosis expert Dr. Jeffrey Starke. International Adoption Examiner. Retrieved from   6 United States. Department of Homeland Security. (2009). Yearbook of Immigration Statistics: 2008. Washington, D.C.: Author.   7 Joint Council on International Children’s Services. (2009). Summary report: A briefing on the CDC’s TB protocols and their impact on adoption. Alexandria, VA: Author.   8 Averhoff, A., et. al. (2008). WHO publication: Tuberculosis and air travel: Guidelines for prevention and control. Atlanta, GA: National Center for Preparedness, Detection and Control of Infectious Diseases, Centers for Disease Control and Prevention (CDC).    9 Mercury News. (2009, August 11). Editorial: TB threat shouldn’t hold up adoptions from China. Mercury News. Retrieved from

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