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1. Purpose 1.1. This standard mandates the visa screening applicant case mix, the screening tests and the visa screening process specifications in the Emirate of Abu Dhabi to ensure quality, reliability, consistency and integrity of the screening services. 2. Scope 2.1. This Standard applies to HAAD licensed healthcare providers approved under contract to provide visa screening services. 3. Duties on Healthcare Providers 3.1. All licensed healthcare providers (facilities and healthcare professionals) involved in providing visa screening services must:

3.1.1. Comply with the requirements and adhere to the processes as specified in this Standard;

3.1.2. Obtain prior consent from applicants for visa screening (Appendix 1), including for consent to be screened for pregnancy, TB treatment and follow up if required;

3.1.3. Educate patients on visa screening tests (Appendix 2) and related health topics in a culturally appropriate manner and an in an easy-to-understand language;

3.1.4. Report and submit complete and accurate data for all individual screening observations to HAAD via the Visa Screening reporting system in accordance with the specified format and timeframe, and in compliance with the HAAD Standard for reporting Public Health Statistics, HAAD Data Standards and Procedures (available from: www.haad.ae/datadictionary) and as set out in the HAAD Regulator Policy Manual, Chapter VI, Data Management. Reported data must include all clinical findings, radiologists findings, blood tests observations and sputum smear results, including negative, reactive and repeatedly reactive test results;

3.1.5. Comply and cooperate with HAAD requests for information on case investigations and follow up, as and when requested by HAAD authorized personnel;

Health Authority Abu Dhabi

Document Title: HAAD Standard for Visa Screening in the Emirate of Abu Dhabi

Document Ref. Number: HAAD/PHR/CD/VS/1.5 Version 1.5

Approval Date: 23/01/2014 Effective

Date: 27/01/2014

Last Reviewed: February 2011 Next Review: January 2016

Revision History

February 2011 Version 1.4

March 2010 Version 1.3

November 2009 Version 1.2

Document Owner: Communicable Diseases Department

Applies to: Visa Screening Providers

Classification: Public

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3.1.6. Comply with HAAD policies and standards on health information retention and disposal and managing patient medical records requirements, including develop effective recording systems, maintain patient records, and maintain confidentiality, privacy and security of patient information;

3.1.7. Maintain, and make available for HAAD audit, all records and files pertaining to the visa screening services, including but not limited to policies and procedures and patient records; and

3.1.8. Comply and cooperate with the HAAD authorized auditors, as required for inspections and audits by HAAD.

4. HAAD Role 4.1. Establish the requirements for Visa Screening Program in the Emirate of Abu Dhabi, including the:

4.1.1. Core screening tests as defined by the Federal Law no. (27) For the year 1981, and its subsequent amendments; and

4.1.2. Additional screening tests that may be determined and mandated by HAAD, from time to time;

4.2. Develop and mandate Standards to ensure the quality and integrity of screening services in support of the Visa Screening Program in the Emirate of Abu Dhabi;

4.3. Provide guidance and training for healthcare providers involved in the provision of Visa Screening services to support the effective implementation of the standards and services; 4.4. Oversee and manage the Visa Screening process through analysis, review and assessment of data submitted by Visa Screening service providers; 4.5. Audit and inspect Visa Screening service providers;

4.6. Control and authorize the issuance of fitness certificates;

4.7. Perform contact identification, tracing and referral for investigation, vaccination, prophylaxis and follow up if applicable. 5. Standard 1 Applicants Case Mix and Identification

5.1 All visa applicants wishing to enter Abu Dhabi for residency purposes, including for working, residence or study, are required to undertake Visa Screening. To do so, applicants must either have a valid residence visa (renewal application) or entry permit for work, residency or study issued in the Emirate of Abu Dhabi;

5.2 All applicants for entry permit for periodical short business or work missions must also be screened;

5.3 Applicants for a visit visa are excluded from visa screening requirements;

5.4 All residency visa applicants are required to conduct the Visa Screening tests in a HAAD approved visa screening healthcare facility, except in the following cases:

5.4.1. Visa screening applicant admitted to a public or private Hospital and unable to attend to the screening providers facility, in which case the blood tests results and Chest X-ray (CXR) film may be provided by the admitting hospital with verified documents, and must be entered into the HAAD visa screening reporting system with indication of the investigating source and review of the CXR film by the visa screening provider radiologists;

5.4.2. Visa screening applicants who are immobile, but not admitted to a hospital and unable to attend to the screening providers facility; such applicants are required to provide a medical report in support of their status. A special home care team may be arranged to facilitate the screening investigations required for the fitness certificate and collection of blood samples. The CXR may be replaced with IGRA test as mentioned in Appendix 3.

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5.4.3. Where a visa applicant is identified to be at risk from repeat exposures to CXR, the visa screening provider is required to follow the directions provided in Appendix 3;

5.4.4. Where either 5.4.1 or 5.4.2 applies, the approved visa screening provider must retain copies of all external investigation cases on their records;

5.5 Approved visa screening providers must ensure that applicants present their original passport and valid residence visa (for residents seeking to renew their residency), or entry permit for work, residence or study, and where applicable, the sponsors changed details document from the Ministry of Labor. A copy of these documents must also be submitted as part of the screening process (Appendix 4); 5.5.1 For all applicants who present a valid work or residency visa issued from other emirates, a valid health card or a valid health insurance card is required as part of visa screening requirements.

5.6 Healthcare providers approved to provide visa screening services must ensure that applicants undergoing visa screening are: 5.6.1. Registered as either new for applicants with an entry permit or renew for applicants with a valid residence visa, and 5.6.2 Uniquely identified using a Unified Number with all of of the following: Name, Date of Birth and Nationality.

6. Standard 2 Home country screening The United Arab Emirates Home Screening Program mandates the pre-departure testing of expatriates from Indonesia, Sri Lanka and Ethiopia who intend to apply for UAE visa.

6.1. All applicants coming from these countries have to complete the screening tests in their respective home country at specific healthcare centres certified by Gulf Cooperation Council (GCC).

6.2. All applicants will be retested upon their arrival to the UAE and they are required to submit the following documents: Original and copy of passport, Original and copy of entry permit, Original or copy of health certificate from the GCC Accredited Medical Clinics

Association (GAMCA) approved centres in their respective countries; 6.3. All visa screening providers must report to HAAD the home screening data form on a

monthly basis (Appendix 5); 6.4. Unfit cases with fit GAMCA certificates must be reported to HAAD with a Copy of the

GAMCA certificate, passport and entry permit; 6.5. HAAD will report to the MOH the home screening data and will notify them about the

unfit cases. 7. Standard 3 Visa Screening Tests according to occupational categories and visa status 7.1. Visa screening tests are classified into occupational categories determined by the federal Law. Approved Visa screening providers must perform the batch of screening tests specified for each occupational group in accordance with the visa screening process as described below at Section 7.2 and 7.3 of this Standard.

Group A: includes all occupational categories except the ones mentioned in group Bi & Bii;

Group Bi: domestic workers including housemaids, servants, nannies and private drivers;

Group Bii: barbers, beauticians and food handlers;

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7.2 PART I: New visa applicants

7.2.1 Screening for new visa applicants Category A includes screening for: leprosy

pulmonary tuberculosis HIV

7.2.2 Screening for new visa applicants in Category Bi includes screening for Leprosy Pulmonary tuberculosis HIV Hepatitis B Syphilis

Pregnancy test for females Vaccination for hepatitis B

7.2.3 Screening for new visa applicants Category Bii includes screening for: leprosy, pulmonary tuberculosis, HIV Hepatitis syphilis

Vaccination for hepatitis B

7.3 PART II: Renew visa applicants

7.3.1 Visa screening service: Screening for all Renewal visa applicants Category A includes screening for :

leprosy pulmonary tuberculosis HIV

7.3.2 Screening for Renewal visa applicants Category Bi includes screening for: leprosy pulmonary tuberculosis HIV hepatitis B syphilis Pregnancy test for females Hepatitis B vaccination status (verify the doses taken).

7.3.3 Screening for Renewal visa applicants Category Bii includes screening for: leprosy pulmonary tuberculosis HIV hepatitis B syphilis Hepatitis B vaccination status (verify the doses taken).

8. Standard 4 Visa Screening Process Specifications 8.1 The visa screening process comprises of the following components; noting that the screening

tests differ from one occupational visa category to another (refer to section 7.2 & 7.3): Physical examination Blood test for HIV, hepatitis B, syphilis

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Pregnancy test Chest X- ray Confirmation Treatment

Referral Follow up of positive cases identified according to Standard 6

Physical examination to detect leprosy or any notifiable communicable disease must fulfil the following requirements:

8.2 The process follows what is outlined in Physical examination at Appendix 6; 8.3 The initial screening can be done by a physician or a trained nurse using a defined checklist; 8.4 The facility must have a written procedure for how to investigate possible cases of leprosy; 8.5 The procedure is available and known by the facilitys medical staff investigating the

applicants screening tests; The procedure follows Essentials of Leprosy Diagnosis & Treatment Available from: http://english.aifo.it/leprosy/courses/leprosy1/lep21.htm

8.6 If the case is suspected of leprosy or any other notifiable communicable disease, the case must be referred for further evaluation by a licensed physician within the same visit;

8.7 Any applicant with skin patches or past history of leprosy must be assessed for the risk of likelihood to acquire or be immune to an infection by taking a comprehensive medical history including asking questions and documentation the findings concerning past infection and/or diagnosis , time period lapsed since symptoms, any treatment received and any other related health issues, among other questions;

8.8 Testing of skin sensation is part of the investigation of suspected cases of leprosy; 8.9 Suspected cases of leprosy are referred to a dermatologist for confirmation; 8.10 Where cases of TB (Suspicion of Extra pulmonary TB) or of notifiable communicable disease

other than TB are suspected during the leprosy physical examination, they must be notified to HAAD in accordance with the HAAD Standards for Reporting Public Health Statistics, and referred to an appropriately qualified HAAD licensed healthcare professional for diagnosis and treatment.

Blood tests to detect HIV, Hepatitis B and Syphilis

8.11 The process of screening for HIV, Hepatitis B and syphilis follows what is outlined in the

process chart at appendix 7; 8.12 The blood collection, storage and transportation must be in accordance with the HAAD

Clinical Laboratory Standards; 8.13 Reactive screening test will need a second sample for confirmation to be conducted

within two weeks of the first sample (standard 6); 8.14 If initial test is reactive and patient didnt show up to provide a second sample upon being

contacted by the provider, then the confirmation may be carried out on the first sample

Chest X-ray Screening to detect pulmonary tuberculosis using digital Chest X-ray must fulfil the following requirements

8.15 The process follows what is outlined at appendix 8 for CXR - Screening for pulmonary tuberculosis;

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8.16 All individuals must be considered for screening using digital CXR. Any exclusion must follow HAAD and UAE regulations, as provided below, and must be documented with supportive evidence: Individuals below 18 years of age are excluded;

The CXR must not be performed for pregnant women whether the pregnancy is obvious, or if a pregnancy test is positive (qualitative detection of gonadotropin, chorionic [hCG] in blood or urine;

8.17 All pregnant applicants must be informed verbally and/or via posted signs at the facility in relevant languages that CXR will be postponed until two months after the expected date of delivery. Where postponement occurs , the visa screening provider must ensure that:

Excluded women are given an appointment for a CXR at two months after the expected date of delivery and it must be documented in the consent form. The visa screening provider must be arranged for the visa applicant and the sponsor;

The sponsor must be informed about the visa applicant pregnancy status and must sign the consent form to release the certificate (refer to Appendix 9);

8.18 The visa screening provider must establish a process to monitor, recall and track deferred CXR appointments and must report to HAAD- Communicable Diseases department on all

8.19 No n attenders cases within two weeks from the date of the re-scheduled appointment; 8.20 Digital CXR, DICOM-7 compliant PACS system, and T2 Internet connection must be used; 8.21 HAAD Hospital Standards for Facility and for Staff Safety must be followed, 8.22 All CXR images must be evaluated and documented by a HAAD licensed digital CXR

radiologist following HAAD visa screening for pulmonary tuberculosis. The reading and reporting Format must be in accordance with HAAD recognized international practices, such as that noted in http://www.cic.gc.ca/english/resources/publications/dmp-handbook/index.asp#chap4.9 (chest X-ray requisition report),

8.23 The HAAD format and forms specified in Appendix 10 must be used for interpretation and reporting of all X-ray images. The digital CXR must only be presented to the reader with the patients age and gender. Other identifiers such as new or renewal of visa, serial number, nationality, name and 1st,2nd and 3rd radiologist reading must not be visible to the radiologists.

8.24 All images evaluated as Abnormal (Not PTB, Old PTB, or Suspicion of Active PTB, Extra pulmonary PTB) by the 1st reader, must be evaluated by a 2nd reader and 3rd reader (Appendix11). The 2nd reader must not be informed of the documented findings or the Final evaluation of the 1st reader. The same requirement applies to the third reader. The CXR must be read and entered by each radiologist independently and findings must not be discussed between readers;

8.25 To measure variability and to increase sensitivity, at least 3% of all CXR results evaluated as negative and 3% of CXR with abnormal findings are evaluated blindly by another radiologist; where discrepancies are identified, then further evaluation is required by a 3rd radiologist. A report must be sent to HAAD (cdd@haad.ae) on quarterly basis;

8.26 All results from Visa Screening CXR must be processed within 24 hours of an applicants attendance at a clinic;

8.27 All initially negative CXR readings must be reported via the HAAD electronic system within 24 hours;

8.28 All excluded CXR tests postponed due to pregnancy must be reported via the HAAD electronic system within 24 hours of performing the test;

8.29 All readings requiring a second reading must be reported via the HAAD electronic system within 24 hours from the first reading, and the third reading must be reported within 48 hours of that reported for the first radiologist;

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8.30 The Rapid TB PCR and TB culture must be performed in accordance to best practice for TB diagnostics and laboratory strengthening (available from: http://www.who.int/tb/laboratory/en/)

8.31 Pregnancy test must be performed for all female new and renew residence visa applicants Category Bi and the test results must be documented. The process must follow that as outlined at Appendix 12;

8.32 Sputum collection for detection of Mycobacterium tuberculosis must comply with the following requirements:

8.3.2.1 Clinical and Laboratory Standards Institute. Laboratory Detection and Identification of Mycobacteria CLSI M48; 8.3.2.2 All procedures are planned to minimize risk of spread of infection and for optimal retrieval of Mycobacterium tuberculosis when present, following the CDC US Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings, 2005 (Available from Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm)

8.3.3 Sputum samples must be collected and investigated with Rapid TB PCR for all suspected PTB cases and culture must be conducted for negative TB PCR cases, as outlined in Appendix 13; 8.3.4 A sputum microscopy will be done for all positive TB PCR to determine the infectivity of

the patient and for the in charge physician to decide the need for admission and isolation; 8.3.5 The sputum sample must be collected within 3 working days after the CXR evaluation for

cases reported as Suspicion of PTB; the applicant or sponsor must be contacted to arrange for this;

8.3.6 All activities to contact and schedule the applicant for sputum collection must be documented in accordance with Appendix 14 (call for investigation);

8.3.7 The visa screening provider must report to HAAD if the applicant failed to continue the follow up investigation for more than 2 weeks after a case has been registered as TB suspected;

8.3.8 Sputum must be collected in a sputum induction booth or in an Airborne Infection Isolation room under supervision of a nurse or physician. A minimum volume of 3 mL sputum must be collected;

8.3.9 Sputum production is induced by inhalation of an aerosol of warm, hypertonic saline; when needed, sputum samples are stored refrigerated and transported to the laboratory so that the risk for spread of infection is minimized and for optimal retrieval of Mycobacterium tuberculosis. 9. Standard 5 Follow up of Positive cases detected through visa screening

A. Follow up of pulmonary tuberculosis cases

9.1 HAAD-Communicable Diseases officers will:

9.1.1 Send a feedback to the Visa Screening Provider with the final recommended action;

9.1.2 Initiate contact tracing if required and inform the infectious diseases clinic for contact investigations;

9.1.3 If the case is unfit, deportation procedures are managed by HAAD- Communicable Diseases Department (CDD) in coordination with the sponsor and Ministry of Interior;

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9.1.4 Further communication of data to MOH or other government entities will be arranged by HAAD-CDD.

9.1.5 Details of final Actions of visa screening are listed at Appendix 15 with the definition of the role of HAAD CDD and visa screening provider (VSP);

9.2 Visa Screening Provider (VSP) must: 9.2.1 Perform screening investigations and follow HAAD Visa screening standards; 9.2.2 Report any suspected CXR to HAAD- CDD by filling the CXR Report of

Tuberculosis for visa screening (Appendix 10) 9.2.3 Send results of investigations of suspected cases via electronic communication

with HAAD IT system consequently according to the time frame recommended by HAAD Standards for each test;

9.2.4 Call the patient for investigations, with the requirement that the first sputum sample must be collected within 3 working days after CXR evaluation. The patient and his/her sponsor must be given the relevant and appropriate education about the patients status and infection control measures that must be taken until the results are finalized (Appendix 16);

9.2.5 Providers must ensure that they complete the process within the maximum interval for investigations, which is two weeks from the first radiology report;

9.2.6 During this period, the applicant may complete remaining screening activities including physical examination, HIV, Hepatitis B, Hepatitis C;

9.2.7 The Results of the Rapid TB PCR, TB culture must be sent to HAAD within 24 working hours for further evaluation of the process;

9.2.8 If the sputum AFB results are positive (in accordance with the HAAD DOT Standard found online at (www.haad.ae), the VSP has to arrange immediate admission and further management of the cases;

9.2.9 The VSP will receive the final action from HAAD and will act accordingly; actions may be: on issue of certificate, follow up of the patient, treatment, or referral to hospitals;

9.2.10 Keep registry of all patients with follow up, issue the certificate and schedule a follow up visits after 3 months;

9.2.11 In the follow up visits, CXR must be performed and compared with previous CXR films to detect any changes;

9.2.12 If there is no change in the CXR films, the patient is reassured and given appointment every 6 months for the next 2 years. If there is change in the CXR or the patient is symptomatic, then further investigations are required to rule out active PTB;

9.2.13 If the patient does not attend the follow up visits, VSP must call and ensure rescheduling of another visit and complete the call for investigation form (Appendix 14);

9.2.14 Reporting of incompliance to the follow up visits is required if the patient does not attend for 2 consecutive visits and HAAD-CDD must be informed.

9.2.15 Monthly reporting of follow up of Patients of inactive PTB is required by completing the Template for follow up visits;

9.2.16 Renewal applicants with old pulmonary tuberculosis will be given the certificates only if the patient and sponsor have signed the consent forms and have agreed to comply with DOTs Program (Appendix17);

9.2.17 Educate the patient and sponsor about the risk of transmission and the measures that need to be taken to prevent the infection transmission until the confirmation is complete.

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B. Follow up of positive cases of HIV, or Hepatitis B cases detected during Visa Screening process

HAAD- CDD will:

9.2.18 Send a feedback to Visa Screening Provider with the final action; 9.2.19 Initiate contact tracing and inform the infectious diseases clinic for contact

investigations; 9.2.20 Review the case according to the laws and policies of deportation and decide

on the subsequent action; 9.2.21 Deportation procedures are managed by HAAD-CDD, and coordination

between the sponsor and Ministry of Interior is arranged; 9.2.22 Evaluate the process on monthly basis.

9.3 Visa Screening Provider must:

9.3.1 Perform screening investigations and follow HAAD Visa screening standards; 9.3.2 Call the patient for 2nd blood sample if the initial sample is reactive; 9.3.3 Collect the second sample and perform the confirmatory test; 9.3.4 Submit the confirmation results to HAAD IT system; 9.3.5 Admit confirmed positive HIV cases to the isolation ward; 9.3.6 If the applicants HIV confirmation results are indeterminate, a follow up visit is

arranged after 1 month and 3 months (from the first test at application) to repeat the confirmation tests;

9.3.7 If the confirmation results of HIV test are repeatedly indeterminate after three months, HAAD will direct to issue the certificate and the VSP will arrange follow up visits after 6 months(from the first test at application) to repeat the western blot test.

C. Follow up of positive cases of Syphilis detected during Visa Screening process

HAAD- CDD will:

9.3.8 Send a feedback to Visa Screening Provider with the final recommended action;

9.3.9 Initiate contact tracing and inform the infectious diseases clinic for contact investigations;

9.3.10 Evaluation and monitoring of Syphilis cases detected through visa screening;

9.4 Visa Screening Provider must: 9.4.1 Perform screening investigations and follow HAAD Visa screening standards; 9.4.2 Call the patient for 2nd blood sample if the initial sample is reactive; 9.4.3 Collect the second sample and perform the confirmatory test; 9.4.4 Submit the confirmation results to HAAD IT system; 9.4.5 Ensure that the patient is treated either in the same healthcare facility or refer

him/her to another for treatment. 9.4.6 Inform the sponsor of the current status of the applicant and the need of

treatment and follow up, and request that he/she signs a consent form after providing the relevant information and education (appendix 18);

9.4.7 Arrange follow up visits after 3 months and 6 months to review the patients status.

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10. Standard 6 Requirements for Laboratory Services 10.1. All laboratory services provided in support of the visa screening process must be conducted in accordance with the HAAD Clinical Laboratory Standards available from: http://www.haad.ae/HAAD/LinkClick.aspx?fileticket=x0qHzbClMj8%3d&tabid=82 11. Standard 7 Use of Identifiers 11.1 Applicants must be checked for previous visa screening encounters. The unique identifiers

of each applicant are sent to HAAD via web portal; 11.2 For new applicants if there is an existing record of a positive or pending result the system

will generate action 11 and must be temporarily stopped; 11.3 For renewal visa applicants, the unique identifier must be used to check if there is an

existing record of a positive or pending result; the system will generate action 11 and must be temporarily stopped.

11.4 Any visa screening application that has action 11 is handled and reviewed by HAAD and the final action will be based on preexisting information in the database.

12. Standard 8 Vaccination 12.1 Applicants eligible for Hepatitis B vaccination include Category Bi and Category Bii, and

any other Category of professions nominated by HAAD from time to time, and with no contraindications and in line with HAAD vaccine standards, are to be vaccinated;

12.2 The vaccination process must follow that as outlined at Appendix 19;

12.3 Each dose is given with 1.0 mL vaccine as an intramuscular injection;

12.4 The first hepatitis B vaccine dose is given at the first visit for an application for a New Visa. The second hepatitis B vaccine dose is given one month after the first dose. The third hepatitis B vaccine dose is given six months after the first dose;

12.5 The visa screening provider is required to arrange an appointment for the second and third vaccination;

12.6 The visa screening provider will be responsible for further contacts with the applicant and/or sponsor if the applicant has not returned within 2 months for the second vaccination or within 8 months for the third vaccination;

12.7 Proof of vaccination will be required on visa renewal and a penalty of 500 AED will be paid by the applicant for non-compliance.

13. Standard 9 Reporting and sharing reports 13.1 All visa screening providers must conduct a satisfaction survey for each center at least

biannually and report the result to HAAD communicable diseases department; reports must represent the screening population

13.2 All visa screening providers must report the visa screening Key Performance Indicators (KPIs) on quarterly basis to HAAD Communicable Diseases Department (Appendix 20);

13.3 All visa screening providers must report cases of fraud or manipulation noticed from applicants or if fraud is committed by their employees.