Author(s): Jennifer (Jenna) Beeler, Joanna Regan, Tarissa Mitchell, Elizabeth Barnett

Millions of travelers enter the United States every year. The majority are non-immigrants (e.g., short-term visitors, students, and temporary workers), but others are immigrants, refugees, or other migrants. Table 11-16 outlines the various immigrant and non-immigrant arrivals into the United States during fiscal year 2019. Many arriving travelers and migrants will encounter the US health care system during their stay; therefore, at some time during their careers, US health professionals likely will provide care to newly arrived foreign-born patients.

Most newly arrived travelers and migrants do not undergo an official medical examination prior to their travel to the United States, but for others, a medical examination is required by the Immigration and Nationality Act (INA). The INA mandates that all immigrants and refugees undergo a medical screening examination before travel to the United States to identify inadmissible health conditions.

The Centers for Disease Control and Prevention (CDC) develops the guidance for and monitors the quality of the screening medical examinations for people who fall under relevant categories listed in Table 11-16. CDC also provides guidance for additional pretravel public health interventions and post-arrival medical screening for US-bound refugees (described later in this chapter). In contrast, no specific guidelines cover the examination of people who do not hold an immigrant or refugee visa, or people categorized as temporary visitors or undocumented migrants.

Table 11-17 summarizes requirements and recommendations for overseas and post-arrival health examinations and public health interventions for immigrants, refugees, and other migrants. For definitions of immigrants, refugees, and other migrants, and the special categories of medical professionals (i.e., panel physicians, civil surgeons) who see them before and after arrival to the United States, see Box 11-04.

The Pretravel Health Assessment

Immigrants

Overseas Medical Screening Examination

A medical screening examination is mandatory for all immigrant visa applicants. CDC guidelines for this examination, referred to as Technical Instructions. The purpose of the screening examination is to detect inadmissible health conditions, including communicable diseases of public health significance, mental health disorders associated with harmful behaviors, and substance-use or substance-induced disorders. The medical screening process includes a brief physical examination, a mental health evaluation, a review of vaccination records, testing for gonorrhea (by nucleic acid amplification), testing for syphilis (by serology), and tuberculosis (TB) screening.

Chest radiographs are required for all applicants ≥15 years of age. Applicants 2–14 years old from high TB-burden countries (i.e., countries with incidence rates ≥20 cases per 100,000 population as estimated by the World Health Organization) must have an interferon-γ release assay (IGRA); those with a positive IGRA are required to have chest radiographs. Additional acid-fast bacillus smears and sputum cultures are required for anyone whose x-ray is suspicious for TB, has signs or symptoms compatible with TB disease, or has known HIV infection. For anyone diagnosed with TB disease, CDC’s Technical Instructions require Mycobacterium tuberculosis culture, drug-susceptibility testing, and directly observed TB therapy through the end of treatment before immigration is permitted. Pre-immigration treatment also is required for certain other inadmissible conditions, including gonorrhea, syphilis, and leprosy (Hansen’s disease).

Classification of Medical Conditions

Medical conditions of public health significance are categorized as either Class A or Class B. Class A, or inadmissible, conditions preclude entry into the United States. An immigrant with a Class A condition might be issued a visa after the condition has been treated or after the Department of Homeland Security US Citizenship and Immigration Services (USCIS) approves a waiver of visa ineligibility. Class B conditions indicate a departure from normal well-being, and post-arrival follow-up with a health care provider is recommended.

Pre-Arrival Vaccinations

Before immigration to the United States, immigrant visa applicants are required to receive any age-appropriate, Advisory Committee on Immunization Practices (ACIP)–recommended vaccines that are available in their country of residence. Panel physicians administer vaccines according to CDC’s Vaccination Technical Instructions for Panel Physicians and Civil Surgeons. These instructions are based on ACIP recommendations, with some modifications for immigrants.

Health Notifications at the Time of Arrival

CDC informs state or local health departments of all arriving immigrants who have received USCIS waivers for Class A (notifiable) conditions, as well as those who have Class B conditions for which follow-up is recommended. Panel physicians document this information in eMedical, an electronic health processing system used to record and transmit most immigrants’ medical examination information. State and local health departments performing medical follow-up are asked to report their findings back to CDC, along with information about any other serious conditions of public health concern identified. This reporting helps CDC track epidemiologic patterns of disease among these populations and enables monitoring of the quality of overseas medical examinations.

Internationally Adopted Children

Overseas Medical Screening Examination

Children adopted internationally by parents residing in the United States (see Sec. 7, Ch. 5, International Adoption) are considered a subcategory of immigrants. As such, an overseas medical screening examination is mandatory, as described in the Technical Instructions.

Vaccinations

Parents adopting children internationally can request an immunization waiver for children <10 years of age by agreeing to begin immunizations ≤30 days of arrival in the United States; they should, however, be made aware of the potential health risks associated with delaying the immunization process, even by a month. Vaccinating children before their arrival to the United States reduces the child’s risk of contracting and importing diseases of public health concern, such as measles, which was reported in unvaccinated children adopted from China in 2004, 2006, and 2013. Of note, as of October 2021, some internationally adopted children (depending on age and country of departure) are required to receive an approved coronavirus disease 2019 (COVID-19) vaccine prior to leaving for the United States.

Health Notifications at the Time of Arrival

The guidance applying to immigrants regarding health notifications at the time of arrival also applies to internationally adopted children.

US-Bound Refugees

Refugees come to the United States through the US Refugee Admissions Program (USRAP). Whereas immigrants travel to the United States individually or with their families, refugees resettle in groups, on a predetermined schedule, with a 3- to 6-month window between the required medical screening examination and departure.

Overseas Medical Screening Examination

Like immigrants, refugees resettling to the United States are required to undergo an overseas medical screening examination with a panel physician. The content and Technical Instructions for this examination are identical to those for immigrants.

Pre-Arrival Vaccinations

Unlike immigrants, refugees bound for the United States are not statutorily required to be vaccinated, leaving them vulnerable to vaccine-preventable diseases during the migration process. In response, a voluntary global immunization program for US-bound refugees was implemented in 2012 as a public health intervention to protect the health of refugees and US health security.

Through this program, overseas panel sites offer refugees bound for the United States most ACIP-recommended vaccines (≤2 doses per vaccine) depending on age, documented immunization history or records, and vaccine availability. Pre-vaccination testing for Hepatitis B virus infection using hepatitis B surface antigen (HBsAg) is also offered where available. The vaccine schedule for US-bound refugees is based on CDC guidance.

Resettled refugees applying for permanent residence in the United States ≥1 year after their arrival are not required to undergo a repeat medical examination; instead, they must demonstrate proof of receipt of age-appropriate, ACIP- recommended vaccinations to a US civil surgeon during the adjustment-of-status process. In some states, refugees’ overseas vaccination records are transferred electronically to state immunization information systems.

Other Overseas Public Health Interventions

The 3- to 6-month window between the predeparture medical screening examination and departure affords an opportunity to implement additional public health interventions aimed at improving the health of US-bound refugees and ensuring US health security.

Parasitic Infections: Presumptive Treatment

Many refugees resettle to the United States from places with high prevalence of region-specific parasites and other neglected tropical diseases. Depending on regional epidemiology, panel physicians offer refugees presumptive oral therapy to treat malaria (artemether/lumefantrine), intestinal roundworms (albendazole), schistosomiasis (praziquantel), and Strongyloides stercoralis (ivermectin) days before the refugee departs for the United States. Details on each of these diseases and their treatment can be found in Section 5, Travel-Associated Infections & Diseases.

Data from 2 large evaluations indicate that this strategy dramatically decreases the prevalence of soil-transmitted helminth infections among US-bound refugees. See further details and regional treatment recommendations.

Fitness to Fly

During the predeparture screening examination, panel physicians might identify refugees who have chronic medical conditions (e.g., cardiac disease, moderate or severe malnutrition, sickle cell disease). While these conditions do not pose a public health risk—and therefore do not make the refugee inadmissible—they can result in decompensation during air travel. CDC, in close collaboration with partners (e.g., the International Organization for Migration), has developed specific protocols to identify, manage, and stabilize refugees with various chronic medical conditions before their departure, with the goal of improving travel fitness.

Health Notifications at the Time of Arrival

The guidance that applies to immigrants regarding health notifications at the time of arrival also applies to refugees bound for the United States.

New-Arrival Health Assessment

In addition to screening for diseases, consider the new-arrival health assessment as an opportunity to deliver needed health care, preventive health services (e.g., vaccines), and individual counseling. Taken together, these activities serve to establish a medical “home” where people newly arrived in the United States can receive ongoing primary care and an orientation to the US health care system.

Challenges to providing comprehensive health services to people newly arrived in the United States include a general lack of health care provider familiarity with diseases endemic to the migrant’s country of origin; lack of access to trained interpreters and translators; insufficient knowledge of social and cultural beliefs and practices of immigrants and migrants; and uncertainty about which elements of the overseas pretravel assessments (screening tests, vaccinations) were completed or when. In addition, immigrants and refugees often have other resettlement priorities (e.g., attending English classes or school, locating permanent housing and work) that can take precedence over accessing health care services.

Medical Screening

Ideally, all immigrants, refugees, and other migrants should receive screening for migration-associated illnesses, communicable and noncommunicable diseases, and any age-appropriate screening. Screening for infectious diseases of long latency, especially hepatitis B, HIV, and TB, is crucial for almost all groups; at each subsequent medical encounter, ensure completeness of screening.

Screening each person for diseases specific to their country of origin, migration route, and individual epidemiologic risk also is important. The Minnesota Center for Excellence in Refugee Health has developed an interactive clinical assessment tool, Clinical Assessment for Refugees (CareRef), based on CDC’s Domestic Screening Guidance for Newly Arrived Refugees. CareRef customizes screening guidance for refugees based on their age, sex, and country of origin. No standard guidelines cover other migrant groups, but the following sections provide an approach, with modified guidance based on experience with refugees and internationally adopted children.

Immigrants & Other Nonrefugee Migrants

Immigrants and other nonrefugee migrants enter the country in different ways, and access health care at different points and with providers who have varying levels of expertise in migrant medicine. Nonetheless, they can derive important benefits from their introduction to the US health care system and participation in a comprehensive new-arrival health assessment. Unlike refugees, who are eligible to receive Medicaid funding or Refugee Medical Assistance (described later in this chapter), immigrants and other nonrefugee migrants do not have access to funding sources to cover the costs of a standard comprehensive health assessment.

Initial Assessment

Initial assessment should include taking a medical and family history and reviewing all medications and treatments a person received before and during migration. Most experts agree that testing for hepatitis B, HIV, and TB should be performed for all new immigrants and other nonrefugee migrants who do not have documentation of post-arrival screening. Repeat screening for these infections if risk is ongoing.

For most people, a complete blood count with differential facilitates finding evidence of a hemoglobinopathy or diagnosing anemia or eosinophilia. Urinalysis, although no longer routinely recommended for screening of asymptomatic people, might be appropriate if the person has symptoms of renal disease or signs or symptoms of a urinary tract infection. A basic metabolic panel might be indicated, especially for people of appropriate age or with evidence of conditions such as diabetes or renal disease.

Follow age- and risk-based guidelines provided by the United States Preventive Services Task Force (USPSTF) for the general US population. Consider diagnostic testing of people who present with symptoms consistent with a particular parasite endemic to their country of origin (e.g., malaria, intestinal parasites). Consider screening for sexually transmitted or congenital infections (e.g., chlamydia, gonorrhea, hepatitis C, HIV, syphilis) beyond what is recommended for the US general population if the person’s migration history places them at substantial risk. See Table 11-18 and Table 11-19 for a summary of screening tests to consider for new-arrival health assessments.

Vaccinations

Many people arrive to the United States without having received predeparture vaccinations. Review all immunization records, laboratory evidence of immunity, and history of vaccine-preventable diseases. Immunization records provided by patients can be considered valid if, at a minimum, the month and year of the vaccine are documented, and the vaccine was given at an appropriate age according to the US vaccination schedule.

Provide age-appropriate immunizations during an initial encounter with a newly arrived immigrant or migrant, and complete immunization series according to ACIP schedules during subsequent encounters . A vaccine series does not need to be restarted if documentation of prior doses is available.

Mental Health Screening

Mental health screening includes gathering information about coping strategies and support systems, and permits appropriate and timely referral to resources if necessary.

Future Travel

Immigrants and other migrants are likely to travel back to their country of origin and might be at risk for travel-associated infectious diseases (see Sec. 9, Ch. 9, Visiting Friends & Relatives: VFR Travel). Ask these patients about future travel plans to allow time to plan appropriate travel vaccines, medications, and advice.

Internationally Adopted Children

See Sec. 7, Ch. 5, International Adoption, for detailed guidance regarding the post-arrival health assessment of international adoptees, and preparation for the family, other household members, and close contacts. In addition, the Red Book: Report of the Committee on Infectious Diseases, published by the American Academy of Pediatrics (AAP), offers guidance to pediatricians and other clinicians who will serve this population after their arrival to the United States. Red Book is free for AAP members.

Refugees

CDC, in collaboration with the US Department of Health and Human Services Administration for Children and Families’ Office of Refugee Resettlement (ORR), clinical and subject matter experts outside CDC, and representatives of the Association of Refugee Health Coordinators (ARHC), has developed evidence-based guidance for domestic refugee medical screening. See comprehensive guidance outlining the screening components and recommended testing. See also population-specific health profiles are available for some refugee populations (Bhutanese, Burmese, Central American minors, Congolese, Iraqi, Somali, and Syrian).

A goal of the domestic refugee health assessment is to arrange and coordinate ongoing primary care. Many refugees have not received age-appropriate screening for chronic conditions (e.g., cancer, diabetes, heart disease; dental, hearing, or vision problems; mental health problems). These screening tests are best introduced in a culturally sensitive way and tailored to the health literacy of the individual patient. Integrating behavioral health screening and services into the domestic health assessment and subsequent primary care visits provides opportunities to screen for acute risk factors and to triage refugees in need of urgent mental health treatment.

Refugees might qualify for state Medicaid programs that cover medical screening and any needed ongoing medical care. Refugees determined ineligible for Medicaid are eligible for Refugee Medical Assistance in many states, which provides for their medical needs for ≤8 months from their date of arrival. For more information, clinicians and refugees can contact their state health department and can access more information through ORR.

Other published resources available to clinicians include consensus documents on evidence-based screening for newly arriving refugees to Canada, provided by the Canadian Collaboration for Immigrant and Refugee Health.