Chapter 9Health Considerations for Newly Arrived Immigrants & Refugees
Arrival in the United States: Process, Health Status, & Screening of Refugees & Immigrants
There is great diversity among immigrant populations arriving in the United States each year, with a concomitant wide spectrum of health needs. Some immigrants arrive with infectious diseases of personal or public health significance; others with untreated chronic conditions such as vitamin deficiencies, diabetes, or hypertension; and many with both infectious and chronic disease issues. Two of these groups, refugees and internationally adopted children, have more health information available than other groups, so much of the published screening recommendations is based on studies of these groups.
State health departments are notified by CDC about refugee new arrivals. A secure electronic system, the Electronic Disease Notification System, alerts states of refugee arrivals that have class A conditions (with waiver) and class B conditions. Class A conditions are defined as those that preclude an immigrant or refugee from entering the United States. Class B conditions are defined as physical or mental abnormalities, diseases, or disabilities that are permanent or serious enough to amount to a substantial departure from normal well-being.
Newly arrived refugees are encouraged to receive stateside evaluation and treatment, conducted at state or local health departments, as well as private clinics and community health centers. Ideally, these examinations are done within 3 months of US arrival. Because there is no required nationwide process for postarrival health assessments, the timing and thoroughness of postarrival refugee health evaluations vary from state to state. For nonrefugee immigrants, no formal mechanism or funding source is available for medical screening; therefore, immigrants, with the exception of international adoptees, do not routinely receive any postarrival medical screening services. Many clinicians are unfamiliar with screening recommendations and diseases endemic to immigrants’ countries of origin and are unprepared to deal with language, social, and cultural barriers in caring for new arrivals. In addition, refugees and immigrants often have other demands related to their new environment that may compete with their perception of need for health evaluations and treatment. To address the special health challenges of refugees, the Office of Refugee Resettlement (ORR), Department of Health and Human Services, provides guidance, resources, and oversight for medical assistance, initial medical screening, and physical and mental health technical assistance and consultation for refugees (www.acf.hhs.gov/programs/orr ). CDC, in collaboration with ORR and other partners, has developed guidelines to assist states and clinicians in providing medical screening services to refugees. These guidelines, found at www.cdc.gov/immigrantrefugeehealth/guidelines/refugee-guidelines.html, include screening for malaria, intestinal parasites, and blood lead levels, as well as a general outline for the history and physical examination.
MEDICAL SCREENING FOR NEWLY ARRIVED REFUGEES
After arrival in the United States, it is recommended but not required that all refugees receive medical screening. In addition, this visit provides an opportunity to provide preventive services, such as immunizations and initiation of treatment for latent tuberculosis (TB) and individual counseling (such as nutritional and mental health), and to establish ongoing primary care. Recommendations for this initial medical evaluation should ideally be tailored to the specific population and based on such factors as receipt of predeparture presumptive therapy (malaria and intestinal parasites), ethnicity, and epidemiologic risks in the country of origin, as well as the country or countries of first asylum. Refugees may be able to qualify for the federally funded, state-administered Refugee Medical Assistance program for their medical care needs. Refugees may be eligible for the program for up to 8 months from the date of their arrival and can apply for the program in their state of residence during that time. For more information, clinicians and refugees can contact their state health departments and also access more information through the Office of Refugee Resettlement (US Department of Health and Human Services), which supports this program (www.acf.hhs.gov/programs/orr/programs/cma.htm).
DOMESTIC HEALTH ASSESSMENT
Many refugees and immigrants originate from countries with a high prevalence of tropical and other infectious diseases, which may be a threat to individual or public health. In addition, untreated chronic health conditions are common. Infectious diseases with long latency periods can be particularly challenging, including TB, hepatitis B, and certain intestinal nematodes, such as Schistosoma spp. and Strongyloides stercoralis.
All migrants who are medically screened should have a detailed history and physical examination. Medical screening for new arrivals should include basic components outlined in Box 9-01. Many refugees will not have had age-appropriate cancer screening, such as a Papanicolaou test, mammography, and colon cancer screening, and these needs should be addressed at early follow-up visits. Clinicians should be aware of cancers with a higher prevalence in many immigrant populations, such as cervical, liver, stomach, and nasopharyngeal cancer. HIV testing has recently been removed from requirements for US admission, which has implications for providers seeing patients from higher-prevalence countries. Culturally sensitive counseling regarding HIV testing is critical.
In addition to CDC’s postarrival domestic medical screening guidelines for refugees, other published resources are available to the clinician to obtain expert opinion regarding appropriate medical screening in refugees. Most recently, the Public Health Authority of Canada has produced consensus documents on the evidence base for screening newly arriving refugees to Canada. The Migrant Health Resources section of this chapter includes a list of clinical resources for providers and organizations.
Box 9-01. Recommended components of domestic health assessments
- Review all available records, chest radiograph (ask for overseas records)
- Complete history and physical examination
- Vision and hearing screening
- Dental evaluation
- Mental health screening
- Laboratory testing (hepatitis B for those arriving from countries with prevalence rates more than 2%, hematologic testing, urinalysis, lead, and HIV testing, when clinically appropriate)
- Presumptive treatment of malaria
- Evaluation for intestinal parasites (ova and parasites [2–3 times], serology for schistosomiasis and strongyloidiasis in certain groups)
- Presumptive treatment for schistosomiasis in groups at risk
- Evaluation and update of immunizations as needed
MEDICAL SCREENING FOR INTERNATIONAL ADOPTEES
There are many similarities in health conditions on arrival between international adoptees and refugees. However, an important distinction is that international adoptees frequently enter into households and communities that are naive to many infections common in resource-poor settings. On the other hand, refugees generally remain within their own cultural group for some time after arrival and have limited interactions with the wider community. This distinction is particularly pertinent for conditions that may continue to be infectious for weeks to months after arrival (such as hepatitis A or Giardia). The American Academy of Pediatrics offers guidance for clinicians who will be serving this population after their arrival in the United States in the Red Book, which may be accessed at http://aapredbook.aappublications.org . For more information, see Chapter 7, International Adoption.
Limited health interventions are provided to immigrants and refugees before their entry into the United States. Points of contact during the migration process, such as overseas examination, transit stops (such as quarantine stations), and postarrival medical visits offer opportunities to intervene to improve the health status of the person, as well as to minimize any public health risk.
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- CDC. Final rule removing HIV infection from US immigration screening. Atlanta: CDC; 2010 [updated 2010 Apr 2; cited 2010 Oct 29]. Available from: http://www.cdc.gov/immigrantrefugeehealth/laws-regs/hiv-ban-removal/final-rule.html.
- CDC. Revised vaccination criteria for US immigration. Atlanta: CDC; 2010 [updated January 19, 2010]. Available from: http://www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/fact-sheet.html.
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