Chapter 9 Health Considerations For Newly Arrived Immigrants & Refugees
Arrival in the United States: Health Status & Screening of Refugees, Immigrants, & International Adoptees
There is great diversity among immigrant and refugee populations arriving in the United States each year, with a concomitant wide spectrum of health needs. Some immigrants and refugees 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.
Although an overseas medical examination is mandatory for all immigrants and refugees before admission to the United States, the purpose of this examination is primarily to identify applicants with inadmissible health-related conditions for the Department of State and US Citizenship and Immigration Services (for more information, see the previous section in this chapter, Before Arrival in the United States: The Overseas Medical Examination). Medical screening after arrival in the United States is recommended but not required for all refugees and international adoptees (a category of immigrants). This postarrival screening is a more comprehensive examination that provides not only an opportunity to screen for communicable and noncommunicable diseases, but also to provide preventive services, including immunizations and initiation of treatment for latent tuberculosis, individual counseling (such as nutritional and mental health), and an opportunity to establish ongoing primary care. Immigrants with medical conditions requiring follow-up (class B conditions) are also recommended to be evaluated after their arrival; however, these evaluations are targeted for particular conditions such as tuberculosis. Ideally, all these evaluations should be done within 30 days of US arrival.
Postarrival medical screenings are often conducted at state or local health departments, as well as private clinics and community health centers. Many clinicians are unfamiliar with screening recommendations and diseases endemic to immigrants’ countries of origin and may feel unprepared to deal with medical issues affecting these populations. In addition, clinicians and health systems are frequently unprepared to cope with language, social, and cultural barriers in caring for new arrivals. Further, refugees and immigrants often have other priorities related to their new environment, such as English classes, schooling, housing, and work, that take precedence over accessing health care services.
Refugees and internationally adopted children have a more formal, organized resettlement process and, as a result, have more health information available than other groups. Therefore, data and recommendations have largely focused on these populations. This section outlines the recommended components of the postarrival health assessment, as well as available resources for refugees, immigrants, and internationally adopted children after arrival.
MEDICAL SCREENING FOR NEWLY ARRIVED REFUGEES
Many refugees and immigrants originate from countries with a high prevalence of tropical and other infectious diseases that may present a threat to individual or public health. In addition, untreated chronic health conditions, such as hypertension, diabetes, and obesity, are becoming increasingly common. Infectious diseases with long latency periods, including tuberculosis, hepatitis B, and certain intestinal nematodes, such as Schistosoma spp. and Strongyloides stercoralis, can be particularly challenging. Recommendations for this postarrival medical evaluation should be tailored to the specific population and based on such factors as country of origin; race; receipt of predeparture interventions, including vaccinations and presumptive therapy for malaria and intestinal parasites; and epidemiologic risks in the country of origin, as well as the country or countries of first asylum.
Medical screening should include a detailed medical and social history, as well as a physical examination. Evidence-based screening guidelines for refugees have been developed by CDC in collaboration with Office of Refugee Resettlement (ORR), the basic components of which are outlined in Box 9-01. Full guidelines, as well as a summary checklist of the components and recommended testing, are available at http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html. Currently, population-specific guidelines do not exist, emphasizing the importance of acquiring local epidemiologic data.
An additional function of the postarrival medical screening is to arrange and coordinate ongoing primary care. Many refugees have not 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 was removed from the requirements for US admission in January 2010, which has implications for providers seeing patients from higher-prevalence countries. HIV screening is highly encouraged in all newly arriving immigrants and refugees. Culturally sensitive counseling regarding HIV testing is critical.
Nutritional deficiencies occur more commonly in refugee populations, a recent example being B12 deficiency in Bhutanese Nepali new arrivals. Prevalences ranged from 64% in people tested before migration to 27%–32% in people tested in the United States after arrival. Clinicians should be aware of the possibility of micronutrient deficiencies and screen and treat accordingly.
In areas of the world from which many refugees originate, potential lead exposures include lead-containing gasoline combustion; burning of fossil fuels and waste; and lead-containing traditional remedies, foods, ceramics, and utensils. Ongoing lead exposure among refugee children in the United States has also been well documented. For these reasons, CDC recommends checking blood lead levels of all refugee children 6 months to 16 years of age at the time of arrival, with follow-up blood lead testing to be done 3–6 months after settling into a permanent residence.
In addition to CDC’s postarrival domestic medical screening guidelines for refugees, other published resources are available to the clinician. Most recently, the Public Health Authority of Canada has produced consensus documents on evidence-based screening for newly arriving refugees to Canada. The following section of this chapter, Migrant Health Resources, includes a list of clinical resources for providers and organizations.
Refugees may qualify for state Medicaid programs to cover this medical screening and any needed ongoing medical care. Refugees determined ineligible for Medicaid are eligible for Refugee Medical Assistance, which provides for their medical care needs for up to 8 months from the date of arrival in the United States. For more information, clinicians and refugees can contact their state health departments and can also access more information through the ORR, which administers this program (www.acf.hhs.gov/programs/orr/programs/cma).
Box 9-01. Recommended components of refugee domestic health assessments1,2
- Review all available records, including chest radiograph (ask for overseas records).
- Complete a history and physical examination, including vision, hearing, and dental evaluation.
- Conduct mental health screening and, when clinically indicated, a more detailed social history, including any history of trauma/torture or rape.
- Evaluate for infectious disease, including tuberculosis, HIV and other sexually transmitted infections, and malaria and other parasitic infections (schistosomiasis and intestinal nematodes, including Strongyloides), depending on local epidemiology.
- Review overseas records for presumptive therapy for strongyloidiasis, schistosomiasis, or malaria, depending on point of departure.
- Evaluate for chronic diseases, including obesity, hypertension, diabetes, and nutritional deficiencies, such as vitamin B12 deficiency in select populations.
- Perform age-appropriate cancer screening, such as mammography, colonoscopy, or Papanicolaou test.
- Update immunizations as needed.
- Complete laboratory testing (hematologic testing, urinalysis, lead (as appropriate), HIV testing, hepatitis B serology for those arriving from countries with prevalence >2%, specific sexually transmitted infection testing, or other screening, such as basic metabolic panel and liver function testing, when clinically appropriate).
1A more detailed discussion of the medical examination of immigrants and refugees is available at www.cdc.gov/immigrantrefugeehealth/guidelines/refugee-guidelines.html.
2 Full refugee health domestic screening guidelines are available at www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html.
MEDICAL SCREENING FOR IMMIGRANTS AND INTERNATIONAL ADOPTEES
For 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 beyond the recommended evaluation for class B conditions. All newly arrived immigrants, however, would benefit from comprehensive postarrival health screening.
Formal postarrival medical examination is recommended for internationally adopted children. There are many similarities in health conditions on arrival between international adoptees and refugees. An important distinction is that refugees generally remain within their own cultural group for some time after arrival and may have limited interactions with the wider community, whereas international adoptees frequently enter into households and communities that are naive to infections common in resource-poor settings. This distinction is particularly pertinent for conditions that may continue to be infectious for weeks to months after arrival (such as hepatitis A or B and Giardia). The American Academy of Pediatrics offers guidance in the Red Book: Report of the Committee on Infectious Diseases for clinicians who will serve this population after their arrival in the United States; the Red Book 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 they enter the United States. Points of contact during the migration process, such as overseas examination, transit stops, 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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- Barnett ED. Immunizations and infectious disease screening for internationally adopted children. Pediatr Clin North Am. 2005 Oct;52(5):1287–309, vi.
- Barnett ED. Infectious disease screening for refugees resettled in the United States. Clin Infect Dis. 2004 Sep 15;39(6):833–41.
- Barnett ED. Immunizations for immigrants. In: Walker PF, Barnett ED, editors. Immigrant Medicine. Philadelphia: Saunders Elsevier; 2007. p. 151–70.
- CDC. Final rule removing HIV infection from US immigration screening. Atlanta: CDC; 2010 [cited 2012 Sep 26]. Available from: http://www.cdc.gov/immigrantrefugeehealth/laws-regs/hiv-ban-removal/final-rule.html.
- CDC. Notice of revised vaccination criteria for US immigration. Atlanta: CDC; 2010 [cited 2012 Sep 26]. Available from: http://www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/revised-vaccination-criteria-immigration.html.
- CDC. Vitamin B12 deficiency in resettled Bhutanese refugees—United States, 2008–2011. MMWR Morb Mortal Wkly Rep. 2011 Mar 25;60(11):343–6.
- Chen LH, Barnett ED, Wilson ME. Preventing infectious diseases during and after international adoption. Ann Intern Med. 2003 Sep 2;139(5 Pt 1):371–8.
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- Minnesota Department of Health. Lead poisoning in Minnesota refugee children, 2000–2002. Disease Control Newsletter [Internet]. 2004 [cited 2012 Sep 26];32(2). Available from: http://www.health.state.mn.us/divs/idepc/newsletters/dcn/2004/0402dcn.pdf.
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