Chapter 9Health Considerations For Newly Arrived Immigrants & Refugees
Before Arrival in the United States: The Overseas Medical Examination
The Immigration and Nationality Act (INA), which relates to the immigration, temporary admission, naturalization, and removal of foreigners, mandates that all refugees and applicants for US immigration undergo an overseas medical screening examination performed by a panel physician to screen for inadmissible conditions. A panel physician is a medically trained, licensed, and experienced medical doctor practicing overseas who has an agreement with a local US embassy or consulate general. More than 760 panel physicians perform overseas medical examinations in accordance with requirements referred to as technical instructions.
MEDICAL EXAMINATION AND TREATMENT
CDC is responsible for providing the technical instructions to the panel physicians and for monitoring the quality of the overseas medical examination process through its quality assessment program. The technical instructions give specific requirements for the screening performed during the medical examination and are periodically updated to reflect current medical practice. The purpose of the mandated medical examination is to detect inadmissible conditions of public health significance. These medical conditions include infectious diseases such as tuberculosis, Hansen disease, and sexually transmitted diseases; mental disorders associated with harmful behavior; and substance abuse or addiction (www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/technical-instructions-panel-physicians.html).
The testing modalities required for the medical examination include a physical examination, mental health evaluation, syphilis serology, review of vaccination records, and chest radiography, followed by acid-fast bacillus smears and sputum cultures if the chest radiograph suggests tuberculosis. Treatment is also required for certain conditions, such as tuberculosis, specified sexually transmitted diseases, and Hansen disease.
In 2007, CDC began implementation of the Culture and Directly Observed Therapy (DOT) Tuberculosis Technical Instructions (www.cdc.gov/immigrantrefugeehealth/pdf/tuberculosis-ti-2009.pdf) in some countries. Priority for implementation is assigned on the basis of the country’s tuberculosis prevalence, volume of US-bound immigrants or refugees, and contribution to tuberculosis prevalence in the United States. These technical instructions require Mycobacterium tuberculosis culture, drug susceptibility testing, and directly observed therapy throughout the course of treatment, before immigration. As of July 2012, approximately three-quarters of US-bound immigrants and refugees are being screened by using the Culture and DOT Tuberculosis Technical Instructions. Since these technical instructions have been implemented in 3 major immigrant source countries, California has reported a decline from 4.2% to 1.5% in the proportion of immigrants with tuberculosis-suspect classifications who were identified with active tuberculosis within the first 6 months of US arrival. CDC is working to complete worldwide implementation of the Culture and DOT Tuberculosis Technical Instructions by 2014.
The required examination also includes evaluation of mental disorders with associated harmful behaviors and substance-related disorders. Inadmissibility based on a physical or mental disorder is limited to applicants with associated harmful or potentially harmful behavior.
For specific refugee populations, the visit to the panel physician additionally provides an opportunity for preventive medical interventions, such as immunizing against vaccine-preventable diseases and administering presumptive therapy for parasitic or other infectious diseases, including nematode infections and malaria, that may be affecting the population at the time of migration.
PROOF OF VACCINATION
In 1996, a subsection was added to the INA requiring that people seeking immigrant visas for permanent residency show proof of receipt of all vaccination series recommended by the Advisory Committee on Immunization Practices (ACIP) (www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html). In 2009, CDC adopted revised vaccination criteria to determine which vaccines recommended by ACIP should be required for immigrant visa applicants. These criteria allow CDC the flexibility to adapt vaccination requirements according to public health needs (www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/revised-vaccination-criteria-immigration.html). The vaccination criteria state that the vaccine must:
- Be age-appropriate
- Protect against a disease that has the potential to cause an outbreak
- Protect against a disease that has been eliminated or is in the process of being eliminated in the United States
These requirements apply to all adult immigrants and most immigrant children. However, internationally adopted children who are aged ≤10 years may obtain a waiver of exemption from the immunization requirements. Refugees are not required to meet the INA immunization requirements at the time of entry into the United States. Instead, they must show proof of vaccination at the time they apply for permanent US residence, typically 1 year after arrival. Updated instructions regarding vaccination requirements are available on the CDC website (www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/vaccination-panel-technical-instructions.html).
CLASSIFICATION OF APPLICANTS
To determine the inadmissibility of an applicant, the medical conditions of public health significance are categorized as class A or B. Class A conditions are defined as those that preclude an immigrant or refugee from entering the United States. An immigrant or refugee who has an inadmissible condition may still be issued a visa after the illness has been adequately treated or after a waiver of the visa ineligibility has been approved by the United States Citizenship and Immigration Services. Class B conditions are defined as physical or mental abnormalities, diseases, or disabilities serious enough or permanent in nature as to amount to a substantial departure from normal well-being. Follow-up evaluation soon after US arrival is recommended for immigrants or refugees with class B conditions. For more information, see Arrival in the United States: Health Status & Screening of Refugees, Immigrants, & International Adoptees later in this chapter.
NOTIFICATIONS AND FOLLOW-UP
The Department of State forms completed by panel physicians are collected at US ports of entry when immigrants and refugees arrive. These forms summarize the results of the overseas medical examination and include classification of health conditions. On the basis of this information, CDC notifies state or local health departments of all arriving refugees, immigrants with class A conditions (with waiver), and immigrants with class B tuberculosis classifications who are resettling in their jurisdictions and need follow-up evaluation and possible treatment. The notification and Department of State form data are transmitted to state or local health departments electronically through CDC’s Electronic Disease Notification System (EDN).
State and local health departments are asked to report to CDC through EDN the results of these US follow-up evaluations, as well as any serious public health conditions identified among recently arrived immigrants and refugees. Reporting allows a better understanding of epidemiologic patterns of disease in recently arrived immigrants and refugees and is a way of monitoring the quality of the overseas medical examination.
In 2008, CDC amended the regulations that govern the required overseas medical examination for immigrants and refugees by adding the following disease categories to those already specified in the INA: 1) quarantinable diseases designated by presidential executive order (www.cdc.gov/quarantine/AboutLawsRegulationsQuarantineIsolation.html) and 2) diseases that meet criteria of public health emergency of international concern and require notification of the World Health Organization under the revised International Health Regulations (2005). This change allows CDC the flexibility to determine which diseases are included in the medical screening and testing of immigrants and refugees in areas of the world that are experiencing outbreaks of specific diseases. These changes reduce the health risk to the United States from emerging diseases, without imposing undue burden on either the immigrants and refugees or the US health care system.
As of January 4, 2010, testing for HIV is no longer a required part of the US immigration medical screening process. HIV infection is no longer an inadmissible condition that prevents non-US citizens from entering the United States (www.cdc.gov/immigrantrefugeehealth/laws-regs/hiv-ban-removal/final-rule.html and www.cdc.gov/immigrantrefugeehealth/exams/ti/hiv-guidance-panel-civil.html).
- CDC. Technical instructions for panel physicians. Atlanta: CDC; 2012 [cited 2012 Sep 26]. Available from: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/technical-instructions-panel-physicians.html.
- Lowenthal P, Westenhouse J, Moore M, Posey DL, Watt JP, Flood J. Reduced importation of tuberculosis after the implementation of an enhanced pre-immigration screening protocol. Int J Tuberc Lung Dis. 2011 Jun;15(6):761–6.
- Maloney S, Ortega L, Cetron M. Overseas medical screening for immigrants and refugees. In: Walker PF, Barnett ED, editors. Immigrant Medicine. Philadelphia: Saunders Elsevier; 2007. p. 111–22.
- Maloney SA, Fielding KL, Laserson KF, Jones W, Nguyen TN, Dang QA, et al. Assessing the performance of overseas tuberculosis screening programs: a study among US-bound immigrants in Vietnam. Arch Intern Med. 2006 Jan 23;166(2):234–40.
- US Department of Homeland Security. Immigration and Nationality Act. Washington, DC: US Department of Homeland Security; 1952 [cited 2012 Sep 26]. Available from: http://www.uscis.gov/portal/site/uscis/menuitem.f6da51a2342135be7e9d7a10e0dc91a0/?vgnextoid=fa7e539dc4bed010VgnVCM1000000ecd190aRCRD&vgnextchannel=fa7e539dc4bed010VgnVCM1000000ecd190aRCRD&CH=act.
- US Department of Homeland Security. Title 8 of Code of Federal Regulations (CFR). Washington DC: US Department of Homeland Security; 1938 [cited 2012 Sep 26]. Available from: http://www.uscis.gov/portal/site/uscis/menuitem.f6da51a2342135be7e9d7a10e0dc91a0/?vgnextoid=fa7e539dc4bed010VgnVCM1000000ecd190aRCRD&vgnextchannel=fa7e539dc4bed010VgnVCM1000000ecd190aRCRD&CH=8cfr.