Chapter 8 Advising Travelers with Specific Needs
Newly Arrived Immigrants & Refugees
According to the Department of Homeland Security, approximately 58,000 refugees were admitted into the United States during fiscal year (FY) 2012. In addition, >1 million immigrants obtained legal permanent resident status during FY 2012; 547,559 of these were already living in the United States, and 484,072 came directly from overseas. Tables 8-06 and 8-07 list the top 10 countries of origin for refugee and new immigrant arrivals in FY 2012.
The Immigration and Nationality Act (INA), which encompasses the immigration, temporary admission, naturalization, and removal of foreign nationals, mandates that all refugees and applicants for US immigration undergo a medical screening examination, performed by an authorized physician, for inadmissible conditions. Refugees undergo the examination overseas, whereas immigrants are examined in the United States or overseas depending on their place of residence. A panel physician is a medical doctor practicing overseas who has an agreement with a local US embassy or consulate general to perform immigration medical examinations; more than 760 panel physicians perform these examinations. A civil surgeon is a special designation for a US physician authorized to perform official immigration medical examinations required for adjustment of status (the process of becoming a permanent US resident). CDC’s Division of Global Migration and Quarantine (DGMQ) works closely with the Department of State, which has agreements with panel physicians, and US Citizenship and Immigration Services within the Department of Homeland Security, which designates physicians as civil surgeons. DGMQ provides technical instructions for conducting the required medical examinations, including mandated screening for specific diseases (such as tuberculosis). In addition, for special populations such as refugees, the CDC issues health recommendations (such as treatment for parasitic diseases). These health recommendations are implemented when funding and logistical support are available but do not have to be completed prior to migration.
Most immigrants are not required to undergo any health screening following arrival in the United States, although there are systems for certain groups who will routinely undergo a new-arrival medical examination (such as refugees). These new-arrival screenings may be carried out by any qualified health professional.
Table 8-06. Top 10 countries of birth for newly arriving refugees, fiscal year 2012
|COUNTRY OF BIRTH||NUMBER OF ARRIVING REFUGEES|
|Congo, Democratic Republic||1,863|
Table 8-07. Top 10 countries of birth for newly arriving immigrants, fiscal year 2012
|COUNTRY OF BIRTH||NUMBER OF ARRIVING IMMIGRANTS|
BEFORE ARRIVAL IN THE UNITED STATES
Overseas Medical Examination and Treatment
CDC provides technical instructions to panel physicians and monitors the quality of the overseas medical examination process. The purpose of the mandated medical examination is to detect inadmissible conditions, including communicable diseases of public health significance, mental disorders associated with harmful behavior, and substance use or substance-induced disorders (www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/technical-instructions-panel-physicians.html). For certain 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 diseases, including nematode infections and malaria (www.cdc.gov/immigrantrefugeehealth/guidelines/refugee-guidelines.html).
The medical examination includes a physical examination, mental health evaluation, syphilis serologic testing, review of vaccination records, and chest radiography, followed by acid-fast bacillus smears and sputum cultures if the chest radiograph suggests tuberculosis. Treatment is required before immigration for certain conditions, such as tuberculosis, specified sexually transmitted diseases, and Hansen disease.
For people diagnosed with tuberculosis infection, technical instructions require Mycobacterium tuberculosis culture, drug susceptibility testing, and directly observed therapy through the end of treatment before immigration. With the addition of culture to the tuberculosis screening requirements, the yield of screening approximately tripled (in 2012, over 60% of those identified with tuberculosis disease had smear-negative, culture-positive sputum results).
Proof of Vaccination
People seeking immigrant visas for permanent residency must show proof that they received 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 be exempted. Clusters of imported measles cases in unvaccinated children were reported in adoptees from China in 2004, 2006, and 2013. Adopting families should be aware that vaccinating children while still overseas reduces the risk of importing disease.
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. Technical instructions regarding vaccination requirements are available at www.cdc.gov/immigrantrefugee health/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 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 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.
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 and 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.
AFTER ARRIVAL IN THE UNITED STATES: HEALTH STATUS & SCREENING OF IMMIGRANTS
Although an overseas medical examination is mandatory for all immigrants, the primary focus of this examination is to identify applicants with inadmissible health-related conditions. Increasingly, US-bound refugees are receiving enhanced health screening, immunizations, and presumptive treatment for such disorders as hepatitis B, anemia, malaria, and other parasitic diseases. Medical screening after arrival is recommended but not required for all refugees and international adoptees (a category of immigrants). The more comprehensive postarrival screening represents an opportunity to screen for communicable and noncommunicable diseases, to provide preventive services (such as immunizations and treatment for latent tuberculosis) and individual counseling (such as nutritional and mental health), and to establish ongoing primary care and a medical home. Nonrefugee immigrants with class B conditions are also advised to be evaluated after their arrival; however, these evaluations are targeted for particular conditions such as tuberculosis.
Routine postarrival medical screenings are generally conducted at state or local health departments, contracted private clinics, or 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, which may take precedence over accessing health care services. However, several organizations can facilitate health screening (such as the Association of Refugee Health Coordinators [ARHC], www.refugeehealthcoordinators.org/default.html), and the networks of clinicians who serve these populations are growing (a clinical e-mail list is available at www.globalhealth.umn.edu/community-initiatives/index.html). Additional resources are provided in Appendix C, Migrant Health Resources.
Clinicians should be aware that a single dose of a vaccine series fulfills the requirement for proof of vaccination for immigration purposes (a completed series is not required before immigration). Therefore, vaccination records should be reviewed to ensure that any additional doses to complete a vaccine series, as well as any age-appropriate vaccinations not required for immigration purposes, are recommended.
A point for clinicians to bear in mind is that immigrant populations often return to their countries of origin to visit friends and relatives. These people, sometimes referred to as VFR travelers, are at higher risk of travel-related infectious diseases (malaria, tuberculosis, typhoid, hepatitis A) than other groups of international travelers and access pre-travel health care less frequently than other groups. Additional resources for counseling this population can be found in this chapter, Immigrants Returning Home to Visit Friends and Relatives (VFRs).
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 increasingly common. Identifying infectious diseases with long latency periods, including tuberculosis; hepatitis B; certain intestinal nematodes, such as Strongyloides stercoralis; and other parasites, such as Schistosoma spp. can be particularly challenging. Recommendations for the 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 the Administration for Children and Families’ Office of Refugee Resettlement (ORR), clinical and subject matter experts outside of CDC, and with representatives of ARHC. The basic components of these guidelines are outlined in Box 8-07. Full guidelines, as well as a summary checklist of the components and recommended testing, are available at www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html. Population-specific guidelines do not exist, which emphasizes the importance of local epidemiologic data. However, population-specific health profiles are being developed to highlight specific health issues that clinicians should be aware of in each population (www.cdc.gov/immigrantrefugee health/profiles/index.html).
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, or 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, but 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, such as B12 deficiency in Bhutanese Nepali new arrivals. Prevalence 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 malnutrition and micronutrient deficiencies and screen and treat accordingly.
In areas of the world from which many refugees originate, potential lead exposures include using lead-containing gasoline, burning fossil fuels and waste, and using lead-containing traditional remedies, foods, ceramics, or 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 aged 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. A list of resources can be found in Appendix C.
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 in many states, 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).
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 recommendation that they be evaluated 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. A 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 households and communities that are clinically naïve 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. Clinicians should encourage updating immunizations for those who travel internationally to meet their adopted children and travel home with them, as well as close family members and caregivers, to ensure optimal protection from vaccine-preventable diseases. More information is available in Chapter 7, International Adoption and at www.cdc.gov/vaccines/parents/adoptions.html.
Box 8-07. 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 as clinically appropriate: hematologic testing, urinalysis, lead, HIV testing, hepatitis B testing 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
1 A 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.
- Barnett ED. Immunizations and infectious disease screening for internationally adopted children. Pediatr Clin North Am. 2005 Oct;52(5):1287–309, vi.
- CDC. Technical instructions for panel physicians. Atlanta: CDC; 2014 [cited 2014 Sep 24]. Available from: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/technical-instructions-panel-physicians.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.
- 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 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.
- Miller LC. International adoption: infectious diseases issues. Clin Infect Dis. 2005 Jan 15;40(2):286–93.
- Minnesota Department of Health. Lead poisoning in Minnesota refugee children, 2000–2002. Disease Control Newsletter [Internet]. 2004;32(2):13–5. Available from: http://www.health.state.mn.us/divs/idepc/newsletters/dcn/2004/0402dcn.pdf.
- Nyangoma EN, Olson CK, Benoit SR, Bos J, Debolt C, Kay M, et al. Measles outbreak associated with adopted children from China—Missouri, Minnesota, and Washington, July 2013. MMWR Morb Mortal Wkly Rep. 2014 Apr 11;63(14):301–4.
- Office of Immigration Statistics. Yearbook of Immigration Statistics: 2012. Washington, DC: US Department of Homeland Security; 2014 [cited 2014 Sep 24]. Available from: http://www.dhs.gov/yearbook-immigration-statistics-2012-legal-permanent-residents.
- Posey DL, Blackburn BG, Weinberg M, Flagg EW, Ortega L, Wilson M, et al. High prevalence and presumptive treatment of schistosomiasis and strongyloidiasis among African refugees. Clin Infect Dis. 2007 Nov 15;45(10):1310–5.
- Posey DL, Naughton MP, Willacy EA, Russell M, Olson CK, Godwin CM, et al. Implementation of new TB screening requirements for U.S.-bound immigrants and refugees—2007–2014. MMWR Morb Mortal Wkly Rep. 2014 Mar 21;63(11):234–6.
- Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ. 2011 Sep 6;183(12):e824–925.
- Walker PF, Barnett ED, editors. Immigrant Medicine. Philadelphia: Saunders Elsevier; 2007.
- Page created: July 10, 2015
- Page last updated: July 10, 2015
- Page last reviewed: July 10, 2015
- Content source: