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Chapter 8 Advising Travelers with Specific Needs

Newly Arrived Immigrants & Refugees

Michelle Russell, Hope Pogemiller, Elizabeth D. Barnett

More than 1 million immigrants obtained legal permanent resident status in the United States during fiscal year (FY) 2014. The Department of Homeland Security reported that 535,126 of these immigrants were already living in the United States, and 481,392 arrived directly from their country of origin. In addition, 69,987 refugees were admitted into the US during FY 2014. Table 8-08 lists the top 10 countries of origin for refugee and new immigrant arrivals in FY 2014.

The Immigration and Nationality Act (INA) mandates that all immigrants and refugees undergo a medical screening examination to identify inadmissible health conditions. This examination is performed by authorized physicians in the applicants’ countries of origin or in the United States for applicants adjusting their status after arrival. A panel physician is a medical doctor practicing outside the United States who has an agreement with a US embassy or consulate general to conduct preimmigration medical screening; >600 panel physicians perform these examinations internationally. A civil surgeon is a US physician authorized by US Citizenship and Immigration Services (USCIS) to perform official immigration medical examinations required for the adjustment of status after arrival in the United States (the process of becoming a permanent US resident).

CDC’s Division of Global Migration and Quarantine (DGMQ) issues Technical Instructions to panel physicians and civil surgeons who conduct the required medical examinations for immigrants and refugees. CDC also issues recommendations for premigration health interventions for special populations, such as refugees, before travel to the United States; these recommended health interventions are not required under the INA (such as treatment for parasitic diseases). CDC’s predeparture recommendations for refugees are implemented based on risk in the origin country and when funding and logistical support are available. CDC’s premigration guidelines for refugee populations are available at www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/overseas-guidelines.html. Refugees are not required by federal regulations to repeat health screening upon arrival in the United States; however, systems are in place in all states for refugees to receive a health assessment shortly after arrival. These may be carried out by any qualified health professional and are usually done in coordination with resettlement volunteer agencies and local health departments. CDC’s postarrival guidelines for refugee screening are available at www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html. Specific protocols may vary by state and are usually available on the websites of the departments of health in the state or region.

The prearrival medical exam is only performed by panel physicians for those applicants who apply for immigrant or refugee status prior to arrival in the United States. US health care providers may encounter a larger number of immigrants in their clinical practice who have not entered the United States on an immigrant or refugee visa (some categories of temporary visitors and undocumented migrants) and, therefore, have not received this immigrant medical exam.

Table 8-08. Top 10 countries of birth for newly arriving refugees and immigrants (from overseas locations), fiscal year 2014

REFUGEE ARRIVALS IMMIGRANT ARRIVALS
COUNTRY OF BIRTH NUMBER OF ARRIVING REFUGEES COUNTRY OF BIRTH NUMBER OF ARRIVING IMMIGRANTS
Iraq 19,651 Mexico 61,682
Burma 14,578 Dominican Republic 36,839
Somalia 9,011 China, People's Republic 36,562
Bhutan 8,316 Philippines 31,275
Dem. Rep. Congo 4,502 India 27,046
Cuba 4,063 Vietnam 25,260
Iran 2,833 Pakistan 14,117
Eritrea 1,445 Bangladesh 13,313
Sudan 1,307 El Salvador 11,661
Afghanistan 758 Jamaica 11,174

 

BEFORE ARRIVAL IN THE UNITED STATES

Overseas Medical Examination and Treatment

CDC provides Technical Instructions to panel physicians and monitors the quality of the premigration 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, a visit to the panel physician also provides an opportunity for health interventions such as 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 is consistent with tuberculosis (TB). Chest radiographs are required for all applicants ≥15 years of age. Applicants 2–14 years of age from high-TB-burden countries (incidence rate ≥20 cases per 100,000 population as estimated by the World Health Organization) must be tested for TB infection using either a tuberculin skin test (TST) or interferon-γ release assay (IGRA); chest radiographs are required for those who have a positive TST or IGRA. For people diagnosed with active TB, CDC’s Technical Instructions require Mycobacterium tuberculosis culture, drug susceptibility testing, and directly observed therapy through the end of treatment before immigration. Treatment is also required before immigration for certain other inadmissible conditions, such as specific sexually transmitted diseases (such as syphilis) and Hansen disease.

Proof of Vaccination

IMMIGRANTS

Applicants who apply for a US immigrant visa outside the United States are required to receive all age-appropriate immunizations before immigrating to the United States. Vaccines are administered by panel physicians according to CDC’s Vaccine Technical Instructions. These requirements are based on the Advisory Committee on Immunization Practices (ACIP) recommendations, with some modifications for immigrant populations. For example, immigrants are not required to complete all doses of a multidose vaccine series as long as they have received the next dose in the series before arrival in the United States. New immigrant arrivals should be encouraged to complete vaccination schedules according to ACIP recommendations after arrival in the United States. CDC’s Vaccine Technical Instructions are available at www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/vaccination-panel-technical-instructions.html.

CHILDREN ADOPTED INTERNATIONALLY

Parents adopting children internationally may request to delay immunization of children <10 years of age by agreeing to begin immunizations within 30 days of arrival in the United States. Adopting families should be aware that vaccinating children before arrival in the United States reduces the risk of importing diseases of public health concern, such as measles, which was reported in unvaccinated children adopted from China in 2004, 2006, and 2013.

REFUGEES

Refugees are not required to meet the INA immunization requirements before entry into the United States; however, CDC is working with domestic and international migration partners to implement a vaccination program for US refugees. Program updates and population-specific schedules can be found at www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/interventions/immunizations-schedules.html. Refugees are required to show proof of vaccination when they apply for permanent US residence (adjustment of status exam performed by a US civil surgeon), typically 1 year after arrival.

Classification of Medical Conditions

Medical conditions of public health significance are categorized into those that preclude an immigrant or refugee from entering the United States (class A) or those that indicate a departure from normal well-being and for which follow-up after arrival is recommended (class B). An immigrant or refugee who has an inadmissible class A 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 USCIS.

Notifications and Follow-Up on Arrival

The results of the immigrant medical exam are collected at US ports of entry when immigrants and refugees arrive. CDC then notifies state or local health departments of all arriving refugees, as well as immigrants with notifiable class A (with waiver) and class B conditions who may need follow-up evaluation after arrival. State and local health departments are asked to report follow-up evaluation results back to CDC, as well as any serious conditions of public health concern identified among recently arrived immigrants and refugees. Such reporting enables CDC to track epidemiologic patterns of disease in recently arrived immigrants and refugees and allows for monitoring of the quality of the overseas medical examinations.

AFTER ARRIVAL IN THE UNITED STATES: SCREENING & HEALTH ASSESSMENT

A comprehensive postarrival health assessment is an opportunity to screen for communicable and noncommunicable diseases, provide preventive services (such as immunizations and treatment for latent tuberculosis) and individual counseling (such as nutritional and mental health), establish ongoing primary care and a medical home, and orient new arrivals to the US health care system.

Challenges for health professionals in providing comprehensive health assessments for new arrivals include lack of familiarity with CDC screening recommendations and diseases endemic to a migrant’s country of origin, inability to find trained interpreters, and lack of knowledge of social and cultural beliefs of new migrant groups. Immigrants and refugees often have other priorities related to their new environment, such as English classes, school, housing, and work, which may take precedence over accessing health care services. Several organizations can facilitate health screenings for refugees (such as the Association of Refugee Health Coordinators [ARHC]), and networks of clinicians who serve refugees and immigrants are growing. Additional resources are provided in the online Yellow Book (see Box 8-08).

Medical Screening

Newly arrived immigrants and refugees may have undiagnosed infectious diseases or untreated chronic health conditions, such as hypertension, diabetes, or hypercholesterolemia. Ideally, each new migrant should receive a complete health assessment that includes screening for migration-associated illness plus the age-appropriate screening and health care recommended for anyone residing in the United States. Clinicians caring for migrants who are not recent arrivals should still ensure that migrant screening has been completed, especially for diseases of long latency such as TB, hepatitis B, and HIV, and complete any missing tests. It would also be ideal to be able to screen each individual for diseases specific to his or her country of origin, migration route, and individual epidemiologic risk. Described below are guidelines available for the 2 populations for which there are the most data to guide screening efforts (refugees and children adopted internationally), followed by an approach to performing health assessments for other categories of immigrants.

HEALTH ASSESSMENT OF REFUGEES

Evidence-based guidelines for refugees have been developed by CDC in collaboration with the Department of Health and Human Services Administration for Children and Families’ Office of Refugee Resettlement (ORR), clinical and subject matter experts outside of CDC, and representatives of ARHC. The full guidelines and a summary checklist of the postarrival exam components and recommended testing are available at www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html. CDC has also developed population-specific health profiles for certain populations (such as Bhutanese or Congolese refugees), available at www.cdc.gov/immigrantrefugeehealth/profiles/index.html.

Another function of the postarrival medical screening is to arrange and coordinate ongoing primary care. Many refugees have not had age-appropriate screening for chronic diseases such as heart disease, diabetes, cancer, or hearing, vision, or dental problems; these needs should be addressed at early follow-up visits. Several cancers are more prevalent in migrant populations, such as cervical, liver, stomach, and nasopharyngeal cancers. Refugees should be educated regarding age-appropriate cancer screening tests, such as mammography, colonoscopy and Papanicolaou tests during the postarrival exam.

HIV testing was removed from the requirements for US admission in January 2010, but HIV screening is highly encouraged in all newly arriving refugees and routinely recommended in the guidelines from the United States Public Health Service (USPHS) and the American Academy of Pediatrics (AAP). Culturally sensitive counseling regarding HIV testing is critical.

Nutritional deficiencies occur commonly in refugee populations. For example, one study found that the prevalence of vitamin B12 deficiency in newly arrived Bhutanese refugees from Nepal was 64% in those tested premigration and 27%–32% in those tested after arrival in the United States. Clinicians should be aware of the possibility of malnutrition and micronutrient deficiencies and screen and treat accordingly.

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 for children 6 months to 6 years of age 3–6 months after settling into a permanent residence. Potential lead exposures include using lead-containing gasoline, burning fossil fuels and waste, and using lead-containing traditional remedies, cosmetics, foods, ceramics, or utensils. Ongoing lead exposure among refugee children after arrival in the United States also has been documented.

Mental health screening for refugees is another component of the postarrival exam and, when clinically indicated, a more detailed social history including any history of trauma, torture, or rape. Risk factors that may predispose refugees to psychiatric symptoms and disorders include exposure to war, state-sponsored violence and oppression, loss of family members, and the stress of adapting to a new culture.

Refugees may qualify for state Medicaid programs to cover medical screening and any ongoing medical care that may be needed. 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 their date of arrival. For more information, clinicians and refugees can contact their state health departments and can access more information through the ORR, which administers this program (www.acf.hhs.gov/programs/orr/programs/cma).

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. A list of resources can be found in the online edition of the Yellow Book (see Box 8-08).

HEALTH ASSESSMENT OF CHILDREN ADOPTED INTERNATIONALLY

There are many similarities in health conditions between international adoptees and refugees. One difference is that refugees generally remain in 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 giardiasis). Clinicians should encourage updating immunizations prior to the adoption for those who travel internationally to meet their adopted children and travel home with them, as well as close family members and caregivers (even if they do not travel). The AAP 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 for free by AAP members at http://aapredbook.aappublications.org). More information is available in Chapter 7, International Adoption. Most families who adopt children internationally are required to have health insurance for the child effective upon arrival, so funding for the postarrival health assessment poses fewer problems than for other immigrant groups.

HEALTH ASSESSMENT FOR OTHER IMMIGRANTS

All newly arrived immigrants would benefit from a comprehensive postarrival health assessment and introduction to the US health system. Because immigrants enter the country in so many different ways, they access health care at multiple different points and with providers who have differing levels of expertise in immigrant medicine. Since there is no formal mechanism or funding source available for a standard comprehensive health assessment, immigrants may never receive any health assessment that targets conditions they may have acquired in their country of birth or during their migration process unless every health professional assumes the responsibility and has the knowledge to assess these issues when caring for patients born outside the United States. A list of screening tests that should be considered for immigrant health assessments is included in Table 8-09.

Most experts agree that testing for TB, hepatitis B, and HIV should be performed for most new arrivals to the United States. Clinicians should also make a habit of ensuring that this screening has been done for every new non–US-born patient they see, regardless of time since the person’s arrival.

Vaccine records, laboratory evidence of immunity, and history of vaccine-preventable diseases should be obtained and age-appropriate vaccines be given as indicated. Vaccine series do not need to be restarted if documentation of prior doses is available.

Basic mental health screening, including coping strategies and support systems, can be included in the assessment so that referrals to resources can be made within the medical home.

A complete blood count with differential and urinalysis is appropriate for most new arrivals for diagnosis of anemia or eosinophilia or to identify evidence of hemoglobinopathy. A basic metabolic panel may be indicated, especially for those of appropriate age or with evidence of conditions such as renal disease or diabetes. Immigrant health care providers should continue to follow the age- and risk-based guidelines provided by the United States Preventive Services Task Force (USPSTF) for the general US population when continuing to care for immigrant patients over time. (See the Guide to Clinical Preventative Services 2014 at www.uspreventiveservicestaskforce.org, click on “Information for Health Professionals” and then on the “Guide to Clinical Preventive Services, 2014”). Per CDC lead screening guidelines for the US population, a blood lead level should be obtained for children 12 months old and 24 months old if resources allow. If a child has additional risks, screening should be started at 6 months. If an immigrant has never had a blood lead level and has lived in a highly industrialized city with potential for exposure to industrial waste, has a developmental delay, or has a medical condition consistent with lead exposure, he or she should be screened for blood lead level as well. Diagnostic testing should be considered if an immigrant presents with symptoms consistent with a particular parasite if endemic in the country of origin (malaria, intestinal parasites). STD screening (syphilis, gonorrhea, chlamydia, HIV), above that of the recommendations for the US general population, should be considered for immigrants if their migration history places them at significant risk. Known medical and family history should be recorded, and medications and treatments received prior to migration should be discussed.

Immigrants who travel back to their country of origin may be at higher risk of travel-related infectious diseases. Thus, travel vaccines can be considered in addition to age-appropriate vaccinations for these immigrants.

Table 8-09. Recommended postarrival laboratory screening tests for immigrants and refugees receiving medical care in the United States

TEST AGE RANGE GEOGRAPHIC AREA COMMENTS
Tuberculosis: IGRA or TST All All Test based on standard guidelines
HIV >13 years1 All Test based on standard guidelines
Hepatitis B: surface antigen All Where prevalence of hepatitis B infection in home country is >2% Consider surface antibody if unimmunized. May consider core antibody. Current recommendations for refugees can apply to both immigrants and refugees.
STDs (syphilis, gonorrhea, chlamydia, others as indicated) 15–65 years or <15 if sexually active All Test choice based on standard guidelines. Consider for all immigrants, taking into account the migration history and if it adds increased risk.
CBC with differential and MCV All All Screen for chronic anemias; look for absolute eosinophilia, as it can be evidence of parasitic infection.
Serology for parasites: schistosomiasis, strongyloidiasis, other soil transmitted helminths All Where endemic if high risk of exposure Consider screening with exposure history, unexplained eosinophilia. Some experts choose to treat empirically. Empiric treatment is recommended when at-risk immigrant is about to receive steroids or become immunocompromised, if testing is unavailable or when there is insufficient time to obtain results.
Malaria All Where malaria is endemic Consider malaria if from highly endemic area within 3–6 months of arrival.
Blood lead level <16 years or if clinical indication All, Consider if never had a lead test and have additional risks: lived in a highly industrialized city with potential exposure to industrial waste, has a developmental delay, or has medical conditions consistent with lead exposure
Varicella antibody >5 years All, but especially those with history of varicella and older children and adults  
Urinalysis, basic metabolic panel All adults or if clinical indication All Screening for renal failure and schistosomiasis (if from an endemic area)

Abbreviations: IGRA, interferon-γ release assay; TST, tuberculin skin test; STD, sexually transmitted disease; CBC, complete blood count; MCV, mean corpuscular volume
1 Consider in younger children who have signs or symptoms of disease, risk factors for transmission, or mother is missing or deceased or has illness compatible with HIV.

 

Box 8-08. Additional migrant health resources for clinicians

William M. Stauffer and Michelle Russell

Historically, the Yellow Book has addressed travel health issues for US residents visiting countries outside the US.  Travel medicine now includes groups who cross international boundaries into and out of the US, including immigrants (documented and undocumented), refugees, asylum seekers, international adoptees, students, and corporate workers. Many clinics serving the traditional travel population also function as contact points within the US medical system for these populations, particularly for immigrants and refugees. This section provides resources for clinicians and organizations that serve these populations to access up-to-date patient care guidelines, online education materials, and print resources.

Clinical References

Websites
Reference Books
Textbooks with a Focus on Migrant Health
  • Immigrant Medicine. Walker PF, Barnett ED, editors. Philadelphia: Saunders Elsevier; 2007.
  • Migration Medicine and Health: Principles and Practice. Gushulak BD, MacPherson D, editors. Hamilton, ON: BC Decker; 2006.
  • Travel Medicine and Migrant Health. Lockie C, Walker E, Calvert L, Cossar J, Knill-Jones R, Raeside F, editors. Edinburgh: Churchill Livingstone; 2000.
  • Refugee and Immigrant Health. A Hand­book for Health Professionals. Kemp C, Rasbridge LA, editors. New York: Cambridge University Press; 2004.

General Resources

Educational Opportunities
Other Resources

BIBLIOGRAPHY

  1. Barnett ED. Immunizations and infectious disease screening for internationally adopted children. Pediatr Clin North Am. 2005 Oct;52(5):1287–309, vi.
  2. CDC. Vitamin B12 deficiency in resettled Bhutanese refugees—United States, 2008–2011. MMWR Morb Mortal Wkly Rep. 2011 Mar 25;60(11):343–6.
  3. CDC. Technical instructions for panel physicians. Atlanta: CDC; 2014 [cited 2016 Sep. 28]; Available from: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/technical-instructions-panel-physicians.html.
  4. 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.
  5. 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.
  6. Miller LC. International adoption: infectious diseases issues. Clin Infect Dis. 2005 Jan 15;40(2):286–93.
  7. Minnesota Department of Health. Lead poisoning in Minnesota refugee children, 2000–2002. Disease Control Newsletter [Internet]; 2004 [cited 2016 Sep. 28]; 32(2):13–5. Available from: http://www.health.state.mn.us/divs/idepc/newsletters/dcn/2004/0402dcn.pdf.
  8. 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.
  9. Office of Immigration Statistics. Yearbook of Immigration Statistics: 2012. Washington, DC: US Department of Homeland Security; 2014 [cited 2016 Sep. 28]; Available from: https://www.dhs.gov/yearbook-immigration-statistics.
  10. 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.
  11. 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.
  12. 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.
  13. Walker PF, Barnett ED, editors. Immigrant Medicine. Philadelphia: Saunders Elsevier; 2007.
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