Chapter 11 Posttravel Evaluation
Newly Arrived Immigrants & Refugees
More than 1 million immigrants obtained legal permanent resident status in the United States during fiscal year (FY) 2016 (October 2015–September 2016). There were 5,378 children adopted internationally and 84,989 refugees admitted into the United States during FY 2016. In addition, more than 6 million people entered the United States as nonimmigrant, long-term visitors (including students, temporary workers, and exchange visitors staying longer than 6 months). Some will likely require some form of health care during their stay. US health care professionals are therefore very likely to interact with foreign-born people at some time in their career.
The Immigration and Nationality Act (INA) mandates that all immigrants and refugees undergo a medical screening examination to identify inadmissible health conditions. An authorized panel physician in the applicant’s country of origin is responsible for performing the screening examination before departure. Applicants who adjust their immigration status after arriving in the United States undergo a medical screening by a civil surgeon.
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 examinations; >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). The CDC Division of Global Migration and Quarantine (DGMQ) issues Technical Instructions to panel physicians and civil surgeons and monitors the quality of the premigration medical examination process.
CDC also issues recommendations for premigration health interventions for special populations, such as refugees (see www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/overseas-guidelines.html). Recommended health interventions (such as treatment for parasitic diseases) are not required under the INA but may be implemented based on level of risk in the origin country.
Although refugees are not required by federal regulations to undergo a repeat medical examination upon arrival in the United States, systems are in place in all states for refugees to receive a health assessment shortly after arrival. CDC’s screening guidelines for newly arrived refugees 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. Any qualified health professional may conduct the health assessment, usually in coordination with resettlement volunteer agencies and local health departments.
In many other cases, health care providers in the United States have medical encounters with migrants who have not received any sort of formal predeparture medical screening examination. These individuals do not hold an immigrant or refugee visa and fall into other categories of temporary visitors and undocumented migrants.
BEFORE ARRIVAL IN THE UNITED STATES
Overseas Medical Screening Examination and Treatment
The purpose of the mandated medical screening 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 intestinal parasite infections and malaria (www.cdc.gov/immigrantrefugeehealth/guidelines/refugee-guidelines.html).
The medical screening examination includes a brief physical exam, a mental health evaluation, serologic testing for syphilis, nucleic acid amplification testing for gonorrhea, a 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 old 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 an interferon-γ release assay (IGRA); chest radiographs are required for those who have a positive 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, including syphilis, gonorrhea, and Hansen’s disease.
Proof of Vaccination
Applicants from outside the United States who apply for a US immigrant visa are required to receive all age-appropriate immunizations before immigration. Panel physicians administer vaccines according to CDC’s Vaccine Technical Instructions. These instructions 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. Encourage new immigrant arrivals to complete their 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 a delay in immunizing 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. For more on the topic of adopting children overseas, see Chapter 7, International Adoption.
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. When applying for permanent US residence, refugees are required to show proof of vaccination to a US civil surgeon during their adjustment of status exam. This occurs typically 1 year after arrival.
Many people will arrive in the United States without having undergone any predeparture medical screening or vaccinations. Ask each patient for his or her health records. Unless documentation is available, do not assume that migrants presenting for care underwent a physical or mental health assessment, laboratory screening for diseases, or are up to date with immunizations.
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 the Department of Homeland Security United States Citizenship and Immigration Services.
Notifications and Follow-Up on Arrival
CDC uses the medical screening examination reports and results (collected at US ports of entry when immigrants and refugees arrive) to notify state or local health departments of all arriving refugees and immigrants who have notifiable class A (with waiver) and class B conditions that require follow-up. State and local health departments are asked to report their findings back to CDC, and to provide information about 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: THE NEW ARRIVAL HEALTH ASSESSMENT
A comprehensive new arrival health assessment is an additional opportunity to screen for communicable and noncommunicable diseases, to provide preventive services and individual counseling, to establish ongoing primary care and a medical home, and to 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 predeparture processes and the diseases endemic to a migrant’s country of origin, lack of access to 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 assessments for refugees (such as the Association of Refugee Health Coordinators [ARHC]), and networks of clinicians who serve refugees and immigrants are growing.
Ideally, each new migrant should receive a complete health assessment that includes screening for migration-associated illnesses plus the age-appropriate screening and health care recommended for anyone residing in the United States. Ensure that migrants who are not recently arrived have completed the screenings associated with the new arrival health assessment, especially for diseases of long latency such as TB, hepatitis B, and HIV; if not, complete any missing tests. It would also be ideal to be able to screen each person 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
CDC has developed evidence-based guidelines for health assessments 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 new arrival 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 (e.g., Bhutanese and Congolese refugees); these are available at www.cdc.gov/immigrantrefugeehealth/profiles/index.html.
A function of the new arrival health assessment 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; address these needs at early follow-up visits. Several cancers are more prevalent in migrant populations, such as cervical, liver, stomach, and nasopharyngeal cancers. Introduce refugees to age-appropriate cancer screening tests, such as mammography, colonoscopy, and Papanicolaou tests during the new arrival exam. Integrate mental health screening into the new arrival health assessment, as it is an opportunity to screen for acute risk factors and triage refugees in need of urgent mental health treatment.
Refugees may qualify for state Medicaid programs that cover 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 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 other resources is available in the online edition of the Yellow Book (see Box 11-02).
HEALTH ASSESSMENT OF CHILDREN ADOPTED INTERNATIONALLY
There are many similarities in the health conditions found in international adoptees and in 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).
Ensure that prospective parents, close family members, and caregivers have all been immunized properly prior to the adoption; this applies equally to those who will travel internationally to meet and bring home the adopted child/children and to those who will be waiting at home. In the Red Book: Report of the Committee on Infectious Diseases, the American Academy of Pediatrics (AAP) offers guidance for clinicians who will serve this population after their arrival in the United States. The Red Book may be accessed by AAP members free-of-charge at http://aapredbook.aappublications.org. Most families who adopt children internationally are required to have health insurance for the child effective upon arrival, so funding for the new arrival health assessment poses fewer problems than for other immigrant groups.
HEALTH ASSESSMENT FOR OTHER IMMIGRANTS
Newly arrived immigrants derive important benefits from their participation in a comprehensive new arrival 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. There is no formal mechanism or funding source available to cover the costs of 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 11-08.
Record all known medical and family history, and discuss medications and treatments received prior to migration. Most experts agree that testing for TB, hepatitis B, and HIV should be performed for all new arrivals to the United States who do not have documentation of prior screening. Make a habit of ensuring that this screening is completed for every new foreign-born patient seen, regardless of time since that person’s arrival in this country.
Obtain any records, laboratory evidence of immunity, and history of vaccine-preventable diseases; give, and age-appropriate vaccines be given as indicated. Vaccine series do not need to be restarted if documentation of prior doses is available.
Adding a basic mental health screening to the assessment (including gathering information about coping strategies and support systems) permits appropriate and timely referral to resources, if necessary. A complete blood count with differential for most new arrivals facilitates making a diagnosis of anemia or eosinophilia, or finding evidence of hemoglobinopathy. A urinalysis and 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. Consider diagnostic testing if an immigrant presents with symptoms consistent with a particular parasite endemic to their country of origin (e.g., malaria, intestinal parasites). STD screening (syphilis, gonorrhea, chlamydia, HIV) beyond what may be recommended for the US general population should be considered for immigrants if their migration history places them at significant risk.
Box 11-02. Additional migrant health resources for clinicians
William M. Stauffer and Michelle Russell Hollberg
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.
- Centers for Disease Control and Prevention
- Immigrant and Refugee Health: Information on immigrants and refugees who are resettling in the United States and resources, available at www.cdc.gov/immigrantrefugeehealth
- International emergency and refugee health: Health information pertaining to complex humanitarian emergencies, at www.cdc.gov/globalhealth/programs/ierh.htm
- Canadian Collaboration for Immigrant and Refugee Health: Clinical preventive guidelines for primary care for newly arriving immigrants and refugees, available at http://www.ccirhken.ca/
- Center for Applied Linguistics (CAL), Cultural Orientation Resource Center: Refugee Backgrounders and Culture Profiles include population-specific resettlement needs and brief demographic information. http://www.culturalorientation.net/learning/backgrounders
- Refugee Health Technical Assistance Center: Multiple refugee resources and online education, available at http://refugeehealthta.org
- Minnesota Department of Health: Multiple resources for clinicians in refugee health at www.health.state.mn.us/divs/idepc/refugee/hcp/index.html, as well as refugee topics, available at www.health.state.mn.us/divs/idepc/refugee/topics/index.html.
- Healthy Roads Media: Health education materials, including video, in a variety of languages, available at http://store.healthyroadsmedia.org/
- EthnoMed: Information about cultural beliefs, medical issues, and other related issues pertinent to the health care of recent immigrants, available at http://ethnomed.org/ethnomed
- Health Information Translations: Common hospital signs with multiple translations, available at www.healthinfotranslations.com
- Health Reach: Multilingual information for clinicians, refugees, and asylum seekers in print, audio, and video formats, available at www.rhin.org
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.
- University of Minnesota/CDC: American Society of Tropical Medicine and Hygiene (ASTMH)-accredited course in global health: Open access to lectures and online content, with a focus on immigrant and refugee health, available at www.globalhealth.umn.edu
- ASTMH-accredited courses in tropical and travel medicine: List of ASTMH-accredited tropical and travel medicine courses, available at https://www.astmh.org/ASTMH/media/Documents/ASTMHdiplomacourselistasof1-13-16_1.pdf
- Harvard Program in Refugee Trauma: http://hprt-cambridge.org
- The Providers’ Guide to Quality and Culture: https://www.msh.org/resources/providers-guide-to-quality-culture
Table 11-08. Recommended new arrival laboratory screening tests for immigrants receiving medical care in the United States
|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. Follow current recommendations for 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 (possibly 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 (especially if 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.
- Barnett ED. Immunizations and infectious disease screening for internationally adopted children. Pediatr Clin North Am. 2005 Oct;52(5):1287–309, vi.
- CDC. Vitamin B12 deficiency in resettled Bhutanese refugees—United States, 2008–2011. MMWR Morb Mortal Wkly Rep. 2011 Mar 25;60(11):343–6.
- CDC. Technical instructions for panel physicians. Atlanta: CDC; 2018 [cited 2018 Mar 17]. Available from: www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/technical-instructions-panelphysicians.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.
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- 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 [cited 2016 Sep 28]; 32(2):13–15. Available from: 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: 2016. Washington, DC: US Department of Homeland Security; 2016. [cited 2018 Mar 17]. Available from: www.dhs.gov/yearbook-immigration-statistics.
- 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):1310–15.
- 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.