Chapter 9Health Considerations for Newly Arrived Immigrants & Refugees

Christine Dubray, Mary P. Naughton, Luis S. Ortega

PANEL PHYSICIANS

The Immigration and Nationality Act (INA), which relates to the immigration, temporary admission, naturalization, and removal of foreigners, mandates that all immigrants and refugees migrating to the United States undergo an overseas medical screening examination performed by panel physicians. A panel physician is a medically trained, licensed, and experienced medical doctor practicing overseas who is appointed by the local US embassy or consulate. More than 760 panel physicians perform overseas predeparture medical examinations in accordance with requirements, referred to as technical instructions, provided by CDC (www.cdc.gov/immigrantrefu...).

In 2008, CDC amended the regulations that govern the required overseas medical examination for immigrants and refugees. In addition to the communicable diseases specified in the INA, the following disease categories were added: 1) quarantinable diseases designated by presidential executive order and 2) diseases that meet the criteria of public health emergency of international concern, which require notification to the World Health Organization under the revised International Health Regulations (2005). CDC also amended the provisions that describe the scope of the medical examination by incorporating a more flexible, risk-based approach based on medical and epidemiologic factors. This approach will 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. In addition, CDC updated the screening requirements for tuberculosis (TB) to be consistent with current medical knowledge and practice. These changes will 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.

MEDICAL EXAMINATION

The mandated medical examination focuses primarily on detecting diseases determined to be inadmissible conditions for the purposes of visa eligibility and on preventing the importation of diseases of public health importance. These medical conditions include infectious diseases such as TB, Hansen disease, and sexually transmitted diseases; mental disorders associated with harmful behavior; and substance abuse or addiction (www.cdc.gov/immigrantrefugeehealth/exams/ti/p...). As of January 4, 2010, testing for HIV is no longer a required part of the US immigration medical screening process, and 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).

The visit to the panel physician also provides an opportunity to give preventive medical interventions, such as updating vaccines and administering presumptive therapy for parasitic or other infectious diseases that may be affecting a specific refugee population at the time of migration, including nematode infections, malaria, and specific vaccine-preventable diseases.

CLASSIFICATION OF APPLICANTS

To determine the inadmissibility of an applicant, medical conditions 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. 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 TB. If an immigrant or refugee has an inadmissible condition, a visa may still be issued after the illness has been adequately treated or after a waiver of the visa ineligibility has been approved by the Citizenship and Immigration Services (www.uscis.gov).

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 at least 1 dose of all vaccination series recommended by the Advisory Committee on Immunization Practices (ACIP) (www.cdc.gov/vaccines/recs/acip). As of December 14, 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 based on public health needs (www.cdc.gov/immigrantrefugeeh...). The new 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 regulations 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. Adoptive parents are required to sign a waiver indicating their intention to comply with the immunization requirements within 30 days of the infant’s or child’s arrival in the United States. Refugees are not required to meet the INA immunization requirements at the time of entry into the United States but 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 (http://www.cdc.gov/im...).

TECHNICAL INSTRUCTIONS

CDC is responsible for providing technical instructions to the panel physicians performing the overseas medical screening examination. The testing modalities recommended for the medical examination include a medical history, physical examination, and diagnostic tests (see Table 9-01). CDC also monitors the quality of the overseas medical examination process through its Quality Assessment Program.

Additionally, CDC notifies state or local health departments of all arriving refugees, immigrants with class A conditions (with waiver), and immigrants with class B TB who are resettling in their jurisdiction and need follow-up evaluation and possible treatment. Department of State forms are collected at US ports of entry at the time of arrival. These forms summarize the results of the overseas medical examination and include classification of health conditions. This information is transmitted to state or local health departments electronically through CDC’s Electronic Disease Notification System.

State and local health departments are asked to report to CDC the results of these US follow-up evaluations and any significant public health conditions identified among recently arrived immigrants and refugees, as a way to better understand epidemiologic patterns of disease in recently arrived immigrants and refugees, and to monitor the quality of overseas medical examination.

BIBLIOGRAPHY

1. CDC. Technical instructions for panel physicians. Atlanta: CDC; 2010 [updated 2010 May 28; cited 2010 Apr12]. Available from: http://www.cdc.gov/immigrantrefuge....
2. Maloney S, Ortega L, Cetron M. Overseas medical screening for immigrants and refugees. In: Walker PF, Barnett ED, editors. Immigrant Medicine. Philadelphia: Saunders; 2007.
3. Office of Immigration Statistics. US Legal permanent residents: 2009. Washington, DC: US Department of Homeland Security; 2010 [cited 2010 Oct 29]. Available from: http://www.dhs.gov/xlibrary/assets/statistics/publications/lpr_fr_2009.pdf.
4. US Department of Homeland Security. Immigration and Nationality Act. Washington, DC: US Department of Homeland Security; 1952 [cited 2010 Nov 22]. Available from: http://www.uscis.gov/portal/site/us....
5. US Department of Homeland Security. Title 8 of Code of Federal Regulations (CFR). Washington DC: US Department of Homeland Security; 1938 [cited 2010 Nov 22]. Available from: http://www.uscis.gov/portal/sit....