Pre-Arrival Medical Screening and Interventions for Newly Arrived Refugees, Immigrants, and Migrants

Introduction

U.S.-based health professionals are likely to provide care to foreign-born patients at some time during their careers. Most of the millions of travelers who enter the United States every year are non-immigrants (e.g., short-term visitors, students, and temporary workers), but others belong to refugee, immigrant, or other migrant (RIM) populations. Some newcomers arrive with designations other than immigrant or refugee, such as humanitarian parolees. These newcomers arrive through different pathways for which pre-arrival medical screening or interventions may not be required. Table 9.1.1 provides the number of various immigrant and non-immigrant arrivals into the United States for fiscal year 2023. Definitions of immigrants, refugees, and other migrants, and the special categories of medical professionals (i.e., panel physicians, civil surgeons) who examine them before and after arrival to the United States are listed in Box 9.1.1.

The Immigration and Nationality Act mandates that all persons designated as immigrants or refugees undergo a health assessment before travel to the United States to identify inadmissible health-related conditions. The Centers for Disease Control and Prevention (CDC) develops the guidance for and monitors the quality of these health assessments and provides guidance for pre-travel public health interventions and post-arrival medical screening for U.S.-bound refugees (see Post-Arrival Medical Screening for Newly Arrived Refugees, Immigrants, and Migrants chapter). Parolee programs may have different medical screening requirements (see Humanitarian or Significant Public Benefit Parole for Individuals Outside the United States). Most non-refugee migrants and other travelers do not undergo an official medical examination before travel to the United States. Table 9.1.2 summarizes requirements and recommendations for overseas and post-arrival health examinations and public health interventions for immigrants, refugees, humanitarian parolees, and other migrants.

Table 9.1.1: Estimated number of newcomer arrivals to the U.S. for fiscal year 2023¹

Box 9.1.1

Table 9.1.2: Health examination and intervention requirements for refugee, immigrant, and migrant populations

The pre-travel health assessment

Immigrants

Overseas health assessment

An overseas health assessment is mandatory for all immigrant visa applicants. Guidance for this examination is referred to as Technical Inst­ructions. The purpose of the health assessment is to detect inadmissible health conditions, including communicable diseases of public health significance, mental health disorders associated with harmful behaviors, and substance-use or substance-induced disorders. The health assessment process includes a brief medical history and physical examination, a mental health evaluation, a review of vaccination records, testing for gonorrhea (by nucleic acid amplification), testing for syphilis (by serology), and tuberculosis (TB) screening.

Classification of medical conditions

Medical conditions of public health significance are categorized as Class A or Class B. Class A, or inadmissible, conditions preclude entry into the United States. An immigrant with a Class A condition might be issued a visa after the condition has been treated or after U.S. Citizenship and Immigration Services (USCIS) approves a waiver of visa ineligibility. Class B conditions indicate a departure from normal well-being, and post-arrival follow-up with a healthcare professional or local health department is recommended.

Required infectious disease screening and treatment

Overseas screening for TB is based on the CDC Tuberculosis Technical Instructions for Panel Physicians. These instructions call for chest radiographs for all immigrant applicants ≥15 years of age. In a recent update to the Technical Instructions, all applicants aged ≥2 years in high TB-burden countries (i.e., countries with incidence rates ≥20 cases per 100,000 population as estimated by the World Health Organization) must also be screened using an interferon-gamma release assay (IGRA). Those aged 2–14 years who have a positive IGRA are required to have chest radiographs taken. Three sputum specimens for acid-fast bacillus smears and cultures, in addition to molecular testing with a nucleic acid amplification test of the first sputum sample, are required for anyone whose chest radiograph is suspicious for TB, who has signs or symptoms compatible with TB disease, or who has known HIV infection. For immigrant applicants diagnosed with TB disease, Mycobacterium tuberculosis culture, drug-susceptibility testing, and directly observed TB therapy through the end of treatment are required before immigration.

Completion of treatment prior to departure is also required for certain other inadmissible conditions, including gonorrhea, syphilis, and Hansen's disease (leprosy).

Pre-arrival vaccinations

Immigrant visa applicants are required to receive any age-appropriate, Advisory Committee on Immunization Practices (ACIP)-recommended vaccines available in their country of residence for which they are eligible before departure to the United States. Panel physicians administer vaccines according to instructions based on ACIP recommendations, with some modifications for immigrants.

Health notifications at the time of arrival

CDC informs state or local health departments through the CDC Electronic Disease Notification (EDN) system of all arriving immigrants who have received USCIS waivers for Class A (notifiable) conditions, as well as those who have Class B conditions for which follow-up is recommended. Panel physicians document this information in eMedical, an electronic health record processing system used to document and transmit most immigrants' medical examination information. State and local health departments performing medical follow-up are asked to report their findings back to CDC, along with information about any other serious conditions of public health concern identified. This reporting helps CDC track epidemiologic patterns of disease among these populations and enables monitoring of the quality of overseas medical examinations.

Internationally adopted children

Overseas medical screening examination

Children adopted internationally by parents residing in the United States are considered a subcategory of immigrants; an overseas health assessment is mandatory (see International Adoption chapter).

Vaccinations

Parents adopting children internationally can request an immunization waiver for children <10 years of age by agreeing to begin immunizations ≤30 days of arrival in the United States. They should be made aware of the potential health risks associated with delaying the immunization process, even by a month. Vaccinating children before their arrival to the United States reduces the child's risk of contracting and importing diseases of public health concern, such as measles, which was reported in unvaccinated children adopted from China in 2004, 2006, and 2013.

Health notifications at the time of arrival

The information applying to immigrants regarding health notifications at the time of arrival also applies to internationally adopted children.

Refugees

Refugees typically resettle to the United States through the U.S. Refugee Admissions Program. While immigrants travel to the United States individually or with their families, refugees resettle in groups, on a predetermined schedule, with a 3- to 6-month window between the required overseas health assessment and departure for the United States.

Overseas medical screening examination

Refugees resettling to the United States are required to undergo an overseas health assessment conducted by a panel physician. The content and Technical Instructions for this examination are identical to those for immigrants (except see below regarding pre-arrival vaccination).

Pre-arrival vaccinations

Refugees resettling to the United States are not statutorily required to be vaccinated, leaving some individuals or groups more vulnerable to vaccine-preventable diseases. Prior to 2012, U.S.-bound refugees did not receive routine pre-departure vaccines, resulting in vaccine-preventable disease outbreaks and travel delays. In response, a voluntary global immunization program for U.S.-bound refugees was implemented in 2012 as a public health intervention to protect the health of refugees and to ensure U.S. health security.

Through this immunization program, overseas panel sites offer refugees bound for the United States most ACIP-recommended vaccines depending on age, historical immunization records, and vaccine availability. Pre-vaccination testing for hepatitis B virus infection using hepatitis B surface antigen (HBsAg) is offered to most refugees, subject to availability.

Resettled refugees applying for permanent residence in the United States ≥1 year after their arrival are not required to undergo a repeat health assessment but must demonstrate proof of receipt of age-appropriate, ACIP-recommended vaccinations to a U.S. civil surgeon during the adjustment-of-status process. In many states, refugee vaccination records from the overseas health assessment are transferred electronically into state immunization information systems at the time of arrival.

Other overseas public health interventions

The 3- to 6-month window between the overseas health assessment and departure affords an opportunity to implement additional recommended public health interventions aimed at improving the health of U.S.-bound refugees and ensuring U.S. health security.

Parasitic infections: presumptive treatment

Many refugees resettle to the United States from places with high prevalence of parasitic infections and other neglected tropical diseases (see Post-Travel Parasitic Disease Including Evaluation of Eosinophilia chapter). Depending on regional epidemiology, panel physicians offer refugees presumptive oral therapy to treat malaria (artemether-lumefantrine; see Malaria chapter), intestinal roundworms (albendazole), schistosomiasis (praziquantel; see Schistosomiasis chapter), and Strongyloides stercoralis (ivermectin) within a few days prior to departure. Data from several evaluations indicate that this strategy is cost-beneficial and dramatically decreases the prevalence of soil-transmitted helminthic infections and malaria among U.S.-bound refugees.

Fitness to fly

Panel physicians might identify refugees who have significant chronic medical conditions (e.g., cardiac disease, moderate or severe malnutrition, sickle cell disease) during the health assessment. While these conditions do not pose a public health risk—and therefore do not render the refugee inadmissible—they can result in complications during air travel. CDC, in close collaboration with partners (e.g., the International Organization for Migration), has developed specific protocols to help panel physicians identify, manage, and stabilize refugees with complicated medical conditions before their departure to enable safe travel.

Health notifications at the time of arrival

States receive all records from refugees' overseas health assessment, including vaccination records, through EDN.

Parolees

Parolees are granted admission to the United States temporarily, for urgent humanitarian reasons or significant public health benefit. They typically enter the United States under specific parolee programs and have different medical screening requirements from immigrants and refugees that can include overseas examinations and pre-travel vaccination requirements, or attestations to obtain screening/vaccines after arrival in the United States (see Humanitarian or Significant Public Benefit Parole for Aliens Outside the United States).

Special immigrant visa program for Afghans

Certain Iraqis and Afghans who were employed by or on behalf of the U.S. government are granted a Special Immigrant Visa (SIV) overseas by the U.S. Department of State and are granted lawful permanent resident status upon admission to the United States. After their arrival, Iraqi and Afghan special immigrants are eligible for the same resettlement assistance and federal public benefits as refugees (see Iraqi and Afghan Special Immigrant Visa Programs).

Individuals entering the United States under these programs are required to undergo overseas health assessments and generally receive vaccinations according to the U.S. requirements for immigrants. Afghan SIV holders may have additional vaccination requirements and are eligible for certain overseas public health interventions, such as presumptive parasite treatment and fitness to fly assessments, based on USRAP guidance.

Post-travel health assessment

Some new arrivals, including refugees and SIV holders, are eligible for a domestic health assessment in the first 90 days after arrival. These health assessments include a medical history and physical examination, screening for infectious and chronic diseases, vaccinations, mental health screening, and provide an opportunity to follow up on conditions identified during the pre-travel health assessment and to identify new medical conditions (see Post-Arrival Medical Screening for Newly Arrived Refugees, Immigrants, and Migrants chapter and CDC's Refugee Health Domestic Guidance).