Health Screening in Immigrants, Refugees, and International Adoptees

Mandatory Immigration Screening in the United States: Medical Component

The routine examination of travelers and migrants is one of the oldest recorded activities directed at civic administration and protecting the health of the public. The development of European quarantine practices in the mid-14th century was associated with the routine inspection of new arrivals, commercial goods, and conveyances in an attempt to prevent the introduction of epidemic infectious diseases. Those deemed to be at risk following inspection were contained, excluded, or expelled. These early public health activities accompanied the European settlement of the Americas.

Shortly after achieving nationhood, early legislative tools were introduced creating the US Public Health Service, whose initial role was to provide medical care to seafarers and to control the importation of serious diseases epidemic at the time, such as cholera and plague. A linkage to immigration later followed, with the screening of immigrants to exclude those with unwanted medical conditions such as certain loathsome diseases, individuals of suspected low moral behavior, and people with mental deficiencies who were likely to become wards of the state. In the United States, this process began in the late 1800s when the control of immigration was legally recognized as a congressional responsibility. Subsequently, the US Immigration Act of 1882 made specific reference to controlling the admission of immigrants on medical grounds. The routine medical inspection of immigrants was legislatively mandated in the United States in 1891.

Public health programs and policies designed to manage the major medical challenges of the day became linked to the routine medical inspection of immigrants on arrival. By the 1920s, the immigration medical inspection was extended to the European points of origin for the majority of migrants, creating a system of pre-departure immigration medical screening that continues to this day.

The legal basis governing inadmissibility to the United States because of health-related conditions and authorization to undertake medical examination to determine that admissibility is found in the Immigration and Nationality Act (INA) (Title 8 US Code). Under these provisions foreign aliens residing outside of the United States can be denied visas and rendered ineligible to enter the country. These provisions also extend to foreigners already residing in the United States who apply to become permanent residents.

The immigration medical examination provides the opportunity to determine whether the foreign national (known as an “alien” in the legislation) is ineligible for permission to enter the United States (known as Class A conditions) or has an illness or disorder that may interfere with independent self-care, education, or employment or may require future extensive medical treatment or institutional support (known as Class B conditions).

Health-related reasons that exclude admission (Class A conditions) to the United States include:

• 1.

  A communicable disease of public health significance

• 2.

  A physical or mental disorder or behavior posing a threat to property, safety, or welfare (either currently present or likely to recur)

• 3.

  Drug abuse or addiction

• 4.

  Failure to present documentation demonstrating having received recommended vaccinations.

The Department of Health and Human Services provides specific regulations (Medical Examination of Aliens 42 CFR, Part 34) to define and implement the health aspects of the INA. These regulations identify those who require medical examination, outline the process, define where and by whom the examinations are performed, and list the specific conditions associated with inadmissibility. The regulations also define conditions or disorders that, while not serious enough for exclusion, are significant enough (Class B conditions) that they must be brought to the attention of consular authorities. The Division of Global Migration and Quarantine at the Centers for Disease Control and Prevention (CDC) administers the regulations.

Currently, the regulations list the following as communicable diseases of public health significance:

• Active tuberculosis

• Infectious syphilis

• Gonorrhea

• Infectious leprosy

• Chancroid

• Lymphogranuloma venereum

• Granuloma inguinale

• Human immunodeficiency virus (HIV) infection

• Quarantinable diseases designated by any Presidential Executive Order

  • Current diseases include cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers, severe acute respiratory syndrome, and influenza caused by novel or re-emergent influenza (pandemic flu)

• Any communicable disease that is a public health emergency of international concern reported to the World Health Organization (WHO) (under revised International Health Regulations of 2005)

  • For example, smallpox, poliomyelitis due to wild-type poliovirus, cholera, or viral hemorrhagic fevers (including Ebola)

Currently a medical examination is required for all refugees entering the United States and all those applying for an immigrant visa from outside the United States. Foreign residents in the United States applying to become permanent residents also require mandated medical examinations. Panel physicians, designated by consular officers of the US Department of State, perform medical examinations abroad, and civil surgeons, designated by the US Citizenship and Immigration Services, perform medical examinations for aliens who are already present in the United States. Both groups of physicians receive technical instruction and guidance from the CDC's Division of Global Migration and Quarantine.

Detailed medical history and physical examination are required for all individuals (see summary in Table 19.1 ). In addition, applicants who are ≥15 years undergo routine chest radiography and serologic testing for HIV and syphilis.

Those between 2 and 14 years of age who reside in a country where tuberculosis incidence rates (based on WHO data) are ≥20 per 100,000 have either a tuberculin skin test (TST) or an interferon gamma release assay (IGRA). If either the TST or IGRA are positive, the individual undergoes chest radiography. Depending on the clinical history, TST, IGRA, and radiological findings, supplementary screening requirements for tuberculosis include smears of respiratory secretions for acid-fast bacilli and cultures for tuberculosis. Any positive cultures undergo drug susceptibility testing.

Those rated Class A for tuberculosis (smear-positive infectious) generally must be treated until their sputum smears are negative before they are allowed to transit for immigration. Those rated Class B for tuberculosis are cleared for travel within certain time limits. Failure to journey to the United States within those time limits will require the individual to undergo rescreening.

Since 1996, individuals applying for immigrant visas to entry into the United States have had to demonstrate proof of vaccination for several vaccine-preventable diseases. Initially, these were general, routine vaccinations as recommended by the Advisory Committee for Immunization Practices (ACIP) for the domestic US population. In 2009, however, specific criteria for those requiring an immigration medical exam were adopted by the CDC.

Those criteria are:

• 1.

  The vaccine must be age appropriate (as recommended by the ACIP).

  • and

• 2.

  At least of these two conditions must be met:

  • a)

    The vaccine must offer protection against a disease with the potential to cause an outbreak.

  • b)

    The vaccine must protect against a disease that has been eliminated or is being eliminated in the United States.

At the time of the preparation of this chapter, required vaccines were:

• Diphtheria

• Tetanus

• Pertussis

• Polio

• Measles

• Mumps

• Rubella

• Rotavirus

• Haemophilus influenzae type b

• Hepatitis A

• Hepatitis B

• Meningococcal

• Varicella

• Pneumococcal

• Influenza

Immunizations recommended and required for US immigration purposes are summarized in the CDC's “Technical Instructions for Panel Physicians for Vaccinations,” available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/vaccination-panel-technical-instructions.html#status .

Pre-admission vaccination requirements do not apply for refugees or non-immigrant visa applicants. However, those individuals are required to meet the vaccination standards when they adjust their status in the United States after admission. As a procedural consequence, the immunization status of refugees is recorded during immigration process.

In the case of children adopted abroad, the vaccination requirements do not apply to those 10 years of age or younger. However, the adoptive parents must sign documentation stating that they are aware of US vaccination requirements and will ensure that all required vaccinations will be received within 30 days of the child's arrival in the United States.

The importance and cost-effectiveness of preventative medical interventions in the overseas environment, before transit to the United States, is receiving greater attention as a potential part of the immigration medical process. Currently, some refugee populations being resettled in the United States who are determined to be at increased risk for specific infections receive population-based treatment for malaria and intestinal parasites in addition to the routine immigration medical screening. Additionally, outbreaks of communicable diseases in refugee camps or transit facilities can trigger additional interventions or treatment prior to arrival.

In terms of harmful behavior, immigration medical screening is intended to identify those with neurologic or behavioral conditions associated with the risk of “ever causing serious injury to others, major property damage or having trouble with the law because of a medical condition, mental condition, or influence of alcohol or drugs” or “ever taken actions to end your [the applicant's] life.” High-risk conditions in this group may be determined to be Class A (inadmissible) or Class B (admissible) conditions by panel physicians, depending on clinical findings, history, and situation.

Drug abuse or addiction (dependence) presents a Class A (inadmissible) situation. Those barred from admission are those who:

• Use a controlled substance (defined by the Controlled Substances Act)

• and

• Meet the Diagnostic and Statistical Manual of Mental Disorders criteria for a mild, moderate, or severe substance use disorder.

It is sometimes possible for those individuals subject to medical examination who are determined to have a communicable disease of public health significance to still enter the United States. The legislation provides for a waiver process by which those determined to be inadmissible may request entry subject to conditions.

Documents providing further operational descriptions on the immigration medical screening process for both applicants abroad and those applying within the United States, including details on applicants seeking a change in immigration status, the use of Panel Physicians and Civil Surgeons, and reporting requirements, are available at http://www.cdc.gov/immigrantrefugeehealth/ .