Refugee children and international adoptees have special medical considerations that must be addressed. Providers must be aware of the immigration history, where, and under what circumstances the child lived and migrated to the United States. Federal guidelines exist regarding which infections should be screened for, and how and when and which vaccines should be administered.
Key points
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Refugee children and international adoptees have special medical considerations that must be addressed.
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Providers must be aware of the immigration history — where and under what circumstances the child lived and migrated to the United States.
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Federal guidelines exist regarding which infections should be screened for and how and when and which vaccines should be administered.
When caring for children who arrive from other countries, it is important to establish whether these children are immigrants or refugees. Children who arrive as refugees are required to undergo a physical examination prior to entering the United States and are required to have a physical evaluation after arrival in the United States. If a child enters the United States as an immigrant, it is important to understand whether he or she is an undocumented immigrant, given that this can impact on what types of infectious diseases should be screened for.
In all cases, it is important to know the countries and situations children were in when they left their native country and began their journey to their new home. Issues of communicable diseases, vaccine delivery, sanitation, nutrition, and the potential for sexual abuse are all important in consideration of infectious diseases. This article addresses screening tests for immigrants and refugees first, next addresses international adoptees who fall under the first category but can potentially have some other infectious issues given their unique background, and then addresses screening tests for migrants without premigration medical examination.
Immigrants and refugees
For immigrants and refugees entering the United States, the Centers for Disease Control and Prevention (CDC) is responsible for providing the instructions for medical examination performed by identified civil surgeon and panel physicians. These instructions were developed to enforce the Immigration and Nationality Act regulations regarding the health-related grounds for inadmissibility of persons applying for admission into the United States. The purpose of the medical examination is to identify applicants with inadmissible health-related conditions for the Department of State and US Citizenship and Immigration Services (USCIS). The infectious diseases–related grounds for inadmissibility include persons who have a communicable disease of public health significance and those who fail to present documentation of having received vaccination against vaccine-preventable diseases ( Table 1 ).
| Category | Medical Examination | Examination Site | Examination Location |
|---|---|---|---|
| Immigrants | Yes | Panel physicians | Overseas |
| Refugees | Yes | Panel physicians | Overseas |
| Status adjusters | Yes | Civil surgeons | United States |
| Nonimmigrants | No | — | — |
| Short-term transit | No | — | — |
| Others a | No | — | — |
a Others include migrants who entered the United States without inspection, including those who entered with and without proper documentation.
Communicable diseases of public health significance in all immigrants include tuberculosis (TB), syphilis, gonorrhea, and Hansen disease. In addition to these 4 specific diseases, screening by history and physical examination includes evaluation for quarantinable diseases designated by any presidential executive order. Current diseases include cholera, diphtheria, plague, smallpox, yellow fever, viral hemorrhagic fevers, severe acute respiratory syndrome (SARS), and influenza caused by novel or re-emergent influenza (pandemic flu). In addition to these infectious diseases, other infectious diseases are reportable as a public health emergency of international concern to the World Health Organization (currently polio, smallpox, SARS, and influenza) and other public health emergencies of international concern (recently includes Ebola virus).
As part of the medical examination for immigration, all immigrants are required to have an assessment for the following vaccine-preventable diseases: polio, tetanus, diphtheria toxoids, pertussis, Haemophilus influenzae type B, rotavirus, mumps, measles, rubella, hepatitis A, hepatitis B, meningococcal disease, varicella, influenza, and pneumococcus.
Persons already in the United States applying for adjustment of status for permanent residency, including refugees, are also required to be assessed for these vaccine-preventable diseases. For vaccines requiring a series, only a single dose is required for immigration purposes with a plan to complete the necessary series of vaccinations. Individuals who want to obtained a personal belief waiver (based on religious or moral conviction) from the vaccine requirements can apply for this with a separate application process.
A list of civil surgeons and medication documentation needs for individuals applying for permanent status is available on the USCIS Web site: http://www.uscis.gov/portal/site/uscis .
The information regarding medical documentation required for individuals applying for immigrant visas is available at the Department of State Web site: http://www.travel.state.gov/visa/visa_1750.html . General information concerning civil surgeons and the medical examination required for immigration purposes is also available at www.uscis.gov .
The blanket designation of health departments as civil surgeons applies only to the vaccination assessment and only to refugees. Also, only health departments that have a physician or physicians meeting the legal definition of civil surgeon can participate in this designation, and accepting the designation is entirely voluntary on the part of health departments. A civil surgeon is legally defined as a licensed physician with greater than 4 years of professional experience. The completed I-693 medical examination form must contain the official stamp or seal of office and be given to a refugee in a sealed envelope for presentation to the USCIS. The vaccine series that must be completed is available from the CDC.
Overseas medical examinations of aliens are valid for variable amounts of time, as discussed later, for specific infectious illnesses.
Medical examinations are valid for 6 months for individuals with the following conditions:
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No class (ie, no apparent defect, disease, or disability)
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Class A other than TB
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Class B2 latent TB infection
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Class B3 TB (contact evaluation)
Medical examinations are valid for 3 months for individuals with the following conditions:
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Class A TB with waiver
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Class B1 TB, pulmonary
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Class B1 TB, extrapulmonary
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HIV infection
The American Academy of Pediatrics recommends that medical screening should be conducted as soon as possible after entry, and refugees should be assured ongoing primary care.
A general medical examination should include a history outlining nutrition and growth with a dietary history, reviewing previous vaccines, history of diseases, and a general physical examination. On physical examination, anthropometric indices of weight, length or height, and head circumference should be obtained.
Previous vaccinations should be recorded into a computerized state vaccination database as well as history of disease (eg, varicella and mumps) or laboratory evidence of immunity (eg, hepatitis B and rubella). The author recommends that any series of vaccinations that has been started should be completed and not repeated if given as recommended by the Advisory Committee on Immunization Practices. If a patient has no documentation, it must be assumed the patient has not been vaccinated unless laboratory evidence of immunity indicates otherwise.
Regarding all refugees, little screening laboratory work is suggested; however, the following is a potential algorithm to consider when evaluating these patients.
Laboratory Recommendations for all Refugees
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Perform pregnancy test as indicated.
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Perform complete blood cell count with differential to be able to look for evidence of anemia and an absolute eosinophil count.
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Some specialists recommend a urinalysis but this is optional in patients unable to provide a clean-catch specimen.
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Consideration of tuberculosis screening.
The 4 most commonly queried categories of infectious illnesses are addressed, specifically given the frequency at which they are encountered when caring for immigrants, migrants, and refugees. These 4 groups of illnesses include TB, malaria, and parasitic infections and sexually transmitted infections (STIs).
Tuberculosis
The current TB screening requirements, called the Technical Instructions for Tuberculosis Screening and Treatment Using Cultures and Directly Observed Therapy, were most recently updated in 2009. These requirements were first created, however, in 1991 and have been updated throughout the years. These technical instructions have been implemented on a country-by-country basis since 2007 and have been used by all countries that screen immigrants and refugees coming to the United States. These instructions include tests and procedures for diagnosing TB more quickly and more accurately. Factors that affect the choice of TB tests for children include their age, whether they have a known HIV infection, and if they have signs or symptoms of tuberculous disease.
TB screening varies by both age and HIV status. In children less than 2 years of age without HIV infection, no TB screening tests need to be performed unless a child has signs or symptoms suggestive of TB or has been in contact with a person with TB. In children between 2 years and 14 years of age without HIV infection, a screening tuberculin skin test (TST) or interferon-gamma release assay (IGRA) is indicated followed by a chest radiograph if either is positive. If the screening radiograph is indicative of TB diseases, then sputum smear and subsequent cultures are obtained and drug susceptibility tests are performed in individuals with positive smears. In teens over 15 years of age, a chest radiograph is required in all patients with subsequent sputum smear and culture and drug susceptibility testing as indicated. If a patient has symptoms of TB, even with negative TST/IGRA and chest radiograph results, sputum tests are indicated.
All children and adolescents with known HIV infection undergo evaluation for TB regardless of symptoms. It is well documented that HIV infection is one of the most common risk factor to cause latent (inactive) TB infection to become (active) TB disease. For children less than 15 years of age, a TST or IGRA is obtained as well as chest radiograph, sputum smear, and culture regardless of the results of the TST or IGRA. For adolescents over 15 years of age, a chest radiograph and sputum smear and cultures and susceptibility testing is proceeded to directly, without need for TST or IGRA.
The different TB tests include the TST, IGRA, sputum sample, sputum smear, sputum culture, and drug susceptibility testing ( Table 2 ). The TST is considered positive in children less than 4 years of age if it measures greater than 5 mm of induration regardless of bacillus Calmette-Guérin vaccination status. Some practitioners consider a measurement of 10 mm or greater as a positive in children. In these situations, a chest radiograph must be obtained and if a child is symptomatic, sputum samples via sputum induction or early morning gastric aspirate is required. These samples are examined for acid-fast smears and cultures that are held for 8 weeks. If a positive sputum culture is obtained, drug susceptibility testing is essential. It is also critical to find the adult who transmitted the disease to the child, although in refugees this may not be possible if a child is separated from parents or adults who cared for the patient prior to entrance to the United States. If children have active TB disease, they usually are treated with directly observed therapy for at least 6 months. For children who have TB infection, this is typically not directly observed therapy but with physician follow-up at intervals and the end of therapy is appropriate.
