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2009 Technical Instructions for Panel Physicians for Vaccinations

Preface

On November 13, 2009, the Centers for Disease Control and Prevention (CDC) adopted specific vaccination criteria that would be required for any person who seeks a U.S. immigrant visa. Previously, the amendment to the Immigration and Nationality Act (INA) required that immigrant visa applicants receive all routine vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) for the U.S. domestic population.

The ACIP is an advisory committee that makes general recommendations on immunizations, including safe and effective vaccination schedules. Prior to 2009, ACIP recommendations had been applied to immigrant visa applicants without consideration for the unique characteristics of overseas medical screening. While routine ACIP vaccination recommendations are appropriate for the general U.S. population, specific criteria for vaccination requirements for immigrants outlined below take into consideration the potential of vaccine-preventable diseases to cause outbreaks and/or be introduced into the United States. Several vaccines specifically listed in the INA as routinely recommended vaccines by ACIP also continue to be required.

The specific vaccination criteria are as follows:

  1. The vaccine must be an age-appropriate vaccine as recommended by ACIP for the general U.S. population,

    AND

  2. At least one of the following:
    • The vaccine must protect against a disease that has the potential to cause an outbreak. An outbreak is defined as the occurrence of more cases of disease than expected in a given area or among a specific group of people. The outbreak must occur over a given period of time. For endemic diseases, an outbreak occurs when incidence rises above the normally expected level. For diseases with seasonal variation, the average incidence rates over particular weeks or months of previous years, or average high or low levels over a period of years, may be used as baselines.
    • The vaccine must protect against a disease that has been eliminated in the United States, or is in the process of being eliminated in the United States.

Further information on the vaccination criteria is available at Notice of Revised Vaccination Criteria for U.S. Immigration

The following age-appropriate vaccinations are required for the immigration examination based on the above criteria or per INA Section 212. (8 U.S.C. 1182)(a)(1):

  • Diphtheria
  • Tetanus
  • Pertussis
  • Polio
  • Measles
  • Mumps
  • Rubella
  • Rotavirus
  • Haemophilus influenzae type b
  • Hepatitis A
  • Hepatitis B
  • Meningococcal
  • Varicella
  • Pneumococcal
  • Influenza

The instructions in this document supersede all previous vaccination-related "Technical Instructions," "Updates to the Technical Instructions," and memoranda or letters to panel physicians. These instructions are to be followed for vaccination requirements for all U.S. immigrant visa applicants.

Inquires regarding vaccination requirements for immigration may be sent to CDC's Division of Global Migration and Quarantine (DGMQ) at cdcqap@cdc.gov.

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Significant Changes in the Vaccination Requirements

  • Human papillomavirus vaccine and zoster vaccine are no longer required.
  • All other age-appropriate, ACIP-recommended vaccines continue to be required.

Significant changes in U.S. immigrant vaccination requirements since the last revision in 2007 of the "Technical Instructions to Panel Physicians for Vaccination Requirements" are—

  • Human papillomavirus vaccine does not need to be given to females 11 through 26 years of age.
  • Zoster vaccine does not need to be given to persons 60 years of age or older.
  • Meningococcal conjugate vaccine, specifically tetravalent meningococcal conjugate vaccine (MCV4), should be given to persons 11 through 18 years of age. Meningococcal polysaccharide vaccine (MPSV) or other forms of meningococcal conjugate vaccine (e.g., monovalent MCV) is not an acceptable alternative for this age group.
  • Influenza vaccine is required for applicants 6 months through 18 years of age during the influenza (flu) season in the country of examination for immigration. Influenza vaccine continues to be required for adults 50 years of age or older.

Further information and updates on the required vaccines are available at CDC's DGMQ website, http://www.cdc.gov/ncidod/dq/health.htm and CDC's National Center for Immunization and Respiratory Disease (NCIRD) website, http://www.cdc.gov/vaccines.

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Procedure for Vaccination Assessment Status

The following instructions and accompanying tables are based on recommendations by ACIP and have been developed to provide guidance to panel physicians performing medical examinations and assessments of vaccination status for any person who seeks a U.S. immigrant visa.

  • Determine the age of each applicant.
  • Review each applicant's medical history and records.
  • Determine the vaccines each applicant needs.
  • Assess contraindications and precautions.
  • Assess each applicant's laboratory needs.

Vaccination Requirements for Immigrant Visa Applicants

All immigrant applicants must be assessed for vaccination requirements (Table 1). The panel physician must review all vaccination records presented by the applicant during this process and record the vaccination assessment results on the U.S. Department of State Vaccination Documentation Worksheet (DS-3025). The required vaccines based on the applicant's age at the time of the medical evaluation must be administered. Age-based immunization schedules recommended by ACIP should be followed and are available at http://www.cdc.gov/vaccines/recs/schedules. For example, if the applicant is 12 months of age at the time of the examination, then he or she is required to receive the following vaccines if he or she had never received them previously:

  • Diphtheria, pertussis, and tetanus (DTP) or diphtheria, tetanus, and acellular pertussis (DTaP) or diphtheria and tetanus (DT)
  • Inactivated poliovirus (IPV) or oral poliovirus (OPV)
  • Measles, mumps, and rubella (individually or in combination, e.g., MMR, MMRV)
  • Haemophilus influenzae type b (Hib)
  • Hepatitis A
  • Hepatitis B
  • Varicella (if no history of varicella disease)
  • Pneumococcal conjugate vaccine
  • Influenza (if flu season in country of examination)

Note: If the applicant receives MMRV, then he or she does not need to receive the single-antigen varicella vaccine.

For example, if the applicant is 35 years of age, then he or she is required to receive tetanus and diphtheria toxoids vaccine (Td) or tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap), MMR, and varicella (if no history of varicella disease). If the applicant had previously received a dose or doses of a required vaccine but had not completed the series, then the next required dose should be administered according to standard ACIP recommendations.

When the panel physician administers the vaccines, he or she must screen the applicant for contraindications and discuss with the applicant any potential adverse reactions. After administering any needed vaccines, the panel physician must complete the DS-3025 and provide a copy of the completed form to the applicant for his or her personal records. After the applicant has received the required vaccinations and the DS-3025 has been completed, the applicant has fulfilled U.S. immigration vaccination requirements.

Because completion of the vaccine series often requires several months, immigrant visa applicants are not required to have received all doses of the ACIP-recommended vaccines prior to departure. Rather, they are required to have received at least one dose of each vaccine, and they are encouraged to receive as many additional doses as possible. The panel physician should stress the need for the applicants to complete the series after arrival in the United States.

Review Vaccination Records

The panel physician should encourage the applicant to submit all available written records of vaccination history for review. This can include records from the applicant's country of origin, and for refugees, records of vaccination from refugee camps or countries of asylum. For applicants who need a medical examination but who do not need to receive vaccinations, panel physicians must complete the DS-3025 if reliable documents are available. For additional instructions about completing the DS-3025, see DGMQ's website, http://www.cdc.gov/ncidod/dq/dsforms.

Vaccination Documentation

Acceptable vaccination documentation must come from a vaccination record, either a personal vaccination record or a copy of a medical chart with entries made by a physician or other appropriate medical personnel. Only those records of doses of vaccines that include the dates of receipt (month, day, and year) are acceptable. The document must not appear to have been altered, and dates of vaccinations should seem reasonable. Self-reported doses of vaccines without written documentation are not acceptable.

Vaccination Documentation for Refugees and Non-Immigrant Applicants

The U.S. Citizenship and Immigration Services (USCIS) has determined that vaccination requirements do not apply to refugees and non-immigrants, such as V or K visa applicants, at the time of their initial admission to the United States. However, V and K visa holders in addition to refugees must meet the vaccination requirements when applying for adjustment of status or permanent resident status in the United States (one year or more after arrival). Therefore, for refugee applicants, panel physicians must complete a U.S. Department of State Vaccination Documentation Worksheet (DS-3025) if reliable documents are available.

Vaccination Documentation for Adoptees

USCIS has determined that vaccination requirements do not apply to adopted children 10 years of age or younger, provided the adoptive parent, prior to the child's admission, signs an affidavit stating that the parent is aware of U.S. vaccination requirements and will ensure that the child will receive required vaccinations within 30 days of the child's arrival in the United States. However, if the country in which the examination is performed is party to the Hague Adoption Convention, adopted children must be vaccinated according to the requirements in these Technical Instructions. For a list of countries that are parties to Hague Adoption Convention, see the Department of State website at http://adoption.state.gov/hague/overview/countries.html.

If the adopted child has a history of vaccinations, the panel physician must complete the DS-3025 form if reliable vaccination documents are available.

Vaccinations Received Outside the United States

Since most vaccines used worldwide are from reliable local or international manufacturers, it is reasonable to assume that any vaccine received by an applicant was of adequate potency. However, the vaccination schedules should be consistent with those recommended by ACIP.

Identify Potential Contraindications or Precautions to Vaccination

  • Vaccines should not be administered when a contraindication, such as severe allergic reaction to a vaccine component, is present.
  • Live vaccines should not be administered to pregnant women and severely immunosuppressed persons.

The panel physician should identify any past or present condition that might be a contraindication or precaution for the administration of a vaccine. A contraindication is a condition in a recipient which is likely to result in a life-threatening problem if the vaccine is given. A precaution is a condition in a recipient that might increase the chance of a serious adverse reaction if the vaccine is administered, or a condition that might compromise the ability of the vaccine to produce immunity.

General contraindications for the administration of a vaccine include:

  • Severe (anaphylactic) allergic reaction to a vaccine component or following a prior dose of a vaccine
  • Severely immunocompromised conditions that contraindicate receiving live attenuated vaccines, notably measles, mumps, and rubella, oral poliovirus, varicella, and intranasal influenza vaccines
  • Pregnancy as a contraindication for receiving live attenuated vaccines for measles, mumps, and rubella, oral poliovirus, varicella, and intranasal influenza
  • Encephalopathy not due to another identifiable cause as a contraindication if it occurs within 7 days of pertussis vaccination.

The following conditions are not contraindications for the administration of a vaccine:

  • Mild to moderate local reactions to a previous dose of vaccine
  • Mild acute illness (e.g., low-grade fever, upper respiratory infection, diarrhea)
  • Recovering from an illness
  • Pregnancy for receiving Td, Tdap, inactivated influenza, or hepatitis B vaccine
  • Breastfeeding
  • Antimicrobial therapy
  • Tuberculin skin testing

Some precautions to vaccination include:

  • Moderate or severe acute illness
  • Any of the following after a previous dose of DTP or DTaP:
    • Fever >40.5° C (>105° F) that is not attributed to another identifiable cause occurring within 48 hours after vaccination
    • Collapse or shock-like state (that is, a hypotonic-hyporesponsive episode) occurring within 48 hours after vaccination
    • Persistent, inconsolable crying lasting 3 hours or more and occurring within 48 hours after vaccination
    • Convulsions with or without fever occurring within 3 days after vaccination.

In general, vaccines are deferred when a precaution condition is present. If the decision to defer a vaccine is reached, the condition should be recorded as a medical condition and the "Contraindication" waiver box on the DS-3025 must be checked.

Contraindications and precautions to specific vaccines are shown at—http://www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm.

For pregnant women, contraindications and precautions are shown at—http://www.cdc.gov/vaccines/pubs/preg-guide.htm.

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Laboratory Support

  • Laboratory evidence of immunity is acceptable for measles, mumps, rubella, hepatitis A, hepatitis B, polio, and varicella.

The panel physician should obtain a good history of acute, vaccine-preventable diseases, including measles, mumps, rubella, and varicella, from the applicant to identify any naturally acquired diseases for optional laboratory confirmation. An applicant who provides a reliable written or oral history of varicella disease does not require laboratory confirmation or further vaccination.

Laboratory evidence of immunity is acceptable for the following diseases: measles, mumps, rubella, hepatitis A, hepatitis B, polio, and varicella. The latter is only necessary when a history of varicella disease is questionable.

Acceptable tests for the presence of antibodies are U.S. Food and Drug Administration (FDA)-approved kits, Clinical Laboratory Improvement Amendments (CLIA)-certified kits or kits approved by similar agencies outside the United States. In the use of any approved kits, the manufacturer's guidelines or instructions must be followed, including not using a kit when past its expiration date or if not maintained according to the manufacturer's directions. Standard precautions in drawing blood (e.g., use of disposable gloves and sterile needles) and appropriate needle disposal must also be followed.

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Procedure for Completing the Vaccination Documentation Worksheet (Form DS-3025)

The panel physician is responsible for—

  • Completing the applicant identification information and all other sections of the DS-3025.
    • Until the DS-3025 is modified to remove vaccines that are no longer required, a line should be marked across human papillomavirus and zoster vaccines, and "Not Required" should be written.
  • Copying the dates of all acceptable documented vaccinations from written records under "Part 1. Immunization Record" in the appropriate "Date received" of DS-3025. Any vaccine administered by the panel physician is to be indicated in the "Vaccine Given by Panel Physician" section of DS-3025.
    • Doses should be recorded chronologically (month, day, and year as numbers corresponding to mm/dd/yyyy), from left to right.
  • Completing the vaccination series.
    • If the applicant has completed the vaccination series, the "Completed Series" box for each vaccine must be checked on DS-3025.
    • If as a result of a laboratory test, the applicant is identified as fully immune, the month, date, and year of the test must be written in the "Completed Series" box for each applicable vaccine.
    • If a reliable written or oral history of varicella disease is given, "VH" (varicella history) must be written in the "Completed Series" box for varicella.
  • Reviewing any incomplete vaccination series to determine if eligible for a blanket waiver.

    A blanket waiver is a waiver that is applied uniformly to a group of conditions and does not require a separate waiver application or fee to be filed with USCIS. In many cases, it might not be medically appropriate to administer a dose of a particular vaccine. Five "Not Medically Appropriate" categories are acceptable when determining an applicant's eligibility for a blanket waiver.

    The five "Not Medically Appropriate" categories are—

    • Not age appropriate

      For each vaccine for which administration is not age appropriate, the "Not age appropriate" waiver box must be checked. For all applicants, this box will need to be checked for at least one vaccine. For example, infants and adults do not need meningococcal vaccine, and adults do not need Hib vaccine.

    • Insufficient time interval between doses

      If the minimum time interval between the last documented dose and the next required dose has not passed, the "Insufficient time interval" waiver box for that vaccine must be checked.

      If administration of the single dose of a vaccine at the time of the medical examination does not complete the series for that vaccine, the "Insufficient time interval" waiver box must be checked to indicate that additional doses will be needed to complete the series for that vaccine.

    • Contraindication

      If an applicant has contraindications to specific vaccines, the "Contraindication" waiver box for that vaccine must be checked.

    • Not routinely available

      When the required vaccine is not licensed or not routinely available in the country where the medical examination is performed, the "Not routinely available" waiver box must be checked.

    • Not fall (flu) season

      Influenza vaccine is required during the influenza (flu) season in the country of examination. The flu season usually occurs during fall and continues through early spring in temperate areas, where influenza activity peaks from December to March. Influenza occurs throughout the year in tropical areas. The influenza vaccine might be available only during the flu season in the country of examination. Therefore, if that is the case, the "Not fall (flu) season" waiver box must be checked at other times of the year.

  • Completing "Part 2. Results."

    After reviewing entries in "Part 1. Immunization Record" for all the vaccines, the appropriate box under "Part 2. Results" must be checked.

    • Vaccination history incomplete: Applicant may be eligible for blanket waiver(s).

      Completion of a vaccine series is not required to conclude the medical examination, because such a requirement would require multiple visits to a panel physician and could lead to unnecessary delay in the immigration process. If any of the boxes under the "Not Medically Appropriate" heading was checked, the "Applicant may be eligible for blanket waiver(s) because vaccination(s) not medically appropriate (as indicated above)" box must also be checked. This box will probably always be checked because some vaccines may not be age appropriate for the applicant.

    • Vaccine history incomplete: Applicant may request a waiver based on religious or moral convictions.

      If an applicant objects to vaccination based on religious or moral convictions, the "Applicant will request an individual waiver based on religious or moral convictions" box must be checked. This is not a blanket waiver, and the applicant will have to submit a waiver request to USCIS.

    • Vaccine history is complete for each vaccine.

      If the applicant has met the vaccination requirements, i.e., completed the series for all required vaccines, the "Vaccine history complete for each vaccine, all requirements met" box must be checked.

    • Applicant does not meet immunization requirements.

      If an applicant's vaccine history is incomplete and the applicant refuses administration of a single dose of any required vaccine that is medically appropriate for the applicant, the "Applicant does not meet vaccination requirements for one or more vaccines and no waiver is requested" box must be checked.

  • Completing "Part 3. Panel Physician."

    The panel physician should review the entire DS-3025 for completeness and accuracy before signing the document. The document must be legible, and all names and dates must be either printed or typed. The panel physician's signature on this document signifies the reliability of the document to the best of the physician's knowledge. The signature should be an original or a stamp of the panel physician's signature.

    The primary intent of this document is for presentation to USCIS to meet immigration vaccination requirements. However, an extra copy must be provided to the applicant as an important vaccination record that might be used later by other health-care providers, schools, and other institutions. In addition to the completed DS-3025, a copy of vaccination records provided by the applicant to the panel physician should be attached.

Vaccine Handling, Storage, and Administration

Proper handling and storage of vaccines are important to ensure the potency of vaccines. If vaccines are not properly handled or stored, their potency is reduced, and they may not produce immunity.

A checklist of essential information on appropriate equipment and standard operating procedures is available at DGMQ's website: http://www.cdc.gov/ncidod/dq/pdf/ti_vacc_handl_admin_guid.pdf[PDF - 22 KB]. Additional guidance on the storage and handing of vaccines is available at the CDC's NCIRD website: http://www.cdc.gov/vaccines/pubs/vac-mgt-book.htm.

Counseling and Resources

The panel physician must counsel all applicants who do not have a complete series for a vaccine to seek a private physician before or after resettlement in the United States who can assist the applicant in becoming fully vaccinated.

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Advisory Committee on Immunization Practices (ACIP) Statements

ACIP statements are published in the Morbidity and Mortality Weekly Report (MMWR) periodically. Updated ACIP recommendations are available at CDC's website: http://www.cdc.gov/vaccines.

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Epidemiology and Prevention of Vaccine-Preventable Diseases

The CDC Pink Book Epidemiology and Prevention of Vaccine-Preventable Diseases provides an overview of vaccine-preventable infectious diseases and the corresponding vaccines. It serves as a useful companion to the ACIP statements and provides appendices that identify search tools and other useful resources. The Pink Book and other immunization materials are available at http://www.cdc.gov/vaccines/pubs/pinkbook.

Table: Requirements for routine vaccination of immigrants examined overseas who are not fully vaccinated or lack documentation.
VaccineAge
Birth-1 Month2-11 Months12 Months-6 Years7-10 Years11-17 Years18-64 Years≥65 Years
DTP/DTaP/DTNOYESNO
Td/TdapNOYES, if 7 years and older (for Td); if 10 years through 64 years (for Tdap- see ACIP schedule); if 65 years and older (for Td)
Polio (IPV/OPV)NOYESNO
Measles, Mumps, and RubellaNOYES, if born in 1957 or laterNO, if born before 1957
RotavirusNOYES, if
6 weeks to 8 months
NO
HibNOYES, if 2 months through 59 monthsNO
Hepatitis ANOYES, if 12 months through 23 monthsNO
Hepatitis BYES, birth through 18 yearsNO
Meningococcal (MCV4)NOYES, if 11 years through 18 yearsNO
VaricellaNOYES
PneumococcalNOYES, if 2 months through 59 months (for PCV)NOYES (for PPV)
InfluenzaNOYES, 6 months and older (annually each flu season)

DTP=diphtheria and tetanus toxoids and pertussis vaccine; DTaP=diphtheria and tetanus toxoids and acellular pertussis vaccine; DT=pediatric formulation diphtheria and tetanus toxoids; Td=adult formulation tetanus and diphtheria toxoids; Tdap=adolescent and adult formulation tetanus and diphtheria toxoids and acellular pertussis vaccine (Boostrix for persons 10-64 years old; Adacel for persons 11-64 years old); IPV=inactivated poliovirus vaccine (killed); OPV=oral poliovirus vaccine (live); Hib=Haemophilus influenzae type b conjugate vaccine; MCV=meningococcal conjugate vaccine; PCV=pneumococcal conjugate vaccine; PPV=pneumococcal polysaccharide vaccine.

Adapted from ACIP recommendations.

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Glossary of Abbreviations

  • ACIP - Advisory Committee on Immunization Practices
  • CDC - Centers for Disease Control and Prevention
  • CLIA - Clinical Laboratory Improvement Amendments
  • DGMQ - Division of Global Migration and Quarantine
  • DT - Diphtheria and tetanus toxoids
  • DTaP - Diphtheria and tetanus toxoids and acellular pertussis vaccine
  • DTP - Diphtheria and tetanus toxoids and pertussis vaccine
  • FDA Food and Drug Administration
  • Hib - Haemophilus influenzae type b conjugate vaccine
  • INA - Immigration Nationality Act
  • IPV - Inactivated poliovirus vaccine
  • MCV - Meningococcal conjugate vaccine
  • MMR - Measles, mumps, and rubella vaccine
  • MMRV - Measles, mumps, rubella, and varicella vaccine
  • MMWR - Morbidity and Mortality Weekly Report
  • MPSV - Meningococcal polysaccharide vaccine
  • NCIRD - National Center for Immunization and Respiratory Diseases
  • OPV - Oral poliovirus vaccine
  • PCV - Pneumococcal conjugate vaccine
  • PPV - Pneumococcal polysaccharide vaccine
  • Td - Tetanus and diphtheria toxoids
  • Tdap - Tetanus and diphtheria toxoids and acellular pertussis vaccine
  • USCIS - United States Citizenship and Immigration Services
 
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