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CDC Domestic Refugee Health Program

Frequently Asked Questions

Domestic Refugee Health Program

The Domestic Refugee Health Program was established to facilitate collaboration between the Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, and its domestic partners, to improve the health-care of refugees after their arrival in the United States, initiate surveillance activities to monitor medical conditions identified post-arrival, work together to ensure adequate follow-up of refugees with medical conditions identified overseas, and strengthen the resources available for post-arrival health assessments and follow-up activities.

Immigration Background

Definitions

An immigrant is an alien admitted to the United States as a lawful permanent resident. Permanent residents are also commonly referred to as immigrants; however, the Immigration and Nationality Act (INA) defines an immigrant as any alien legally admitted for permanent residence in the United States, except for persons legally admitted under specific nonimmigrant categories (INA section 101(a)(15).

A refugee is any person who is outside the country of such person's nationality or, in the case of a person having no nationality, is outside any country in which such person last habitually resided, and who is unable or unwilling to return to, and is unable or unwilling to avail himself or herself of the protection of, that country because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion. Refugees are required to apply for Legal Permanent Resident status one year after entry into and physical presence in the United States.

An asylee is an alien already in the United States or at a port of entry who is found to be unable or unwilling to return to his or her country of nationality or to seek the protection of that country because of persecution or a well-founded fear of persecution, as defined in the refugee category above.

A Certified Victim of Trafficking is an individual 18 years of age or older who has been subjected to a severe form of trafficking and who has been certified by the U.S. Department of Health and Human Services, Office of Refugee Resettlement (ORR) based on the Trafficking Victims Protection Act of 2000. A Certified Victim of Trafficking is eligible for ORR-funded services and benefits to the same extent as refugees. For more information, see the USCIS web site (http://www.uscis.gov) under “Humanitarian Benefits.”

A parolee is an alien who appears to be inadmissible to the inspecting officer but who is permitted entry into the United States for urgent humanitarian reasons or if entry is determined to be for significant public benefit. Under the immigration laws, parole does not constitute a formal admission to the United States and confers only a temporary status to the parolee, requiring him or her to depart the U.S. when the conditions supporting the parole cease to exist (600 INA 212 (d) (5) (a)).

A Cuban or Haitian entrant is (a) any individual granted parole status (by the Department of Homeland Security) as a Cuban/Haitian Entrant (Status Pending…); and (b) Any other national of Cuba or Haiti (1) who: (i) was paroled into the United States and has not acquired any other status under the INA; (ii) is the subject of exclusion or deportation proceedings under the INA; or (iii) has an application for asylum pending with DHS; and (2) with respect to whom a final, nonappealable, and legally enforceable order of deportation or exclusion has not been entered. 45 CFR § 401.2.

An Internally Displaced Person is a person who has been forced to flee his or her home for the same reasons as a refugee but has not crossed an internationally recognized border. (Reference: UNHCR Information and Briefings: Definitions)

A nonimmigrant is an alien who seeks temporary entry to the United States for a specific purpose. The alien must have a permanent residence abroad (for most classes of admission) and qualify for the nonimmigrant classification sought. The nonimmigrant classifications include foreign government officials, visitors for business and for pleasure, aliens in transit through the United States, treaty traders and investors, students, international representatives, temporary workers and trainees, representatives of foreign information media, exchange visitors, fiance(e)s of U.S. citizens, intracompany transferees, NATO officials, religious workers, and some others. Most nonimmigrants can be accompanied or joined by spouses and unmarried minor (or dependent) children.

An adjustment of status is a procedure allowing certain aliens already in the United States to apply for immigrant status. Aliens admitted to the United States in a nonimmigrant, refugee, or parolee category may have their status changed to that of lawful permanent resident if they are eligible to receive an immigrant visa and one is immediately available.

Reference: United States Citizenship and Immigration Service (www.uscis.gov)

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Immigration

What is the Code of Federal Regulations?

The Code of Federal Regulations is the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the Federal Government. It is divided into 50 titles that represent broad areas subject to Federal regulation (GPO Access: http://www.gpoaccess.gov/cfr/index.html). The section of the United States Code that deals with immigration is Title 8, Aliens and Nationality.

Where is the Code of Federal Regulations on Aliens and Nationality located?

The Code of Federal Regulations, Title 8, Aliens and Nationality, can be found on the Government Printing Office website. Access the site at http://www.gpoaccess.gov/cfr/index.html.

What is the Immigration and Nationality Act?

The Immigration and Nationality Act (INA) was enacted in 1952. Before the INA, a variety of statutes governed immigration law but were not organized in one location. The McCarran-Walter bill of 1952, Public Law No. 82-414, collected and codified many existing provisions and reorganized the structure of immigration law. The Act has been amended many times over the years but is still the basic body of immigration law.

Although it stands alone as a body of law, the Act is also contained in the United States Code. The code is a collection of all the laws of the United States, arranged in 50 subject titles by general alphabetic order. Title 8 of the U.S. Code, one of the 50 titles, deals with "Aliens and Nationality." Although it is correct to refer to a specific section by either its INA citation or its U.S. code, the INA citation is more commonly used. Reference: United States Citizenship and Immigration Service

Where can I find the Immigration and Nationality Act?

The Immigration and Nationality Act can be found on the United States Citizenship and Immigration Service website at http://www.uscis.gov/portal/site/uscis.

What is the U.S. Department of Health and Human Services?
The Department of Health and Human Services (DHHS) is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. The mission of the DHHS is to enhance the health and well-being of Americans by providing for effective health and human services and by fostering strong, sustained advances in the sciences, evidence-based medicine, public health, and social services. For more information, see http://www.hhs.gov/about/whatwedo.html

How does CDC fit into the Department of Health and Human Services?

The Centers for Disease Control and Prevention (CDC) is one of the 13 major operating components of the Department of Health and Human Services. Working with states and other partners, CDC provides a system of health surveillance to monitor and prevent disease outbreaks (including bioterrorism), implement disease prevention strategies, and maintain national health statistics. CDC also guards against international disease transmission, with personnel stationed in more than 25 foreign countries.

What is the Public Health Service Act?

The Public Health Service Act (42CFR6A) is legislation relating to the Public Health Service and its legal responsibilities. The full text is found at http://www.gpoaccess.gov/cfr/index.html .

What is the Public Health Service?

The Commissioned Corps of the Public Health Service is one of the seven Uniformed Services of the United States. It was designed to assign specialized individuals to Federal, State or local agencies or international organizations. The mission of the Public Health Service is to promote the protection and advancement of the Nation's physical and mental health (http://www.os.dhhs.gov/about/opdivs/phs.html and http://www.usphs.gov/AboutUs/mission.aspx).

What is CDC’s role in immigration?

Under the authority of the Immigration and Nationality Act and the Public Health Service Act, the Secretary of Health and Human Services promulgates regulations outlining the requirements for the medical examination of aliens seeking admission into the United States and for those applying for permanent resident status. The Division of Global Migration and Quarantine of the Centers for Disease Control and Prevention provides the Department of State (DOS) and the U.S. Citizenship and Immigration Services (USCIS) of the Department of Homeland Security (DHS) with medical screening guidelines for all examining physicians, which outline in detail the scope of the medical examination. The purpose of the medical examination is to identify, for the DOS and USCIS, applicants with inadmissible health-related conditions.

What part of the Public Health Service Act is the Division of Global Migration and Quarantine (DGMQ) responsible for?
DGMQ is responsible for implementing quarantine laws of the Public Health Service Act (42 U.S.C. 264(b)). DGMQ has the statutory responsibility to make and enforce regulations necessary to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the United States. Quarantine regulations apply to all persons entering the United States, whether legally or illegally. The following communicable diseases are specified as quarantinable by Executive Order of the President, as amended April 11, 2005 and updated on July 31, 2014: cholera; diphtheria; infectious tuberculosis; plague; smallpox; yellow fever; and viral hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named); severe acute respiratory syndromes; and influenza caused by novel or reemerging influenza viruses that are causing, or have the potential to cause, a pandemic.

Does CDC have the authority to assign immigration status?

CDC does not have the authority to confer immigration status. Please contact the United States Citizenship and Immigration Service for assistance (http://www.uscis.gov).

What law applies to the adjustment of status for refugees?

The law concerning refugee adjustment of status and the medical examination requirement is located in the Code of Federal Regulations, Part 8, Section 209, Part 209.1(c) on the United States Citizenship and Immigration Service website. See also INA Section 245.

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HIV and the Immigration Process

What is the process for HIV-positive refugees coming to the US?

HIV-positive refugees are required to have an I-602 waiver for the Class A condition of HIV infection. The HIV-positive refugee should also have a completed HIV Addendum to Assurance. This form is used to identify both the refugee’s local sponsoring agency and the U.S. health-care provider who has been identified by the local agency.

Can an HIV-positive refugee be denied adjustment to lawful permanent resident because of his/her HIV status?

An HIV-positive refugee will not be denied adjustment of status to lawful permanent resident solely because of his/her HIV status. At the time of application for adjustment of status, the refugee applies for a new I-602 waiver and must again identify a U.S. health-care provider. A new medical examination is required for adjustment of status.

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Medical Screening: General Information

What is CDC’s role in medical screening?

The Division of Global Migration and Quarantine, CDC, provides the technical instructions and guidance to physicians conducting the medical examination for immigration. These instructions are developed in accordance with Section 212(a)(1)(A) of the INA, which states those classes of aliens ineligible for visas or admission based on health-related grounds. The health-related grounds include those aliens who have a communicable disease of public health significance, who fail to present documentation of having received vaccination against vaccine-preventable diseases (immigrants only), who have or have had a physical or mental disorder with associated harmful behavior, and who are drug abusers or addicts.

Who performs the medical examination?

Outside the United States, medical examinations are performed by physicians called panel physicians, who are selected by Department of State Consular Officials. In the United States, medical examinations are performed by physicians called civil surgeons, who are designated by district directors of the USCIS.

What is a panel physician?

A panel physician is a physician outside the United States who performs the medical examinations for refugees and individuals applying for an immigrant visa. These physicians are selected by Department of State Consular Officials.

What is a civil surgeon?

A civil surgeon is a physician who performs medical examinations in the United States for aliens applying for adjustment of their immigration status to that of permanent resident. These physicians are designated by district directors of the U.S. Citizenship and Immigration Service.

Who is required to have a medical examination?

A medical examination is mandatory for all refugees coming to the United States and all applicants outside the United States applying for an immigrant visa. Aliens in the United States who apply for adjustment of their immigration status to that of permanent resident are also required to be medically examined. Aliens applying for nonimmigrant visas (temporary admission) may be required to undergo a medical examination at the discretion of the consular officer overseas or immigration officer at the U.S. port of entry, if there is reason to suspect that an inadmissible health-related condition exists. Asylees are not required to have a medical examination.

What is the required overseas medical screening for a refugee?

Overseas, U.S.-bound refugees must undergo a medical examination as part of the visa application process. The purpose of the medical examination is to identify the presence or absence of certain physical or mental disorders that could result in ineligibility for admission to (or exclusion from) the United States under the provisions of the Immigration and Nationality Act. Waivers of ineligibility are available for certain medical grounds of inadmissibility. For details and requirements of the examination, please see the Technical Instructions for Medical Examination of Aliens.

How long are laboratory results valid for?

The 1991 Technical Instructions for Medical Examination of Aliens do not address the validity of laboratory results. However, the physician who performs the exam is required to ensure that all medical tests are properly conducted and that test results are in fact those of the applicant and are current. A standard medical examination is valid for immigration purposes for one year from the date of the physician’s signature.

What is the allowable time interval between the overseas examination (validity period) and U.S. arrival?

The allowable time interval between the completion of the overseas examination and U.S. arrival is 12 months. If the applicant has a Class A or TB classification, the interval is 6 months. For Hmong and Burmese refugees resettling from Thailand, the allowable time interval between the overseas examination and U.S. arrival is 3 months, regardless of whether the refugee has a TB classification. For Class B1 refugees, the 3-month interval begins when the culture results are reported; culture results are usually reported within 8 weeks of sputum collection.

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Medical Screening: Technical Instructions

What are the Technical Instructions for Medical Screening of Aliens?

The Technical Instructions for Medical Screening of Aliens are instructions that must be followed by panel physicians and by U.S. Department of State Consular Officers who evaluate aliens applying for immigrant visas and aliens applying for refugee status at locations outside the United States. The Division of Global Migration and Quarantine (DGMQ) is responsible for providing the Technical Instructions to civil surgeons (who perform the medical examination for adjustment of status in the U.S.) and panel physicians to ensure that aliens entering the United States do not pose a threat to the public health of this country. Under the Code of Federal Regulations 42 CFR 34, all medical examinations shall be carried out in accordance with such technical instructions for physicians conducting the medical examination of aliens as may be issued by the Director, DGMQ.

Where can I find a copy of the Technical Instructions for Medical Examination of Aliens?

See the Technical Instructions for Medical Examination of Aliens webpage. For medical examinations conducted outside the United States, select the Technical Instructions for Panel Physicians. For medical examinations conducted inside the United States, select the Technical Instructions for Civil Surgeons.

Are there formal recommendations from CDC for screening refugees?

Yes, the Technical Instructions for Medical Examination of Aliens serve as DGMQ’s guidance for the panel physicians who perform the medical screening exams for refugees overseas.

I have heard that new Tuberculosis Technical Instructions are being created. When will these be implemented?

In January 2007, new Technical Instructions for Tuberculosis Screening and Treatment for overseas medical screening of applicants for U.S. immigration were issued, with slight interim modifications in April 2007. The new tuberculosis requirements will be implemented over the next several years in a phased roll-out fashion. When the instructions are implemented in a country, DGMQ will notify officials at each state health department.

What are Class A and Class B conditions?

The health-related grounds for exclusion of aliens set forth in the law are implemented by a regulation, "Medical Examination of Aliens" (42 CFR, Part 34). The regulation lists certain disorders that, if identified during the medical examination of an alien, are grounds for exclusion (Class A condition) or represent such significant health problems (Class B condition) that they must be brought to the attention of consular authorities.

The purpose of the medical examination is to determine whether the alien has 1) a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders him or her ineligible for admission or adjustment of status (Class A condition); or 2) a physical or mental disorder that, although not constituting a specific excludable condition, represents a departure from normal health or well-being that is significant enough to possibly interfere with the person's ability to care for himself or herself, or to attend school or work, or that may require extensive medical treatment or institutionalization in the future (Class B condition).

Class A conditions include:

  • active or infectious tuberculosis
  • untreated syphilis
  • untreated chancroid
  • untreated gonorrhea
  • untreated granuloma inguinale
  • untreated lymphogranuloma venereum
  • human immunodeficiency virus
  • Hansen’s disease
  • addiction or abuse of specific substance without harmful behavior and/or any physical or mental disorder with harmful behavior or history of such behavior, along with likelihood that behavior will recur.

Class B conditions include:

  • inactive or noninfectious tuberculosis
  • treated syphilis
  • other sexually transmitted diseases
  • pregnancy
  • treated, tuberculoid, borderline or paucibacillary Hansen’s disease
  • sustained, full remission of abuse of specific substances* and/or any physical or mental disorder (excluding addiction or abuse of specific substances but including other substance-related disorders) without harmful behavior or history of such behavior considered unlikely to recur (*amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, sedative-hypnotics and anxiolytics).

For additional information, please see the Technical Instructions for Panel Physicians.

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Medical Screening: Tuberculosis Testing

I have heard that new Tuberculosis Technical Instructions are being created. When will these be implemented?

In January 2007, new Technical Instructions for Tuberculosis Screening and Treatment for overseas medical screening of applicants for U.S. immigration were issued, with slight interim modifications in April 2007. The new tuberculosis requirements will be implemented over the next several years in a phased roll-out fashion. When the instructions are implemented in a country, DGMQ will notify officials at each state health department.

What are the tuberculosis classifications?

Please see the information on TB classifications.

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Medical Screening: STDs

What STD screening tests are done overseas on refugees?

The sexually transmitted diseases that are screened/tested for are HIV, syphilis, chancroid, gonorrhea, granuloma inguinale, and lymphogranuloma venereum. The medical history and physical examination must include a search for symptoms or lesions consistent with these diseases. Further testing should be done as necessary to confirm a suspected diagnosis. Routine laboratory testing is performed only for HIV and syphilis.

At what age are refugees screened overseas for syphilis and HIV?

All applicants 15 years of age or older must be tested for evidence of syphilis and HIV infection. Applicants under the age of 15 must be tested for HIV if there is reason to suspect HIV infection (e.g., a child with hemophilia or a child whose mother or father is HIV positive). Applicants under the age of 15 must be tested for syphilis if there is reason to suspect infection with syphilis.

Are hepatitis panels routinely done on all refugees overseas?

Hepatitis panels are not routinely done on refugees overseas.

If an overseas blood screening reveals syphilis, what procedure are the overseas panel physicians following to assess whether the condition is actually syphilis and not another treponemal infection?

If the screening test is positive, a confirmatory test must be done. The applicant must be treated by using a standard treatment regimen before he/she can travel to the United States. (Please see Appendix F [PDF - 199 KB, 1 page) of the Technical Instructions for Panel Physicians for the recommended treatment of syphilis.) Once the recommended treatment is completed, syphilis is no longer considered a Class A condition. Post-treatment, the syphilis would be considered a Class B condition only if the applicant has some residual disability (e.g., an individual treated for neurosyphilis who has a residual neurologic abnormality).

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Medical Screening: Vaccinations

Who is required to have vaccinations as part of the medical screening?

On September 30, 1996, the U.S. Congress amended the Immigration and Nationality Act by adding to the health-related grounds of inadmissibility a new subsection, “Proof of Vaccination Requirements for Immigrants.” This new subsection requires any person who seeks an immigrant visa to show proof of having received vaccination against vaccine-preventable diseases, as recommended by the U.S. Advisory Committee on Immunization Practices.

The U.S. Immigration and Naturalization Service – now Department of Homeland Security, United States Citizenship and Immigrant Service – has determined that the vaccination requirements do not apply to refugees and nonimmigrants at the time of their initial admission to the United States. However, refugees and V (spouses or children of permanent residents) and K (fiancé(e) of permanent resident) visa holders in the U.S. must comply with the vaccination requirements when they apply for adjustment of status to Legal Permanent Resident; for refugees this application occurs one year after arrival in the United States.

Are asylees required to have vaccinations?

No, asylees are not required to have any vaccinations. However, asylees must comply with the vaccination requirements if they apply for adjustment of status to Legal Permanent Resident.

What is the Advisory Committee on Immunization Practices (ACIP)?

The ACIP is a committee appointed by the Secretary of the U.S. Department of Health and Human Services to provide federal recommendations on the routine administration of and schedules for vaccines.

Where are the federal immunization guidelines located?

Current ACIP federal immunization guidelines are available on the ACIP website at http://www.cdc.gov/vaccines/recs/acip/default.htm.

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Medical Screening: Domestic

Is there domestic guidance for states performing refugee health assessments for newly arrived refugees?

Currently, the guidance for states for the domestic follow-up examination for newly arrived refugees is the 1995 ORR Medical Screening Protocol (State Letter 95-37). Many states have added requirements in addition to the ORR protocol. The Department of Health and Human Services is now drafting guidance for an expanded domestic protocol for states.

Is the post-arrival medical screening mandatory for immigrants and refugees who have B1 or B2 tuberculosis classifications?

The post-arrival medical screening for immigrants and refugees with TB conditions is not mandatory, but it is highly recommended that the assessment be done. Any follow-up examination should be completed within 30 days post-arrival.

What are the post-arrival requirements for health assessments of HIV-positive refugees?

The health-care provider should perform an initial evaluation, counseling, and follow-up for the refugee. The post-arrival HIV(+) health assessment is procedurally distinct from the standard post-arrival health assessment. CDC should receive a copy of a letter from the health-care provider stating that the refugee has received an initial evaluation. For more information, see the USCIS Adjudicator’s Field Manual on the USCIS website at http://www.uscis.gov.

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Notifications & the Electronic Disease Notification (EDN) System

What are the DS forms?

The DS forms are Department of State forms used to collect the medical screening results from the overseas examinations. All immigrant visa and refugee applicants must undergo a physical examination and mental status assessment as part of their application process. The panel physicians complete these forms overseas, and the refugee carries copies to the United States. After processing the documents of the refugee or immigrant at the Port of Entry, the CDC Quarantine Station sends the DS forms to the state or local health department at the refugee’s or immigrant’s destination. These forms, located at the U.S. Department of State website, http://www.state.gov/, include the U.S. Department of State Medical Examination for Immigrant or Refugee Applicant (DS-2053) and the associated worksheets:

  • DS-3024 (Chest X-Ray and Classification Worksheet)
  • DS-3025 (Vaccination Documentation Worksheet)
  • DS-3026 (Medical History and Physical Examination Worksheet)

Quarantine Station Jurisdiction and Contact Information

What is EDN?

The Electronic Disease Notification (EDN) system is a web-based system that improves and automates the process that notifies state or local health officials of the arrival of immigrants with notifiable conditions and refugees to their jurisdictions. EDN provides relevant overseas medical screening and treatment information for stateside follow-up. EDN was launched on March 20, 2006 and as of July 2007 has been deployed to 18 states.

Who should I contact if I have technical problems with EDN?

Please contact the EDN help desk. The e-mail address is edn@cdc.gov, and the phone number is 1-866-226-1617.

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Pandemic Influenza

Is any information available for migrants regarding pandemic influenza?

Planning checklists and other additional information can be found on the HHS PandemicFlu.gov site at http://www.pandemicflu.gov.

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