Medical Screening of US-bound Refugees

Somali refugees who have been identified for resettlement to the United States receive a required medical examination. Depending on the country of processing, refugees may receive additional health checks (Figure 5). As outlined below, the full required medical examination occurs 3 to 6 months before departure; the pre-departure medical screening (PDMS) and pre-embarkation checks (PEC), if conducted, occur closer to or immediately before departure for the United States. As the security clearance process is lengthy, many Somali refugees referred for resettlement to the United States must undergo repeat medical screenings if the required medical exam expires prior to departure.

The medical assessment of US-bound refugees consists of three key components: the overseas medical examination, pre-departure medical screening, and fit to fly pre-embarkation checks. The overseas medical examination occurs no more than 6 months before departure for all refugees, and screens for inadmissible conditions. The pre-departure medical screening occurs within three weeks of departure for refugees with significant complex medical conditions (as needed), and those with Class B1 TB. Lastly, fit to fly pre-embarkation checks generally occur 24-48 hours (no more than 72 hours) prior to departure. All refugees undergo fit to fly checks, and are given presumptive albendazole and ivermectin (depending on the country of departure).

Figure 5: Medical Assessment of US-bound Refugees * "Class B1 TB, Pulmonary" refers to an admissible medical condition in which there is an abnormal screening chest x-ray but negative sputum TB smears and cultures, or to TB diagnosed by the panel physician and fully treated by directly observed therapy.

Overseas Medical Examination

The overseas medical examination is mandatory for all refugees coming to the United States and must be performed according to CDC’s Technical Instructions. This examination is generally performed approximately 6 months before initial scheduled resettlement; the medical exam may be repeated if resettlement is delayed. Generally, the medical exam is valid for 6 months. However, the medical exam is only valid for 3 months for those with Class B1 conditions. The purpose of this overseas medical examination is to identify applicants with inadmissible health-related conditions. These include, but are not limited to, mental health disorders with harmful behavior, substance abuse, and specific sexually transmitted infections (if untreated). Active tuberculosis (TB) disease (untreated or incompletely treated) is an inadmissible condition of great concern due to its infectious potential and public health implications.

Somali refugees are processed in several countries including, but not limited to, Kenya, Ethiopia, Uganda, and South Africa. The required medical examinations for Somali refugees, including those conducted in Kenya, Ethiopia, Uganda, and South Africa, are conducted by physicians from the International Organization for Migration (IOM). In other countries, examinations may be performed by local panel physicians appointed by the US Embassy.

TB screening and treatment are critical components of the overseas medical examination. All Somali refugees referred for resettlement to the United States are required to be evaluated, and treated if necessary, for TB before coming to the United States. Panel physicians are required to conduct these mandatory screenings in accordance with the CDC Tuberculosis Screening and Treatment Technical Instructions (TB TIs) using Cultures and Directly Observed Therapy (DOT) for Panel Physicians.

CDC provides the technical oversight and training for all panel physicians, regardless of affiliation. All panel physicians are required to follow the Technical Instructions developed by CDC. In addition, in countries where IOM conducts the examination, refugees also receive a PDMS and PEC.

Information collected during the refugee medical examination is reported to CDC’s Electronic Disease Notification system (EDN) and sent to US state health departments in states where refugees resettle.

Pre-departure Medical Screening

Depending on the country of processing, PDMS is conducted approximately 2 weeks before departure for the United States for refugees previously diagnosed with a Class B1 TB, pulmonary condition (abnormal chest x-ray with negative sputum TB smears and cultures, or pulmonary TB diagnosed by panel physician and treated by directly observed therapy). The screening includes a medical history and repeat physical exam. This screening primarily focuses on TB signs and symptoms, and includes a chest x-ray and sputum collection for sputum TB smears (if required). Technical Instructions for Tuberculosis Screening and Treatment, which include more information on pre-departure medical screenings, are available on CDC’s website. Depending on the country of processing, refugees with other chronic or complex medical conditions may receive pre-departure evaluation to assess fitness for travel.

Pre-embarkation Checks

Depending on the country of processing, IOM physicians perform a PEC, or “fit to fly” assessment, within 72 hours (often 24-48 hours) of the refugee’s departure for the United States. PECs are conducted to determine fitness for travel, and to administer presumptive therapy for intestinal parasites and malaria.

Vaccination Program for US-bound Refugees

In addition to vaccines received through national immunization programs and NGO vaccination campaigns, Somali refugees are likely to receive vaccines as part of the voluntary Vaccination Program for US-bound Refugees. Depending on age, vaccine availability, and other factors, refugees may receive vaccines to protect against hepatitis B, rotavirus, Haemophilus influenzae type b, pneumococcal disease, diphtheria, pertussis, tetanus, polio, measles, mumps, and rubella. Hepatitis B surface antigen testing is conducted for refugees receiving hepatitis B vaccine, and positive results are documented on the DS forms. Those with hepatitis B infection require follow-up after arrival in the United States. For those without infection, the hepatitis B vaccine series is usually initiated before departure, and vaccination should be completed after arrival, according to an acceptable ACIP schedule.

All vaccines administered through the Vaccination Program for US-bound Refugees, as well as records of historical (prior) vaccines provided by NGOs and national programs, are documented on the DS-3025 (Vaccination Documentation Worksheet) form. US providers are strongly encouraged to review each refugee’s records to determine which vaccines were administered overseas.

Additional information about the CDC-Bureau for Population, Refugees, and Migration (PRM) Vaccination Program for US-bound Refugees is available on CDC’s Immigrant, Refugee, and Migrant Health website.

Presumptive Therapies for Parasitic Infections

Depending on the country of processing and place of birth, Somali refugees may receive pre-departure presumptive albendazole for soil-transmitted helminthic infection, ivermectin for strongyloidiasis, praziquantel for schistosomiasis, and/or artemether-lumefantrine (Coartem®) for malaria. Refugees receive presumptive treatment via DOT at PEC. US providers should refer to each refugee’s PDMS form to determine which therapies for parasitic infections were administered overseas.

Additional information regarding presumptive therapy for parasitic infections can be found here.