CDC Domestic Refugee Health Program

An immigrant is an individual 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 person 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. In addition, it is a person 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 1 year after entry into and physical presence in the United States.

An asylee is a person 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 who has been subjected to a severe form of human 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.

A parolee is an individual who appears to be inadmissible, 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  formal admission to the United States and confers only a temporary status to the parolee, requiring him or her to depart the United States when the conditions supporting the parole cease to exist (INA 212(d)(5)(a)).

A Cuban or Haitian entrant is

• any individual granted parole status by the Department of Homeland Security as a Cuban/Haitian entrant ; and
• any other national of Cuba or Haiti who:
  • was paroled into the United States and has not acquired any other status under the INA;
  • is the subject of exclusion or deportation proceedings under the INA; or
  • has an application for asylum pending with the Immigration and Naturalization Service; and 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 (IDP) 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.

The Department of Health and Human Services (HHS) 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 HHS 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 evidence-based medicine, public health, social services, and the sciences.

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.

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.”

Under the authority of the Immigration and Nationality Act and the Public Health Service Act, the Secretary of Health and Human Services disseminates regulations outlining the requirements for the medical examination of aliens seeking admission into the United States and for those applying for permanent resident status. CDC’s Division of Global Migration and Quarantine (DGMQ), 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 (technical instructions) 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.

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. Refugees are also subject to quarantine laws of the Public Health Service Act upon arrival in the United States. By Executive Order of the President, as amended April 11, 2005 and updated July 31, 2014, federal isolation and quarantine are authorized for the following communicable diseases: 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 re-emerging influenza viruses that are causing, or have the potential to cause, a pandemic.

The Refugee Act of 1980 (Section 412 of the Immigration and Nationality Act) created The Federal Refugee Resettlement Program to provide for the resettlement of refugees and to assist refugees in achieving economic self-sufficiency as soon as possible after arrival in the United States.

The CDC’s DGMQ has been delegated certain responsibilities under this act. These responsibilities include:

• providing for the identification of refugees who have been determined to have medical conditions affecting the public health and requiring treatment;
• assuring that State and/or local health officials at the resettlement destination of each refugee are promptly notified of the refugee’s arrival and provided with all applicable medical records;
• providing for such monitoring of refugees identified with medical conditions affecting public health and requiring treatment, ensuring that they receive appropriate and timely treatment; and developing and implementing methods for monitoring and assessing the quality of medical screening and related health services provided to refugees awaiting resettlement to the United States.

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.

Information regarding immigration laws and regulations can be found on the U.S. Citizenship and Immigration Services (USCIS) website. Additional information regarding CDC and DGMQ legal authority can be found on the CDC Immigrant, Refugee and Migrant Health website.

CDC does not have the authority to assign immigration status. Please contact the United States Citizenship and Immigration Service for additional information and assistance.

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 identifies those classes of persons 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 and adjustment of status applicants), who have or have had a physical or mental disorder with associated harmful behavior, and who are drug abusers or addicts.

Outside the United States, medical examinations are performed by physicians called panel physicians. In the United States, medical examinations are performed by physicians called civil surgeons.

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.

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 the U.S. Citizenship and Immigration Service. For more information, please see the USCIS website.

A medical examination is required for all refugees coming to the United States and all applicants outside the United States applying for an immigrant visa. Persons in the United States who apply for adjustment of their immigration status to that of permanent resident are also required to be medically examined. Persons 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 a U.S. port of entry if there is reason to suspect that an inadmissible health-related condition exists.

Refugees coming to the United States must undergo a medical examination as part of the application process. The purpose of the medical examination is to identify the presence or absence of certain health-related conditions that could result in ineligibility for admission to (inadmissible) the United States under the provisions of the Immigration and Nationality Act. Waivers of ineligibility are available for certain health-related grounds of inadmissibility. For details and requirements of the examination, please see the Technical Instructions for Medical Examination of Aliens.

Guidelines for malaria and intestinal parasites have been developed, and are available on CDC’s Immigrant and Refugee Health website. Information regarding presumptive parasitic infection treatment schedules, and the CDC-Department of Population, Refugees, and Migration Vaccination Program for US-bound Refugees is also available.

The length of time medical examinations are valid vary. The Tuberculosis Screening and Treatment Technical Instructions (TB TIs) using Cultures and Directly Observed Therapy (DOT) for Panel Physicians determine the validity of the required medical examination.

Medical examinations are valid for 6 months for individuals with the following conditions:

• No Class (i.e., No Apparent Defect, Disease, or Disability)
• Class A Other than TB
• Class B2 Latent TB Infection (LTBI)
• Class B3 TB (Contact Evaluation)
• Class B, all except TB, including specific Class B conditions
• Class B Other conditions

Medical examinations are valid for 3 months for individuals with the following conditions:

• Class A TB with Waiver
• Class B1 TB, Pulmonary
• Blass B1 TB, Extrapulmonary
• HIV infection

However, the validity period for overseas medical examinations may vary depending on the refugee population being referred for resettlement.

The Technical Instructions for Medical Examination of Aliens are instructions that must be followed by panel physicians and by U.S. Department of State Consular Officers who evaluate persons applying for immigrant visas or refugee status at locations outside the United States. The Division of Global Migration and Quarantine (DGMQ) is responsible for providing the Technical Instructions to   panel physicians to ensure that persons entering the United States do not pose a threat to the public health of this country.

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.

The “Medical Examination of Aliens” (42 CFR, Part 34) regulation lists certain health-related conditions that, if identified during the medical examination, are grounds for inadmissibility (Class A condition) or represent such significant health problems (Class B condition) that must be brought to the attention of consular authorities.

Class A conditions include diseases that may pose a threat to public health or may require an individual to be quarantined. Class A conditions include:

• active tuberculosis;
• untreated syphilis;
• untreated gonorrhea;
• Hansen’s disease, which is also known as leprosy;
• pandemic flu;
• severe acute respiratory syndrome (SARS);
• viral hemorrhagic fevers such as Marburg and Ebola;
• cholera;
• diphtheria;
• plague;
• smallpox; and
• yellow fever.

The list of diseases that are considered Class A conditions can change. New diseases may be added to the list in the event of a public health emergency, and the President of the United States can issue an Executive Order to make updates to the list of Class A conditions. The World Health Organization may also identify a global public health emergency that requires CDC to update or change the list of Class A conditions.

Other Class A conditions are:

• Physical or mental disorders with current associated harmful behavior or history of associated harmful behavior that is likely to recur; and
• Substance-related disorders

Class B conditions are health-related conditions that may require extensive medical treatment or follow-up. Class B conditions include:

• inactive or noninfectious tuberculosis;
• treated syphilis and other sexually transmitted diseases;
• Hansen’s disease (leprosy), which has been treated or meets certain criteria;
• certain substance-related disorders that are in remission; and
• certain physical or mental disorders that don’t have associated harmful behaviors or behaviors that are likely to recur.

Class B conditions will not prevent a person from being admitted into the United States. However, Class B conditions are significant enough to interfere with a person’s ability to care for themselves or their ability to attend work or school. Class B conditions often require extensive medical treatment or institutionalization.

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

The Tuberculosis Screening and Treatment Technical Instructions (TB TIs) using Cultures and Directly Observed Therapy (DOT) for Panel Physicians provides the evaluation and testing guidelines for tuberculosis in refugees coming to the United States. As of October 1, 2013, all refugees are being screened using these TB TIs. CDC will continue to update these Technical Instructions, as needed, and inform state health department officials of any changes.

Following TB screening, refugees and immigrant applicants are given a TB classification (Class A, B1, B2, B3, or no TB classification). This classification determines if an applicant is cleared for travel to the United States. The tuberculosis classifications are described in the Tuberculosis Screening and Treatment Technical Instructions (TB TIs) using Cultures and Directly Observed Therapy (DOT) for Panel Physicians.

The sexually transmitted diseases that are screened/tested for are syphilis and gonorrhea. The medical history and physical examination must include a search for symptoms or lesions consistent with these diseases. Routine laboratory testing for syphilis is performed for those applicants 15 years of age and older. Applicants younger than 15 years of age must be tested if there is reason to suspect infection with syphilis or if there is a history of syphilis. Testing is also performed for gonorrhea. For more information, please see Technical Instructions for Panel Physicians.

As of January 4, 2010, HIV infection is no longer considered a Class A inadmissible condition. Therefore, refugees are no longer required to be tested for HIV infection as part of the U.S. immigration medical examination process.

On November 2, 2009, the Department of Health and Human Services (HHS) and Centers for Disease Control and Prevention (CDC) published a final rule that removed HIV infection from the list of communicable diseases of public health significance. As a result, HIV infection no longer prevents non-U.S. citizens from entering the United States. Further, HIV testing is no longer required for U.S. immigration medical screening, and an HIV-positive refugee will not be denied adjustment status based on his/her HIV status.

Hepatitis panels are not routinely done on refugees overseas.

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 – 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 United States must comply with the vaccination requirements when they apply for adjustment of status to Legal Permanent Resident; for refugees, this application occurs 1 year after arrival in the United States.

Additional information about overseas vaccination programs for U.S.-bound refugees is available on the CDC Immigrant and Refugee Health website.

No, refugees are not required to meet vaccination requirements before coming to the United States. School-aged children may be required to meet school-entry vaccination requirements upon school enrollment in the United States. However, refugees must comply with the vaccination requirements when they apply for adjustment of status to Legal Permanent Resident.

No, asylees are not required to have any vaccinations. School-aged children may be required to meet school-entry vaccination requirements upon school enrollment in the United States. However, asylees must comply with the vaccination requirements if they apply for adjustment of status to Legal Permanent Resident.

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.

Current ACIP federal immunization guidelines are available on the ACIP website.

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.

Current domestic medical screening guidelines for newly arrived refugees are available on CDC’s Immigrant and Refugee Health website.

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.

Current CDC guidelines for the United States recommend HIV screening in healthcare settings for all persons, including refugees, 13-64 years of age. Screening of refugees ≤12 years and ≥64 years of age is also recommended upon arrival. Repeat screening 3-6 months following resettlement is recommended for refugees with a recent exposure or high-risk activity to identify individuals who may be in the “window period” when they arrive in the United States.

Screening should be performed on all refugees unless they decline (opt out). When a refugee declines an HIV test, this decision should be documented in the medical record. Refugees should be clearly informed orally or in writing that HIV testing will be performed. Oral or written information should include an explanation of HIV infection and the meanings of positive and negative test results, and the patient should be offered an opportunity to ask questions. Appropriate referral for care, treatment, and preventive services should be made for all individuals confirmed to be HIV infected.

All immigrant visa and refugee applicants must undergo a physical examination and mental status assessment as part of their application process. Panel physicians in foreign countries conduct these examinations. DS forms are Department of State forms used to the medical screening results from these medical examinations.

DS forms include the U.S. Department of State Medical Examination for Immigrant or Refugee Applicant (DS-2054) and the associated worksheets:

• DS-3030 (Tuberculosis Worksheet)
• DS-3025 (Vaccination Documentation Worksheet)
• DS-3026 (Medical History and Physical Examination Worksheet)

The Electronic Disease Notification (EDN) system is a web-based system that notifies state or local health officials when immigrants with notifiable conditions and refugees arrive in their jurisdictions. EDN provides medical information recorded on the DS form during the application process to these health officials for stateside follow-up. EDN was launched on March 20, 2006, and has been deployed to all states.

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