Medical Exams for U.S. Bound Refugees Refugee and International Health Unit Cross-Cutting Epidemiology, Programs and Partnerships Section Infectious Disease, Epidemiology and Prevention Division Minnesota Department of Health

Types of Medical Exams Overseas Visa Medical Examination United States Public Health Service Domestic Refugee Health Assessment Minnesota Department of Health Adjustment of Status Medical Examination US Citizenship and Immigration Services Needed to obtain a Green Card Adjusts status from temporary to permanent resident The Overseas Medical Exam is overseen by the US Public Health Service with CDC training Panel Physicians around the world to perform this exam. This exam is required for entry into the United States. The domestic health screening exam is recommended but not required. Each state determines the office which coordinates this exam. This exam is done both to contain infectious diseases, but also for the refugee’s wellbeing and introduction into the US healthcare system. The Adjustment of Status exam is highly recommended for refugees who wish to adjust from a lawful temporary resident to a lawful permanent resident, a process that generates a long term work authorization or “green card.”

Overseas Visa Medical Examination Mandatory for refugees and immigrants Completed by Panel Physicians trained and overseen by CDC Is exclusionary in nature Results recorded on form DS-2053, etc.

Medical Screening for Entry into the United States “Excludable” conditions: Communicable diseases of public health significance Physical and mental disorders with associated harmful behaviors Psychoactive substance abuse and dependence Other physical or mental abnormalities, disorders or disabilities Refugees, like immigrants, are required to receive an overseas visa medical exam one year prior to their departure to the U.S. The criteria for this examine is set forth in the Immigration and Nationality Act. The purpose of this examine is to exclude persons who have the above conditions- The quality and comprehensiveness of the visas medical examination vary. Because the examine is good for six months to one year before departure, a refugee can develop infectious conditions after the overseas medical exam and before departure to the U.S. Likewise, screening for many other infectious disease such as malaria and other intestinal parasitic infections is not routine. * Note: every immigrant regardless of their arrival category must have this screening completed in order to come to the USA Refugee Health Program, Minnesota Department of Health

Communicable Diseases of Public Health Significance Infectious tuberculosis Syphilis Other Sexually Transmitted Diseases (STD) e.g. chancroid, gonorrhea, granuloma inguinale, lymphogranuloma venereum Hansen’s disease (leprosy) CDC has updated screening and testing for tuberculosis at many sites to utilize current medical knowledge and best practice. Source: www.cdc.gov/immigrantrefugeehealth/exams/diseases-vaccines-included.html (accessed in July 2013)

Communicable Diseases of Public Health Significance Vaccine-Preventable Diseases Mumps Measles Rubella Polio Tetanus Diphtheria Pertussis Haemophilus influenzae Type B Rotavirus Hepatitis A Hepatitis B Meningocococcal disease Varicella Pneumococcal pneumonia Influenza CDC has updated screening and testing for tuberculosis at many sites to utilize current medical knowledge and best practice. Source: Centers for Disease Control and Prevention www.cdc.gov/sars/quarantine/exec-2004-04-03.html, (accessed in July 2013)

Quarantinable Diseases Designated by Presidential Executive Order Cholera Diphtheria Infectious tuberculosis Plague Smallpox Yellow Fever Viral Hemorrhagic Fevers Severe Acute Respiratory Syndrome (SARS) Pandemic Influenza viruses CDC has added a risk-based approach for aliens screened outside of the US that is based on medical and epidemiologic factors, to determine when and where additional screening, testing and treatment for specific infectious diseases should be conducted. Source: Centers for Disease Control and Prevention www.cdc.gov/sars/quarantine/exec-2004-04-03.html, (accessed in July 2013)

A PHEIC is defined as an extraordinary event which is determined: Events that are reportable as a public health emergency of international concern (PHEIC) to WHO A PHEIC is defined as an extraordinary event which is determined: to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.1 Examples include: Smallpox, Severe Acute Respiratory Syndrome (SARS), Pandemic Influenza and Other public health emergencies of international concern 1Source: World Health Organization, www.who.int/ihr/procedures/pheic/en/ (accessed July 2014)

Types of Medical Exams Overseas Visa Medical Examination United States Public Health Service Domestic Refugee Health Assessment Minnesota Department of Health Adjustment of Status Medical Examination US Citizenship and Immigration Services Needed to obtain a Green Card Adjusts status from temporary to permanent resident It is recommended that all refugees undergo a more comprehensive medical exam once they resettle in the United States. In Minnesota this process is overseen by the Refugee Health Program at the Minnesota Department of Health.

Domestic Refugee Health Screening: Best Practices Exam w/in the first 90 days of arrival Public health clinics &/or private providers Goal: ...to control communicable disease among, and resulting from, the arrival of new refugees through: health assessment treatment referral The Federal Refugee Act of 1980 created a uniform system of services for refugees resettleing in the United States. Funding is available to states where refugees resettle, including dollars to state health departments to coordinate this health exam process. The process is done in partnership with resettlement agencies, state and local public health departments and private clinics.

National Guidance on Domestic Refugee Health Screening Developed in collaboration with Centers for Disease Control, Division of Global Migration and Quarantine (DGMQ/CDC) www.cdc.gov/immigrantrefugeehealth/ Office of Refugee Resettlement (ORR) NIH Substance Abuse Mental Health Services Administration (SAMHSA) Minnesota’s provider guide: www.health.state.mn.us/refugee/guide/ In 2007 the CDC, ORR and SAMHSA agreed to develop national guidelines for domestic refugee health screening. This guidance exists to help states develop best practices in their screening programs.

Types of Medical Exams Overseas Visa Medical Examination United States Public Health Service Domestic Refugee Health Assessment Minnesota Department of Health Adjustment of Status Medical Examination US Citizenship and Immigration Services Needed to obtain a Green Card Adjusts status from temporary to permanent resident This exam is part of the immigration and citizenship process and is overseen by the U.S. Citizenship and Immigration Services (USCIS).

What is a “Green Card”? Refugees: adjusts immigration status from Lawful Temporary Resident (LTR) to Lawful Permanent Resident (LPR); provides permanent residence and work authorization. Immigrants: permission to reside and work in the United States After immigrants and refugees have been in the United States for one year they are eligible to get a “green card” or long term work authorization. While there are many steps in this process, some of them are medical in nature. Obtaining a green card helps refugees and immigrants secure greater protection by the US government and places them on the path to citizenship.

Adjustment of Status Exam (Green Card Exam) Civil Surgeon MUST perform the full physical exam needed for immigrants, asylees ONLY immunizations are needed for refugees, unless they arrived with a Class A medical waiver Local public health medical director may act as civil surgeon for refugees www.uscis.gov for needed information and forms

Requirements to be a Civil Surgeon Licensed physician Four years professional experience beyond internship and residency Good standing with local and state medical boards Must apply to local USCIS office (not applicable for LPH MD acting as civil surgeon)

Refugees and Adjustment of Status No medical exam unless arrived with Class A condition, then exam is required Vaccination requirements only I-693 can be signed by state or local health department officials who meet definition of civil surgeon Place original signed I-693 in envelope, seal and give to refugee Give copy of completed I-693 to refugee

Immunizations for Adjustment of Status Exam NEW POLICY 2008 All vaccinations recommended by the Advisory committee on Immunization Practices (ACIP) are required for everyone applying to adjust their status.