1. Vaccinations for Immigrants
Joanna Regan, MD, MPH
Medical Assessment and Policy Team
Immigrant, Refugee, and Migrant Health Branch
Panel Physician Workshop
March 2017
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

2. Learning Objectives Explain the origins of vaccination requirement
After this workshop, you should be able to
Explain the origins of vaccination requirement
Use the Vaccine TI table and ACIP tables to determine which vaccines are needed and how to give them
Complete the DS 3025
ACIP= Advisory Committee on Immunization Practices

3. Vaccinations are recommended for their health
Question I
An adult applicant at your panel site is completing their medical exam. They ask if vaccinations are recommended or required in order for them to immigrate to the United States. Which is the best answer to their question?
Vaccinations are recommended for their health
The vaccinations are required
I’m not sure
Answer=B

4. Vaccinations in Immigration Law
Immigration and Nationality Act (INA) amended in 1997
Immigrants not admissible if
They fail to present documentation of having received vaccination against vaccine-preventable diseases including
Mumps, measles, rubella, polio, tetanus, diphtheria, pertussis, influenza B*, hepatitis B
Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP)
* Interpreted to mean Haemophilus influenzae type B

5. A. Diversity visa (DV) applicants
Question 2
The INA vaccine amendment applies to all of the following applicants EXCEPT:
A. Diversity visa (DV) applicants
B. Special immigrant visa (SIV) applicants
C. Fiancé K visa applicants
D. Adoptees
Answer = C
Fiance applicants do not have to be vaccinated before coming to the US

6. Those Included in the INA Amendment
INA amendment applies to all immigrants including
Immigrant visa (IV) applicants
Diversity visa (DV) applicants
Special immigrant visa (SIV) applicants
Adoptees
INA amendment does not apply to
Refugees
Asylees
Parolees
Nonimmigrants
K visa
The k visa is the fiancé visa

7. Refuse to provide consent for examination
Question 3
Two U.S. parents bring a 9-year-old orphan they are adopting into your office. You review the child’s vaccine records. The parents state they want the child vaccinated in the United States. How do the parents accomplish this?
Refuse to provide consent for examination
Write to CDC for a waiver on medical grounds
Apply for a waiver for all vaccinations on religious or moral grounds
Sign an affidavit
Answer = D

8. Vaccination Exemption for Adoptees
Amendment to INA
Adoptees 10 years of age and younger
Parents sign an affidavit
Vaccinations will be provided after arrival to the United States
Adoptees 11 years of age and older
Follow Vaccine Technical Instructions

9. Clarifying ACIP Recommendations in the Context of Immigration
ACIP recommends many vaccinations for many circumstances
INA does not specify which ACIP recommendations to follow for applicants
General public
Travelers
Special circumstances
Immigrant vaccine requirements needed further clarification with new criteria

10. Criteria for Required Vaccinations for Immigration
2009 Federal Register Notice
Criteria
The vaccine must be age-appropriate for the immigrant applicant
The vaccine must protect against a disease that has the potential to cause an outbreak in the US
The vaccine must protect against a disease that has been eliminated or is in the process of being eliminated in the United States

11. No, YF is not a required vaccination for US immigration
Question 4
You live in a country that is endemic for yellow fever (YF). You examine an applicant who is 30 years old and last received a YF vaccine >10 years ago. Should you require the applicant to get a YF vaccine?
No, YF is not a required vaccination for US immigration
Yes, to protect the health of the individual applicant
Yes, to protect the US population from re-introduction of YF
No, the applicant doesn’t need another YF vaccine dose as an adult
Answer = A

12. Required Vaccinations for US Immigration
Mumps
Measles
Rubella
Tetanus
Diphtheria
Meningococcal disease
Pneumococcal disease
Haemophilus influenzae type B
Rotavirus
Varicella
Influenza
Hepatitis A
Hepatitis B
Pertussis
Polio

13. Vaccine Technical Instructions (TI)
Developed by the CDC MAP team based on INA amendment and PRN criteria
Goal
Interpret the US immigration vaccine requirements into usable instructions for panel physicians about how they must vaccinate applicants
Ensure applicants can present documentation of having received the age-appropriate required vaccinations for immigration

14. Issues Vaccine TIs created to Address
What is allowed as previous documentation?
Who gives the vaccines?
What vaccine recommendations are followed:
In-country, World Health Organization (WHO), or ACIP?
Which vaccines are required for applicants of different ages?

15. Process as Defined in the Technical Instructions
Determine applicant’s age
Review his/her vaccination records and medical history
Determine the vaccines applicant needs by referring to
Vaccine TI table
Current age-appropriate ACIP schedule
Assess contraindications and precautions
Determine if testing for laboratory evidence of immunity is indicated
Provide needed vaccines
Complete DS 3025

16. Vaccination Records

17. Experience: Which of the following applies to your practice?
Question 5
Experience: Which of the following applies to your practice?
We have never seen applicant vaccination records that we thought were fraudulent
We rarely see vaccine records that we think are fraudulent
We frequently see vaccine records that we think are fraudulent
I am not a panel physician
Answer = A

18. Vaccination Records
Acceptable for applicants to have received vaccinations prior to the panel physician encounter
Applicants with appropriate documentation of receipt of vaccinations do not need to repeat those doses
Examination of vaccination records is very important

19. Examination of Vaccine Records
Are the dates of vaccination reasonable?
Were the vaccines available on the dates of administration?
If the record has handwriting:
Is all the ink the same color?
Does all the ink appear to have been written at the same time?
Is handwriting different for different vaccines (at different times)?
Is the format consistent with other records?

20. Advise applicant to apply for a vaccine waiver
Question 6
You examine a 24-year-old applicant. He does not provide a vaccination record but is adamant he has been vaccinated. What should you do?
Advise applicant to apply for a vaccine waiver
Provide influenza and MMR vaccines
Refuse to complete the medical examination before he provides vaccination records
Write for advice
Perform laboratory testing for immunity
Answer = E

21. Laboratory Evidence of Immunity
Acceptable for the following diseases:
Measles
Mumps
Rubella
Hepatitis A
Hepatitis B
Polio
Varicella
Use kits that have regulatory approval in your country

22. We have immunity tests available, but we never use them
Question 7
Experience: Which of the following statements best describes your practice?
We have immunity tests available, and we frequently use them for applicants
We have immunity tests available, but we never use them
We don’t have immunity tests available
I am not a panel physician
Answer = A

23. In which arm would you like the varicella shot?
Question 8
You examine a 24-year-old female applicant who mentions that she can’t wait to start a family in the US. She has no record of varicella vaccine, and states she had chicken pox at 7 years-old. What should you ask her next?
In which arm would you like the varicella shot?
Can you describe the symptoms you had at 7?
Do you have any chicken pox scars?
Were you seen by a doctor when you had chicken pox?
B, C, and D
Answer = E

24. Countries of Origin of Cruise Ship Crew Members with Varicella Reported to CDC, January 2010-February 2016
Note there is some bias because more crew members are from the Philippines and India, however, map reflects the trend of varicella occurring at older age in tropical countries
Total number of cases = 422

25. Varicella Vaccination
Keep in mind the following:
For varicella, credible history of the disease is adequate at this time
Ask questions to make sure applicant describes a clear history of the disease
Exposure is likely to occur, so make sure the applicant understands the risk
If history is uncertain, test for immunity can be used

26. Exercise: Review of Vaccination Records

27. Break

28. How to Use Vaccine TI Table and ACIP Recommendations

29. Vaccination Table in Vaccination Technical Instructions

30. ACIP-recommended Immunization Schedule for Persons Ages 0 Through 18 Years – United States, 2016

31. ACIP-recommended Adult Immunization Schedule – United States, 2016

32. ACIP routine immunization schedule for children
Question 9
You examine a 13-year-old applicant who has documentation of receiving 1 polio vaccine, but no other vaccines. What table should you follow to determine the diseases she must be vaccinated against in order to immigrate to the US?
ACIP routine immunization schedule for children
WHO Expanded Programme on Immunization (EPI) schedule
ACIP catch-up immunization schedule
Vaccine TI table
Answer = D

33. Vaccine TI Table and ACIP Tables
Vaccine TI table provides structure for meeting US immigration immunization requirements
Where differences exist between vaccine TI table and ACIP tables:
Follow vaccine TI table
ACIP tables are comprehensive for that vaccine, including for contraindications
Use as detailed resource once you commit to giving a specific vaccine based on the TI table

34. Vaccine TI Table
Strengths
Quick way to determine diseases an applicant must be vaccinated against
All age groups are on one table
Weaknesses
Does not provide number of doses
Does not explain spacing of doses
Does not provide detailed information about contraindications

35. ACIP Tables
Strengths
Provides number of vaccine doses, spacing and catch up schedules
Comprehensive information for specific vaccines including contraindications
Weaknesses
Multiple documents, lots of detail
U.S. domestic recommendations for individual patient health, not immigration requirements
Some differences from TIs (e.g., HPV, zoster)

36. Summary of Process for Using Vaccine TI and ACIP Tables
Refer to Vaccine TI table
Shows you which diseases an applicant must be vaccinated for by age
Go to ACIP tables
Age
Number of doses needed, spacing, contraindications
Where there are differences between vaccine TI table and ACIP tables
Follow vaccine TI table

37. How to Complete the DS Forms

38. To understand her infectious disease risk Your nurse is confused
Question 10
A 22-year-old K visa applicant presents for her examination. She has been to the CDC website and knows she does not have to be vaccinated, so she did not bring her record. She asks why your nurse requested her vaccination record. What do you tell her?
To understand her infectious disease risk
Your nurse is confused
To provide required vaccinations for U.S. immigration
To provide a comprehensive vaccination record in English which she will need in the US
Answer=D

39. DS 3025 Officially: Documents whether or not applicant is inadmissible
Documents that applicant has received required vaccinations
In addition:
Comprehensive vaccination record
Resource for applicant after arrival to the United States
Captures vaccine doses given as part of special program for U.S.-bound refugees

40. For All Applicants
Obtain vaccine history
Document vaccine history
Provide a copy of the DS 3025 to the applicant

41. DS 3025 Page 1
Vertical orientation
All diseases listed must have a vaccine disposition
Panel physician must sign and date the form

42. Immunization Record
Record vaccines previously given to applicant in the first four columns
Immigrants will only receive one dose of a specific required vaccine by the panel physician before travel
Thus, only one column for vaccines you give

43. Blanket Waiver
To our knowledge, no applicant has completed every required vaccine series at the time of the panel physician examination
Therefore, “Blanket Waiver” is needed to allow immigration process to continue
Blanket waivers for the specific reasons defined are given by the panel physician

44. Blanket Waiver Category Examples
A – Age not appropriate
If applicant does not need specific vaccine
B – Insufficient time interval to complete series
Child receives dose in series but will travel before next dose is due
C – Contraindicated
D – Not routinely available
In country or region
Specific vaccine not licensed for age of applicant
F – Not flu season
Influenza season is fall-winter in either hemisphere
Tropics: Give if product available in your country
Not responsible for stocking both hemisphere vaccines
H – Known chronic hepatitis B virus infection
Document if known, but do not test

45. Coordinate with a new supplier or local pharmacy to obtain vaccine
Question 11
The panel physician has trouble ordering MMR vaccine from his usual supplier. Other physicians in the community have supplies. How is the DS 3025 documented?
Coordinate with a new supplier or local pharmacy to obtain vaccine
Mark Blanket waiver “A” not age appropriate
Mark Blanket waiver “B” insufficient time interval
Mark Blanket waiver “D” not routinely available
Answer = A

46. Maintain stock of both Northern and Southern Hemisphere vaccine
Question 12
You practice in a tropical country. An applicant visits you in September for a medical examination. What do you do about influenza vaccine?
If available, provide either Southern Hemisphere vaccine or Northern Hemisphere vaccine
Maintain stock of both Northern and Southern Hemisphere vaccine
Provide Northern Hemisphere vaccine because applicant will immigrate to Northern Hemisphere
Perform laboratory testing for immunity
Answer = A

47. Summary for Immigrant Visa Applicants
Complete, but requests a Blanket Waiver
Applicant is admissible
U.S. vaccination requirements not complete
Individual waiver
Must be opposed to all vaccinations
Applicant should discuss the waiver process with the Consular Section
Adoptee exemption
Applicant refuses vaccinations – Not Admissable!

48. Refugee Vaccine Initiative
CDC partnering with the International Organization for Migration (IOM) and U.S. Department of State to vaccinate refugees
Doses provided through that program are documented in these columns
Initiative uses different guidance provided by CDC than what is in the Vaccine TI

49. DS 3025 Page 2

50. Cases

51. Helpful Resources
Pink Book page explaining all contraindications and helpful screening questions in a box
Table of contraindications
Guidelines for Vaccinating Pregnant Women
Vaccine Storage and Handling Toolkit
Pink Book= Epidemiology and Prevention of Vaccine-Preventable Diseases

52. Thank you cdcQAP@cdc.gov http://www.cdc.gov/panelphysicians
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA
Telephone: CDC-INFO ( )/TTY:
Visit: | Contact CDC at: CDC-INFO or
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

53. Answers B C D A E