Health of Asylees Compared to Refugees in the United States Using Domestic Medical Examination Data, 2014-2016: A Cross-Sectional Analysis

Abstract

Between 2008 and 2018, persons granted asylum (asylees) increased by 168% in the United States. However, little is known about the health of asylees to guide clinical practice. We analyzed domestic medical examination data from nine US sites from 2014 to 2016. We compared prevalence of infectious diseases such as latent tuberculosis infection (LTBI) by refugee or asylee visa status. Approximately 15% of asylees were diagnosed with LTBI. Prevalence of LTBI (Prevalence Ratio [PR]=0.8), hepatitis B (0.7), hepatitis C (0.5) and Strongyloides (0.5) infections were significantly lower among asylees than refugees. Prevalence of other reported conditions including Schistosoma did not differ by visa status. Compared to refugees, asylees included in our dataset were less likely to be infected with some infectious diseases but had similar prevalence of other reported conditions. The CDC domestic medical examination guidance can also assist clinicians in the care of asylees during the routine domestic medical examination.

Article Summary Line:

About 15% of asylees in the United States were diagnosed with latent tuberculosis infection and 52% of asylee adults were susceptible to hepatitis B virus infection; however, asylees were less likely to be infected with some infectious diseases compared to refugees.

INTRODUCTION

Refugees and asylees are persons who are outside their countries of nationality and who are unable to return to their countries of nationality 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 (1). Applicants for refugee status are outside the United States and are typically planned migrations, whereas applicants seeking asylum are already present in the United States or are seeking admission at a United States port of entry (2). Refugees and other immigrants receive a medical screening exam overseas according to the Technical Instructions written by the US Centers for Disease Control and Prevention (CDC) (3) and have access to overseas health interventions, such as vaccines or parasite treatments before departure to the United States (4). However, asylees do not receive an overseas medical screening exam or access overseas health interventions available to US-bound refugees because they seek asylum after US arrival. After being granted asylum, individuals (now asylees) are eligible for many of the same domestic benefits as refugees under the US Refugee Admissions Program (USRAP), including resettlement assistance and health-related benefits in the United States (5,6).

The number of persons granted asylum in the United States increased by 168% between 2008 and 2018 (2). In 2018, the number of principal asylees (38,687) surpassed the number of refugee arrivals (22,405) for the first time since 2003 (2), although this was likely related to the steady reduction in planned US refugee admissions since 2016. Countries of nationality for individuals granted asylum vary each year. In 2014, the leading countries of nationality of persons granted asylum were China (35.0%) and Egypt (10.1%) (7), whereas in 2018, the leading countries were China (17.8%) and Venezuela (15.7%) (2). In contrast, the leading countries of nationality for refugees resettling in the United States from 2008 to 2018 included Burma, Iraq, Bhutan, Somalia, and Democratic Republic of the Congo (8), but countries of nationality for refugees also vary each year.

The CDC recommends that asylees receive a domestic medical examination soon after being granted asylum status (9). Refugees are recommended to receive the examination as soon as possible after arrival in the United States, ideally within 30 days (9). While principal applicants for asylum status do not receive an overseas medical screening exam (3), family members who follow to join them in the United States (derivative asylees) would undergo the required medical examination overseas, prior to resettlement, in addition to being eligible for the domestic medical examination (9). However, derivative asylees are ineligible for and do not access overseas vaccines or parasite treatments.

Clinicians conducting the domestic medical examination for asylees have been encouraged to follow CDC’s Guidance for the US Domestic Medical Examination for Newly Arrived Refugees (10). Because the CDC guidance were originally developed for refugee populations, reporting on the guidelines’ effectiveness in capturing health conditions among asylee populations is limited (10). Minimal information about the health of asylees exists in the literature (11-13). Increasing clinician knowledge about common health conditions encountered in asylees may facilitate diagnostic screening, targeted clinical evaluation, and referrals to additional healthcare providers in the United States. Further, more data are needed comparing the health of asylees and refugees given the potential similarities in reasons for United States resettlement and because both populations are eligible to receive the domestic medical examination. However, differences due to countries of origin and conditions of emigration or transit likely exist between these two populations and can contribute to differences in risks of disease exposure. Assessing differences in health profiles between these populations can inform clinical management and whether public health interventions, including domestic medical examination guidance, should be tailored to specific groups.

Therefore, the purpose(s) of this analysis are two-fold: 1) describe the frequency and prevalence of screened medical conditions among asylees during the domestic medical examination and 2) compare the prevalence of medical conditions in asylees and refugees during domestic medical examinations.

METHODS

Analysis Design, Participants, and Setting

A cross-sectional analysis was conducted to examine the prevalence of medical conditions among asylees compared to refugees during the domestic medical examination. Participants included asylee and refugee adults (≥18 years old) and children (<18 years old) who received a domestic medical examination in the United States between January 2014 and December 2016. Sites were not able to provide information about whether asylees were principal asylees or derivative asylees. CDC collaborated with nine state, local, and academic partners as part of a cooperative agreement (CK12-1205) to collect domestic medical examination data for analysis. Further details about partners and methodology can be found elsewhere (14,15). This project was reviewed in accordance with CDC institutional review policies and procedures and was determined to be non-research.

Data Sources

Each site collected domestic medical examination data, including basic demographic information, anthropometric measurements, and results of laboratory testing. For any missing data on nationality, data from CDC’s Electronic Disease Notification (EDN) system was used to capture this missing information. EDN is the centralized reporting system that captures overseas medical examination information of all refugees as well as immigrants with health conditions requiring medical follow-up. CDC guidance recommend screening for both communicable (e.g., tuberculosis [TB] and hepatitis B) and non-communicable (e.g., elevated blood lead levels) conditions during the domestic medical examination (10). Details on diagnosis and categorization of each condition are described further in Tables 2 and 3. CDC also recommends evaluation for other conditions, including mental health disorders, during the domestic medical examination. However, screening for such conditions is usually based on clinical judgement, provider comfort, and/or state and clinic-based policies; thus, these conditions were not included in our analysis.

Table 2. Domestic Medical Examination Results among Asylees and Refugees who Resettled to the United States, 2014–2016^*,^†.

Medical Screening Characteristic	Adults ≥18 years old			Children <18 years old
	Asylee n (%)	Refugee n (%)	P value	Asylee n (%)	Refugee n (%)	P value
Total
Tuberculosis ‡	n = 2,123	n = 28,350	<0.0001	n = 822	n = 17,193	<0.0001
No evidence of Tuberculosis	1,787 (84.2)	21,526 (75.9)		783 (95.3)	15,654 (91.1)
Clinically active	1 (0.1)	54 (0.2)		0	14 (0.1)
Not clinically active	10 (0.5)	423 (1.5)		0	88 (0.51)
Latent tuberculosis infection	325 (15.3)	6,347 (22.4)		39 (4.7)	1,437 (8.4)
Hepatitis B §	n = 2,757	n = 42,770	< 0.0001	n = 1,040	n = 25,955	0.004
Susceptible	1,422 (51.6)	17,172 (40.2)		286 (27.5)	6,346 (24.5)
Uninfected, susceptibility unknown	304 (11.0)	6,892 (16.3)		308 (29.6)	8,081 (31.1)
Infected	75 (2.7)	1,579 (3.7)		7 (0.7)	351 (1.3)
Immune
Natural infection	266 (9.7)	4,832 (11.3)		12 (1.2)	458 (1.8)
Hepatitis B vaccination	663 (24.1)	10,395 (24.3)		423 (40.7)	10,363 (39.9)
Not specified	27 (1.0)	1,810 (4.2)		4 (0.4)	356 (1.4)
Hepatitis C ¶	n = 2,065	n = 24,603	0.002	n = 698	n = 11,320	0.24
Screened, positive	26 (1.3)	561 (2.3)		2 (0.3)	81 (0.7)
Malaria #	n = 1,491	n = 7,582	0.74	n = 518	n = 3,252	0.03
Screened, positive	3 (0.2)	13 (0.2)		0	29 (0.9)
Strongyloidiasis **	n = 581	n = 8,724	0.02	n = 192	n = 6,890	1.0
Screened, positive	11 (1.9)	331 (3.8)		2 (1.0)	83 (1.2)
Schistosomiasis **	n = 143	n = 4,306	0.02	n = 41	n = 4,135	1.0
Screened, positive	20 (14.0)	303 (7.0)		1 (2.4)	128 (3.1)
Pathogenic Intestinal Parasites ††	n = 2,286	n = 21,139	0.52	n = 907	n = 13,164	0.93
Screened, positive	7 (0.31)	50 (0.24)		7 (0.77)	98 (0.74)
Syphilis ‡‡	n = 2,609	n = 31,270	0.83	n = 527	n = 5,960	1.0
Screened, positive	23 (0.9)	294 (0.9)		2 (0.4)	26 (0.4)
Chlamydia §§	n = 631	n = 8,363	0.07	n = 160	n = 1,823	0.69
Screened, positive	18 (2.9)	150 (1.8)		2 (1.3)	19 (1.0)
HIV §§	n = 2,771	n = 36,365	0.26	n = 1,003	n = 19,969	0.73
Positive, screened/ unscreened (type 1, type 2, or unknown)	27 (1.0)	283 (0.8)		1 (0.1)	47 (0.2)
Blood lead level (mcg/dL)¶¶				n = 845	n = 24,757	<0.0001
<5	N/A	N/A		787 (93.1)	21,709 (87.7)
5–9	N/A	N/A		52 (6.2)	2,707 (10.9)
10–19	N/A	N/A		6 (0.7)	293 (1.2)
20–44	N/A	N/A		0	43 (0.1)
45–70	N/A	N/A		0	5 (0.02)

^*Percentages may not add up to 100% because of rounding. We used χ² or Fisher’s exact tests to compare characteristic or disease condition by status at entry (asylee vs. refugee). Fisher’s exact tests were used if frequency per cell was < 5. Statistical significance was noted at a p value < 0.05.

^†Proportion of all asylees who were not screened for a particular medical condition: latent tuberculosis infection (6%); hepatitis B virus (2%); hepatitis C virus (32%); malaria (50%); strongyloides (81%); schistosomiasis (95%); other intestinal parasites (21%); syphilis (22%); chlamydia (80%); HIV (7%); and elevated blood lead level (children only: 22%).

^‡For tuberculosis (TB), information on diagnosis was reported and categorized as no evidence of TB, clinically active, not clinically active and latent tuberculosis infection (LTBI) [23]. TB disease diagnosis was made by a positive smear, culture, or clinical diagnosis of pulmonary TB. A classification of not clinically active TB was made when a person had a history of previous episode(s) of TB or abnormal stable radiographic findings and had a positive reaction to tuberculin skin test (TST), negative cultures, and no clinical and/or radiographic evidence of current disease. Diagnosis of LTBI was made by a positive interferon gamma release assay (IGRA) or TST and negative diagnostic workup for TB. The majority of asylee adults (99%) were tested using IGRA. Among children tested for LTBI, 92% were tested using IGRA and 8% were tested using TST. Data were included if states provided information about TB diagnosis for an individual.

^§Hepatitis B virus status was categorized as susceptible (HBsAg, anti-HBc, and anti-HBs all negative), uninfected/susceptibility unknown (HBsAg negative, anti-HBc and anti-HBs unknown), infected (HBsAg positive), immune through natural infection (HBsAg negative, anti-HBc positive and anti-HBs positive), immune through hepatitis B vaccination (HBsAg negative, anti-HBc negative, and anti-HBs positive) and immune but not specified (HBsAg negative, anti-HBs positive and anti-HBc unknown) [24] .

^¶Hepatitis C was diagnosed by any of the following: detection of antibody to hepatitis C virus (anti-HCV), a positive recombinant immunoblot assay (RIBA) result, or a positive HCV RNA polymerase chain reaction (PCR) result. Since the type of test used was not specified, individuals who screened positive for hepatitis C may have either current or past infection.

^#Malaria diagnosis was laboratory-confirmed using either microscopy or by a rapid diagnostic test.

^**Strongyloides and schistosomiasis diagnoses were laboratory-confirmed using either microscopy or by serology testing.

^††Intestinal parasite infection diagnoses were laboratory-confirmed using stool ova and parasite testing.

^‡‡Syphilis diagnosis was made via a positive non-treponemal test (Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR]) followed by a positive confirmatory treponemal test (e.g., Treponema pallidum-particle agglutination [TP-PA], microhemagglutination assay for Treponema pallidum [MHA-TP]). Syphilis testing is recommended in all persons ≥15 years of age if no overseas testing results are available, and in persons <15 years of age if sexually active.

^§§Chlamydia and HIV diagnoses were made via laboratory-confirmed testing.

^¶¶Blood lead level screening applies to children from 6 months up to 16 years of age only.

Table 3. Adjusted Prevalence Ratios for Select Medical Conditions among Asylees and Refugees who Resettled to the United States, 2014–2016^*.

Medical Conditions	All	Adults ≥18 years old	Children <18 years old
	aPR (95% CI) Ref: Refugee	aPR (95% CI) Ref: Refugee	aPR (95% CI) Ref: Refugee
Latent tuberculosis infection	0.76 (0.62-0.94)	0.76 (0.63-0.94)	0.70 (0.52-0.96)
Hepatitis B †
Susceptible	1.19 (0.93-1.52)	1.21 (0.93-1.57)	1.08 (0.85-1.36)
Infected	0.73 (0.55-0.98)	0.72 (0.54-0.97)	0.43 (0.23-0.83)
Immune through vaccination	0.89 (0.73-1.09)	0.83 (0.60-1.16)	0.97 (0.85-1.11)
Hepatitis C	0.54 (0.46-0.63)	0.56 (0.46-0.67)	0.38 (0.14-1.04)
Strongyloides	0.53 (0.36-0.80)	0.50 (0.33-0.75)	0.79 (0.50-1.26)
Schistosomiasis	2.06 (1.01-4.20)	1.88 (0.99-3.57)	--
Elevated blood lead level (≥ 5 mcg/dL)	N/A	N/A	0.6 (0.3-1.1)

^*Poisson regression was used to model the adjusted prevalence ratios (adjusted for age and sex) to assess association of status at entry (asylee vs. refugees) and outcomes. Refugee status was used as reference.

^†Hepatitis B virus status was categorized as susceptible (HBsAg, anti-HBc, and anti-HBs all negative), infected (HBsAg positive), and immune through hepatitis B vaccination (HBsAg negative, anti-HBc negative, and anti-HBs positive).

aPR=adjusted prevalence ratio

CI=confidence interval

Measures

Demographic information provided included sex, age, nationality, and primary language spoken by the applicant or used by an interpreter. We examined the results of laboratory testing for tuberculosis, hepatitis B, hepatitis C, malaria, strongyloidiasis, schistosomiasis, other pathogenic intestinal parasites, syphilis, chlamydia, and human immunodeficiency virus (HIV); most outcomes were categorized as either ‘screened and positive’ or ‘screened and negative.’ During the period of data collection, CDC guidance recommended screening blood for lead in children aged six months to 16 years, with elevated blood lead levels [EBLL] defined as ≥5 mcg/dL (10). For most conditions, we were unable to collect detailed information on the method of screening (i.e., type of test) used by partners. Persons who were not screened, or those who were screened but whose results were unknown, were excluded from the outcomes analysis.

Statistical Methods

Frequencies and proportions were calculated to describe demographic characteristics and prevalence of medical conditions; results were stratified by asylee or refugee status and age at screening visit (adult ≥18 years, child <18 years). We used χ² tests or Fisher’s exact tests to compare each medical condition by refugee/asylee status. Fisher’s exact tests were used if the frequency per cell was less than five. Statistical significance was noted at a P value < 0.05. Denominators for medical conditions varied because of missing data and screening differences across sites.

A modified Poisson regression was used to model the adjusted prevalence ratio (adjusting for age and sex) while accounting for state-level clustering. Status at entry (refugee status as reference) was the primary exposure variable, and select medical conditions (i.e., latent tuberculosis infection [LTBI], hepatitis B virus [HBV], hepatitis C virus [HCV], strongyloidiasis, schistosomiasis, and elevated blood lead levels [EBLL]) were the primary outcome variables. Medical conditions with five or fewer cases or that were not statistically significant in the bivariate analysis (Table 2) were excluded from the analyses.

RESULTS

Of the 78,062 individuals included in our analysis, 4,044 (5%) were asylees and 74,018 (95%) were refugees (Table 1). For adults, the average age was 36.0 years for asylees (standard deviation [SD]: 14.1) and was 35.4 years for refugees (SD: 12.7). For children, the average age was 9.3 years for asylees (SD: 4.7) and was 8.0 years for refugees (SD: 5)). There were 88 nationalities represented by asylees, and 115 nationalities represented by refugees. The leading nationalities for all asylees were China (24%), Iraq (10%), and Iran (9%), while the leading nationalities for refugees were Burma (24%), Iraq (19 %), and Somalia (11%). Both asylee and refugee populations had six nationalities in common among the top ten nationalities represented by both populations. These nationalities included Iraq, Iran, Somalia, Syria, Afghanistan, and Eritrea. About 82 primary languages were spoken by or used by an interpreter for asylees.

Table 1. Demographic Characteristics of Asylees and Refugees who Resettled to the United States, 2014–2016^*.

Demographic Characteristics	All		Adults ≥18 years old		Children <18 years old
	Asylee n (%)	Refugee n (%)	Asylee n (%)	Refugee n (%)	Asylee n (%)	Refugee n (%)
Total	4,044	74,018	2,901	45,113	1,143	28,905
Sex			n = 2,901	n = 45,108	n = 1,143	n = 28,898
Female	1,933 (47.8)	35,973 (48.6)	1,390 (47.9)	21,882 (48.5)	543 (47.5)	14,091 (48.8)
Male	2,111 (52.2)	38,033 (51.4)	1,511 (52.1)	23,226 (51.5)	600 (52.5)	14,807 (51.2)
Age in years			n = 2,901	n = 45,113	n = 1,143	n = 28,898
Mean (SD)	25.1 (17.8)	28.1 (16.1)	36.0 (14.1)	35.4 (12.7)	9.3 (4.7)	8.0 (5.0)
0–2					92 (8.1)	5,081 (17.6)
3–5					203 (17.8)	5,697 (19.7)
6–17					848 (74.2)	18,127 (62.7)
18–44			2,267 (78.2)	34,508 (76.5)
45–64			552 (19.0)	8,258 (18.3)
≥65			82 (2.8)	2,347 (5.2)
Nationality	n=4,044	n = 74,018	n=2,901	n=45,113	n=1,143	n=28,905
China	950 (23.5)	132 (0.2)	645 (22.2)	94 (0.2)	305 (26.7)	38 (0.1)
Iraq	389 (9.6)	14,170 (19.1)	323 (11.1)	9,368 (20.8)	66 (5.8)	4802 (16.6)
Iran	367 (9.1)	6,392 (8.6)	319 (11.0)	5,488 (12.2)	48 (4.2)	904 (3.1)
Egypt	337 (8.3)	60 (0.8)	204 (7.0)	27 (0.06)	133 (11.6)	33 (0.1)
Ethiopia	208 (5.1)	905 (1.2)	150 (5.2)	530 (1.2)	58 (5.1)	375 (1.3)
Afghanistan	191 (4.7)	2,396 (3.2)	104 (3.6)	1407 (3.1)	87 (7.6)	989 (3.4)
Syria	190 (4.7)	4,136 (5.6)	134 (4.6)	1873 (4.2)	56 (4.9)	2,263 (7.8)
Nepal	173 (4.3)	288 (0.4)	113 (3.9)	160 (0.4)	60 (5.3)	128 (0.4)
Eritrea	154 (3.8)	950 (1.3)	133 (4.6)	526 (1.2)	21 (1.8)	424 (1.5)
Somalia	110 (2.7)	8,288 (11.2)	101 (3.5)	4,332 (9.6)	9 (0.8)	3,956 (13.7)
Burma	29 (0.7)	17,674 (23.9)	19 (0.7)	10,764 (23.9)	10 (0.9)	6,910 (23.9)
Democratic Republic of the Congo	28 (0.7)	6,387 (8.6)	18 (0.6)	3,074 (6.8)	10 (0.9)	3,313 (11.5)
Ukraine	6 (0.2)	167 (0.2)	6 (0.2)	108 (0.2)	--	59 (0.2)
Bhutan	6 (0.2)	4,200 (5.7)	4 (0.1)	2,938 (6.5)	2 (0.2)	1,262 (4.4)
Other nationalities	906 (22.4)	7,873 (10.6)	628 (21.7)	4,424 (9.8)	278 (24.3)	3,449 (11.9)

^*Percentages may not add up to 100% because of rounding. SD, standard deviation.

Adults

Overall, 1787 (84%) asylee adults (vs. 76% of refugee adults) had no evidence of tuberculosis disease, and 15% (vs. 22%) were diagnosed with LTBI (Table 2). Approximately 52% of asylee adults were susceptible to HBV infection compared to 40% of refugee adults (Table 2). In the adjusted analysis, there were no differences in status of susceptibility to HBV infection between asylees and refugees. However, another 11% of asylee adults and 16% of refugee adults who were uninfected with HBV had unknown HBV susceptibility (i.e., status of anti-HBc and anti-HBs unknown); therefore, the proportion of each population susceptible to hepatitis B may differ. Compared to refugees, asylees were less likely to have LTBI (PR: 0.8; 95% CI: 0.6–0.9), HBV (0.7; 95% CI: 0.5–0.97), HCV (0.75; 95% CI: 0.5–0.7), and Strongyloides infection (0.5; 95% CI: 0.3-0.8) in the adjusted analysis (Table 3). While a greater proportion of asylee adults screened positive for schistosomiasis (14%) compared to refugee adults (7%), there were no differences in the prevalence of schistosomiasis in the adjusted analysis. There were no differences in the prevalence of malaria, other pathogenic intestinal parasites, syphilis, chlamydia, and HIV between asylees and refugees.

Children

Overall, 783 (95%) asylee children (vs. 91% of refugee children) had no evidence of tuberculosis disease, and 5% (vs. 8% of refugee children) had a diagnosis of LTBI (Table 2). Asylee children were less likely to have LTBI compared to refugee children (PR: 0.7; 95% CI: 0.5–0.96). About 28% of asylee children (vs. 25% of refugee children) were susceptible to HBV infection, although this proportion may differ given that 30% of asylees were uninfected, with their susceptibility unknown. Approximately 0.7% of asylees (vs. 1% of refugees) were HBV-infected, while 42% were immune (vs. 43%). Compared to refugees, asylees were less likely to be infected with HBV (PR: 0.4; 95% CI: 0.2–0.8). Approximately 7% of asylees (vs. 12%) had EBLL. In adjusted analysis, there was no difference in the prevalence of HCV, strongyloidiasis, schistosomiasis, other pathogenic intestinal parasites, syphilis, chlamydia, HIV, and EBLL between asylee and refugee children who were screened for each condition (Table 3).

Asylees Not Screened for a Particular Condition

The proportion of all asylees who were not screened for a particular medical condition were as follows: latent tuberculosis infection (6%); hepatitis B virus (2%); hepatitis C virus (32%); malaria (50%); strongyloidiasis (81%); schistosomiasis (95%); other intestinal parasites (21%); syphilis (22%); chlamydia (80%); HIV (7%); and elevated blood lead level (children only: 22%). The proportion of refugees who were not screened for a particular medical condition have been reported elsewhere (14).

DISCUSSION

In our analysis, the majority of asylees who received a domestic medical examination between 2014 to 2016 were from China, Iraq, and Iran, while most refugees were from Burma, Iraq, and Somalia. About 15% of adult asylees were diagnosed with LTBI, as compared to 22% of adult refugees. About half of asylee adults and over a quarter of asylee children were susceptible to HBV infection. When compared to refugee adults, asylee adults were less likely to be infected with LTBI, HBV, HCV, and Strongyloides, but had similar prevalence of other reported conditions, such as other pathogenic intestinal parasites. Compared to refugee children, asylee children were less likely to have LTBI or HBV infection, but had a similar prevalence of other reported conditions.

Few published studies exist describing the physical health profile of asylee populations in the United States (11-13,16), although it is possible that asylees were included in other studies of newcomer populations, but not specifically identified. To the authors’ knowledge, this is one of few analyses among asylee populations in the United States that reports screening data for most of the conditions screened as part of the domestic medical examination. In contrast to other published studies, our analysis included data from multiple sites across the country.

Prevalence of reported communicable diseases among asylees varied across studies with LTBI ranging from 5 to 41% (11-13), and HBV infection ranging from 2 to 9% (11,12). Differences in estimates between our analysis and other studies could be related to sample size, the definition of ‘asylee’ used (e.g., not differentiating between asylum-seekers and asylees or primary and derivative asylees), nationalities of asylees receiving a health examination during the time period of the study, and the average duration of US residence of asylees. For example, disease exposures in countries with high incidence or prevalence of conditions, such as tuberculosis disease and HBV infection before emigration or during transit and the availability of and accessibility to vaccination programs and health care before and after journey to the United States can influence the presence of some health conditions among asylees (17,18).

Asylees in our analysis had either a lower or similar prevalence of reported conditions (e.g., similar prevalence of pathogenic intestinal parasites) compared to refugees. Asylees also had a similar susceptibility to HBV infection. This is despite refugees having access to the overseas presumptive parasite treatment program and the voluntary Vaccination Program for US-bound Refugees, which was created to provide one to two doses of certain vaccines overseas (including hepatitis B vaccine) (4); however, both of these programs were still in the early stages of global expansion during the data collection period, and hence the current picture may differ. These results are consistent with findings in a smaller study comparing prevalence of certain conditions between asylees and refugees from 2003 to 2007, including tuberculosis and HBV infection (11). Differences between asylees and refugees could be due in part to the different prevalence of/risk of exposure to certain conditions, such as hepatitis B, intestinal parasites, and tuberculosis, in the countries of emigration or transit and availability and access to clinical and preventive health services prior to or after US arrival (in the case of asylees). Principal asylees who have been present in the United States for any significant period of time—because the length of the asylum process can vary between six months to several years (19)—may have had access to health care services (12), and it is possible that any identified health conditions and vaccinations were addressed before the domestic medical examination.

Given the potentially serious outcomes of some medical conditions identified during the domestic medical examination (such as tuberculosis and HBV infection) if not evaluated and managed promptly, US clinicians should refer to CDC’s Guidance for the US Domestic Medical Examination for Newly Arrived Refugees to screen for and manage conditions found in asylees and offer vaccinations to those without laboratory evidence or a historical record of vaccination for conditions such as HBV infection (10). Because asylees do not receive pre-departure presumptive parasite treatment, and because the majority of asylees did not receive screening for strongyloidiasis and schistosomiasis (although it is possible some asylees were ineligible for screening due to countries of origin or transit), US clinicians should strongly consider screening and treating for intestinal parasites, including strongyloidiasis and schistosomiasis, according to CDC guidance, to prevent further transmission or complications. While mental health diagnoses were not reported in this analysis, a recent systematic review reported that close to a third of refugees and asylum seekers had posttraumatic stress disorder and depression, while 11% had anxiety disorders (20). Therefore, clinicians should ensure that asylees are screened and referred for further mental health services, if needed.

Of note, while the leading nationalities of asylee populations who received a domestic medical examination and were included in our analysis were China, Iraq, and Iran, the leading nationalities of all persons granted asylum between 2014-2016 were China (22-34%), Egypt (12%) and El Salvador (8-11%). Therefore, our findings may not be representative of the characteristics of all asylee populations over the time period (21). It is possible that asylees of other nationalities did not reside in the states included in our analysis (although up to 60% of individuals granted asylum affirmatively resided in California or New York from 2014-2016) or were not captured in the dataset, even if they received a domestic medical examination (22). It is also possible that asylees of other nationalities (e.g., Egypt and El Salvador) did not access or minimally accessed healthcare benefits or services. Many asylees may be unaware that they are eligible for health care benefits, including the domestic medical examination, or how to access health services and other benefits upon being granted asylum (4,5). Language barriers, fear or mistrust of healthcare systems and government authorities, and social exclusion or discrimination by members of their own or other communities may also prevent asylees from accessing benefits and services (23). Some asylees may have already accessed healthcare if they have been present in the United States for some time before being granted asylum (19). Therefore, greater outreach to individuals who were recently granted asylum could be conducted to improve awareness of benefits and identify and resolve access barriers. These efforts may require collaboration across different entities, including legal organizations processing asylum cases, resettlement agencies, the US Citizenship and Immigration Services, community-based organizations working with asylum seeker populations, and state refugee health programs. Outreach efforts may include providing information regarding healthcare services and providers when individuals are awarded asylum status, in addition to building trust and/or assuaging fears or mistrust of entities providing these benefits or services.

Limitations

This analysis has several limitations. First, health screening data were not collected and reported uniformly across all nine sites; therefore, denominators across medical conditions and diagnoses varied. Generally, while screening and testing were conducted according to CDC guidance, variation by location existed, as the guidance are meant to be customized in each jurisdiction. Second, the CDC domestic medical examination guidance (14) differentiate screening according to nationality, age of patient, and availability of overseas health records; thus, not all tests were conducted for all asylees and refugees. Third, as noted previously, we do not have domestic medical examination data for all individuals granted asylum, considering that the leading populations from our dataset differ from leading populations granted asylum in the United States during the similar time period covered by this analysis. Because data from asylees who did not receive the domestic medical examination or who did receive one but were not captured in the dataset were not available, estimates of medical conditions among all asylees and any reported differences in estimates between asylees and refugees may be under- or overestimated. Further, data were collected from nine sites and, therefore, are not be representative of all asylee populations in the United States from 2014 to 2016. Fourth, sites only shared whether asylees and refugees screened positive or negative for different infections, but the tests used were not reported; therefore, we may be unable to determine if the person has a current infection. With HCV infection, it is possible that a person can test positive for HCV antibody but have undetectable levels of HCV RNA, indicating that a person may not be currently infected. Therefore, based on the screening test used, the prevalence estimates reported in this analysis may be under- or overestimated. Fifth, we were unable to distinguish between principal asylees and derivative asylees. Due to likely differences in migration patterns, countries of origin, and pre- and post-migration disease exposures, estimates of medical conditions between these two asylee populations will likely differ. Sixth, we were not able to assess screening coverage and results for most non-communicable conditions, including mental health conditions. Lastly, compared to the number of refugees included in our analysis, the number of asylees included was much smaller, representing 5.2% of the entire sample.

Conclusions

In our analysis, we observed that 15% of asylees were diagnosed with LTBI and 52% of asylee adults were susceptible to HBV infection. Compared to refugees, asylees included in our dataset were less likely to be infected with LTBI and HBV but had similar prevalence of other reported conditions. However, estimates for LTBI and HBV are higher than for the general US population (US, LTBI: up to 5%; HBV: <2%) (24,25). Therefore, in addition to guiding screening for refugees, CDC domestic medical examination guidance can also assist refugee health programs and clinicians in the care of asylees during the routine domestic medical examination (14). Based on the results of this analysis, clinicians should ensure that asylees receive the appropriate screening procedures and follow up (including vaccines) as indicated, paying attention to conditions such as LTBI, HBV, and, among children, EBLL. With the help of community and public health partners, greater outreach to asylees when asylum status is awarded and ongoing communication after being granted asylum may be needed to ensure awareness of available benefits and identify and resolve barriers to accessing benefits, including the domestic medical examination. This may include implementing programs and health systems changes to facilitate their access to healthcare benefits, such as ensuring availability of culturally sensitive providers and access to medical interpretation services. Future analyses can explore other aspects of health among asylee populations, including non-communicable diseases (including mental health conditions) and vaccination coverage, as well as identify any existing barriers to receiving healthcare and accessing benefits. It may also be valuable to repeat our analysis every few years, given the changing demographic landscape of asylee populations in the United States.

Biography

Gayathri S. Kumar is a Medical Officer within the Immigrant, Refugee and Migrant Health Branch in the Division of Global Migration and Quarantine at the CDC. Her primary research interests include the health of resettled refugee populations and populations eligible for refugee health benefits in the United States.