Management of Refugees and International Adoptees

Abstract

Refugee children and international adoptees have special medical considerations that must be addressed. Providers must be aware of the immigration history, where, and under what circumstances the child lived and migrated to the United States. Federal guidelines exist regarding which infections should be screened for, and how and when and which vaccines should be administered.

Key points

• •Refugee children and international adoptees have special medical considerations that must be addressed.
• •Providers must be aware of the immigration history — where and under what circumstances the child lived and migrated to the United States.
• •Federal guidelines exist regarding which infections should be screened for and how and when and which vaccines should be administered.

When caring for children who arrive from other countries, it is important to establish whether these children are immigrants or refugees. Children who arrive as refugees are required to undergo a physical examination prior to entering the United States and are required to have a physical evaluation after arrival in the United States. If a child enters the United States as an immigrant, it is important to understand whether he or she is an undocumented immigrant, given that this can impact on what types of infectious diseases should be screened for.

In all cases, it is important to know the countries and situations children were in when they left their native country and began their journey to their new home. Issues of communicable diseases, vaccine delivery, sanitation, nutrition, and the potential for sexual abuse are all important in consideration of infectious diseases. This article addresses screening tests for immigrants and refugees first, next addresses international adoptees who fall under the first category but can potentially have some other infectious issues given their unique background, and then addresses screening tests for migrants without premigration medical examination.

Immigrants and refugees

For immigrants and refugees entering the United States, the Centers for Disease Control and Prevention (CDC) is responsible for providing the instructions for medical examination performed by identified civil surgeon and panel physicians. These instructions were developed to enforce the Immigration and Nationality Act regulations regarding the health-related grounds for inadmissibility of persons applying for admission into the United States. The purpose of the medical examination is to identify applicants with inadmissible health-related conditions for the Department of State and US Citizenship and Immigration Services (USCIS). The infectious diseases–related grounds for inadmissibility include persons who have a communicable disease of public health significance and those who fail to present documentation of having received vaccination against vaccine-preventable diseases (Table 1 ).

Table 1.

Who is required to have a medical examination for migration to the United States?

Category	Medical Examination	Examination Site	Examination Location
Immigrants	Yes	Panel physicians	Overseas
Refugees	Yes	Panel physicians	Overseas
Status adjusters	Yes	Civil surgeons	United States
Nonimmigrants	No	—	—
Short-term transit	No	—	—
Othersa	No	—	—

^aOthers include migrants who entered the United States without inspection, including those who entered with and without proper documentation.

Courtesy of US Department of Homeland Security.

Communicable diseases of public health significance in all immigrants include tuberculosis (TB), syphilis, gonorrhea, and Hansen disease. In addition to these 4 specific diseases, screening by history and physical examination includes evaluation for quarantinable diseases designated by any presidential executive order. Current diseases include cholera, diphtheria, plague, smallpox, yellow fever, viral hemorrhagic fevers, severe acute respiratory syndrome (SARS), and influenza caused by novel or re-emergent influenza (pandemic flu). In addition to these infectious diseases, other infectious diseases are reportable as a public health emergency of international concern to the World Health Organization (currently polio, smallpox, SARS, and influenza) and other public health emergencies of international concern (recently includes Ebola virus).

As part of the medical examination for immigration, all immigrants are required to have an assessment for the following vaccine-preventable diseases: polio, tetanus, diphtheria toxoids, pertussis, Haemophilus influenzae type B, rotavirus, mumps, measles, rubella, hepatitis A, hepatitis B, meningococcal disease, varicella, influenza, and pneumococcus.

Persons already in the United States applying for adjustment of status for permanent residency, including refugees, are also required to be assessed for these vaccine-preventable diseases. For vaccines requiring a series, only a single dose is required for immigration purposes with a plan to complete the necessary series of vaccinations. Individuals who want to obtained a personal belief waiver (based on religious or moral conviction) from the vaccine requirements can apply for this with a separate application process.

A list of civil surgeons and medication documentation needs for individuals applying for permanent status is available on the USCIS Web site: http://www.uscis.gov/portal/site/uscis.

The information regarding medical documentation required for individuals applying for immigrant visas is available at the Department of State Web site: http://www.travel.state.gov/visa/visa_1750.html. General information concerning civil surgeons and the medical examination required for immigration purposes is also available at www.uscis.gov.

The blanket designation of health departments as civil surgeons applies only to the vaccination assessment and only to refugees. Also, only health departments that have a physician or physicians meeting the legal definition of civil surgeon can participate in this designation, and accepting the designation is entirely voluntary on the part of health departments. A civil surgeon is legally defined as a licensed physician with greater than 4 years of professional experience. The completed I-693 medical examination form must contain the official stamp or seal of office and be given to a refugee in a sealed envelope for presentation to the USCIS. The vaccine series that must be completed is available from the CDC.

Overseas medical examinations of aliens are valid for variable amounts of time, as discussed later, for specific infectious illnesses.

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

• •No class (ie, no apparent defect, disease, or disability)
• •Class A other than TB
• •Class B2 latent TB infection
• •Class B3 TB (contact evaluation)

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

• •Class A TB with waiver
• •Class B1 TB, pulmonary
• •Class B1 TB, extrapulmonary
• •HIV infection

The American Academy of Pediatrics recommends that medical screening should be conducted as soon as possible after entry, and refugees should be assured ongoing primary care.

A general medical examination should include a history outlining nutrition and growth with a dietary history, reviewing previous vaccines, history of diseases, and a general physical examination. On physical examination, anthropometric indices of weight, length or height, and head circumference should be obtained.

Previous vaccinations should be recorded into a computerized state vaccination database as well as history of disease (eg, varicella and mumps) or laboratory evidence of immunity (eg, hepatitis B and rubella). The author recommends that any series of vaccinations that has been started should be completed and not repeated if given as recommended by the Advisory Committee on Immunization Practices. If a patient has no documentation, it must be assumed the patient has not been vaccinated unless laboratory evidence of immunity indicates otherwise.

Regarding all refugees, little screening laboratory work is suggested; however, the following is a potential algorithm to consider when evaluating these patients.

Laboratory Recommendations for all Refugees

• •Perform pregnancy test as indicated.
• •Perform complete blood cell count with differential to be able to look for evidence of anemia and an absolute eosinophil count.
• •Some specialists recommend a urinalysis but this is optional in patients unable to provide a clean-catch specimen.
• •Consideration of tuberculosis screening.

The 4 most commonly queried categories of infectious illnesses are addressed, specifically given the frequency at which they are encountered when caring for immigrants, migrants, and refugees. These 4 groups of illnesses include TB, malaria, and parasitic infections and sexually transmitted infections (STIs).

Tuberculosis

The current TB screening requirements, called the Technical Instructions for Tuberculosis Screening and Treatment Using Cultures and Directly Observed Therapy, were most recently updated in 2009. These requirements were first created, however, in 1991 and have been updated throughout the years. These technical instructions have been implemented on a country-by-country basis since 2007 and have been used by all countries that screen immigrants and refugees coming to the United States. These instructions include tests and procedures for diagnosing TB more quickly and more accurately. Factors that affect the choice of TB tests for children include their age, whether they have a known HIV infection, and if they have signs or symptoms of tuberculous disease.

TB screening varies by both age and HIV status. In children less than 2 years of age without HIV infection, no TB screening tests need to be performed unless a child has signs or symptoms suggestive of TB or has been in contact with a person with TB. In children between 2 years and 14 years of age without HIV infection, a screening tuberculin skin test (TST) or interferon-gamma release assay (IGRA) is indicated followed by a chest radiograph if either is positive. If the screening radiograph is indicative of TB diseases, then sputum smear and subsequent cultures are obtained and drug susceptibility tests are performed in individuals with positive smears. In teens over 15 years of age, a chest radiograph is required in all patients with subsequent sputum smear and culture and drug susceptibility testing as indicated. If a patient has symptoms of TB, even with negative TST/IGRA and chest radiograph results, sputum tests are indicated.

All children and adolescents with known HIV infection undergo evaluation for TB regardless of symptoms. It is well documented that HIV infection is one of the most common risk factor to cause latent (inactive) TB infection to become (active) TB disease. For children less than 15 years of age, a TST or IGRA is obtained as well as chest radiograph, sputum smear, and culture regardless of the results of the TST or IGRA. For adolescents over 15 years of age, a chest radiograph and sputum smear and cultures and susceptibility testing is proceeded to directly, without need for TST or IGRA.

The different TB tests include the TST, IGRA, sputum sample, sputum smear, sputum culture, and drug susceptibility testing (Table 2 ). The TST is considered positive in children less than 4 years of age if it measures greater than 5 mm of induration regardless of bacillus Calmette-Guérin vaccination status. Some practitioners consider a measurement of 10 mm or greater as a positive in children. In these situations, a chest radiograph must be obtained and if a child is symptomatic, sputum samples via sputum induction or early morning gastric aspirate is required. These samples are examined for acid-fast smears and cultures that are held for 8 weeks. If a positive sputum culture is obtained, drug susceptibility testing is essential. It is also critical to find the adult who transmitted the disease to the child, although in refugees this may not be possible if a child is separated from parents or adults who cared for the patient prior to entrance to the United States. If children have active TB disease, they usually are treated with directly observed therapy for at least 6 months. For children who have TB infection, this is typically not directly observed therapy but with physician follow-up at intervals and the end of therapy is appropriate.

Table 2.

Tuberculosis screening tests and turnaround time for tests

Tuberculosis Screening Tests	Turnaround Time for Testing Results
TST	48–72 h
IGRA	<7 d depending on laboratory
Chest radiograph	Same day
Sputum smears	3 d after last sputum collection
Sputum culture	8 wk
Drug susceptibility test	2–4 wk

Malaria

Refugees who arrived from sub-Saharan Africa (SSA) countries that are endemic for Plasmodium falciparum and who do not have a contraindication should be assumed to have received predeparture presumptive antimalarial therapy with artesunate combination therapy. Tests for refugees who require postarrival testing or presumptive treatment include polymerase chain reaction (PCR) testing, traditional blood films, and/or a rapid antigen test. The most sensitive test for persons with subclinical malaria is PCR; when PCR is not available, traditional blood films and/or a rapid antigen test may be used but have limited sensitivity in asymptomatic persons.

In refugees from SSA, who did not receive presumptive treatment prior to departure or refugees from a malaria-endemic country with signs or symptoms of infection should receive a thorough evaluation. Individuals who do not receive presumptive therapy include children weighing less than 5 kg at the time of departure, pregnant or lactating women, or those for whom presumptive treatment was contraindicated. Any refugee from a malaria-endemic country with signs or symptoms of infection should receive a thorough evaluation. Refugees from SSA who receive presumptive treatment prior to departure and asymptomatic refugees from malaria-endemic countries outside the SSA do not require postarrival testing or presumptive treatment on arrival.

Parasites

Postarrival screening for endoparasites depends on the region of departure and predeparture presumptive therapy received.

Currently, all refugees without contraindications from the Middle East, South and Southeast Asia, and Africa receive a single dose of albendazole prior to departure. In addition, all SSA refugees without contraindications receive treatment with praziquantel for schistosomiasis. The only population currently receiving presumptive therapy for Strongyloides is refugees from Myanmar, who receive ivermectin if they do not have contraindications.

For those who have contraindications or who did not receive complete predeparture therapy, the following screening is recommended.

All refugees who received no predeparture treatment or partial predeparture treatment or for whom their treatment status is unknown should be provided presumptive treatment or screened for roundworms and Strongyloides. All SSA refugees should be screened for schistosomiasis if not treated with praziquantel. An absolute eosinophil count should be reviewed in the complete blood cell count.

Sexually transmitted infections

STIs should be screened for in refugees if there is a history of sexual abuse, if an adolescent is sexually active, if a patient’s mother tested positive for an STI, or if a patient has symptoms consistent with an STI.

If screening tests are positive for syphilis, then a confirmation test should be performed as well, because there are some countries that are endemic for other treponemal subspecies besides syphilis (eg, yaws, bejel, and pinta)

As of 2010, refugees are no longer tested for HIV infection prior to arrival in the United States; however, refugees less than 12 years of age can be screened unless their parents opt out or a mother’s HIV status can be confirmed as negative and there is no history of potential high-risk exposures (blood transfusions and sexual abuse). Screening should be repeated 3 and 6 months after resettlement for those who had recent exposure or are at high risk.

Children less than 18 months of age who test positive for HIV antibodies should be tested with DNA or RNA assays. Results of positive antibody tests in this age group can be unreliable because they may detect persistent maternal antibodies. All individuals who are confirmed as HIV-infected should be referred to infectious diseases specialists who care for these children. As for children born in the United States, the provider should initiate prophylactic trimethoprim/sulfamethoxazole for all children born to or breastfed by an HIV-infected mother, beginning at 6 weeks of age and continuing until they are confirmed uninfected.

International adoptees

The medical examination process for an adopted child typically begins overseas with an evaluation by a physician affiliated with the adoption agency. These medical records, including immunization records, can range from very useful and accurate, to scant or difficult to read, to belonging to another patient. They must be looked at with scrutiny, and parents frequently ask for an opinion of the health of the child based on an assessment of these medical records, a photo, or brief video. When parents make a decision to adopt a child, they visit a Department of State–designated medical doctor (panel physician) who performs medical examinations overseas for international adoptees as well as other immigrants and refugees coming into the United States. Panel physicians are located in many countries in the world and must refer to CDC guidelines on medical examinations. As with documented refugees, the purpose of the overseas medical examination is to identify applicants with class A conditions. Children with these conditions must be treated or get a waiver before they can get a visa to come to the United States. Again, this visa medical examination includes physical examination, vaccines, TB screening, and a blood test for syphilis in children greater than 15 or with concerns for infection. Some adopted children can receive a waiver to have their vaccinations delayed until after they arrive in the United States. The Immigration and Nationality Act requires that all immigrant visa applicants, including adopted children, show proof of having received certain vaccinations named in the law as well as others recommended by the Advisory Committee on Immunization Practices before they may be granted an immigrant visa. Vaccination requirements depend on the age of the child. The age-appropriate vaccinations the child may require can be found in the vaccination schedules for children and Web sites about vaccinations for international adoptions. The US Consulate informs the parents whether the waiver was granted. If the waiver is granted, the child receives a visa. If a waiver is granted, the adoptee must begin receiving the required vaccines once arriving in the United States. At the author’s international adoption clinic, families are asked to request a second copy of the sealed packet so that these medical examination forms can be given to the child’s personal physician. After arrival to the United States, if the child is doing well, a physical examination with the child’s personal physician within several weeks of arrival in the United States is recommended. If a child is symptomatic, immediate evaluation should be performed by the child’s personal physician.

If a child is found to have a class A condition, parents should talk to the panel physician and the US Consulate to find out if it is possible to get a waiver. Thus, all tests must be completed and read by the panel physician before a class can be assigned. The USCIS within the Department of Homeland Security makes the final decision to approve or deny the waiver. This is with an opinion from the CDC to USCIS or the American Embassy about a patient’s infectious situation.

The point of the physical examination and laboratory testing performed in the country of origin is to identify class A conditions, which include the following infections: TB, syphilis, gonorrhea, Hansen disease, cholera, diphtheria, plague, smallpox, yellow fever, viral hemorrhagic fevers, SARS and novel influenza (eg, pandemic flu), polio, and other potential public health emergencies of international concern. The class A condition that is most relevant for international adoptees is TB. Individuals with class A conditions are to be treated with their country of origin; however, in patients with TB whose medical situations suggest that they would benefit from receiving their TB treatment in the United States, the Department of Homeland Security may grant a waiver (also called a class A waiver), allowing them to travel to the United States before the end of the TB treatment. This is often the case in poor, overcrowded orphanage settings.

Migrants without premigration evaluation

This group of children and adolescents, migrants without premigration evaluation, brings up all the same concerns plus other potential risk factors for infections but they often present in challenging settings, such as a free medical clinic or emergency department, or are new to a practice. There are often language barriers and sometimes there is a reluctance to share a child’s entire story for concerns of immigration status or judgment of the care providers who may not be the child’s parents. There are often challenges associated with payment for services and treatment as well. Providers need to ensure culturally sensitive care for refugees and ensure the competence of interpreters and bilingual staff to provide language assistance to patients/families with limited English proficiency. Finally, these children often present with progression of disease rather than infection being discovered with screening laboratories.

All the diseases discussed previously can present in these patients and it remains important to consider financial concerns in these patients who may only be able to come to the physician at certain times. At times, it may be more prudent to treat presumptively rather than screen for extensive infections when considering parasitic infections. The local health department is designed to aid in these situations where individuals cannot afford medications that are a concern for the well-being of the community (eg, TB).

Summary

With an ever-evolving geopolitical climate, it is important to understand where refugees, immigrants, migrants, and adoptees may come from as they enter the United States. Depending on their country of origin and their path to the United States or Canada, different infectious diseases may be of concern when evaluating each child. The more common infectious issues of concern for children and adolescents include TB, malaria, parasitic infection, and STI. There are both governmental requirements that must be followed for legal entry into a country as well as medical issues that should be addressed depending on a child’s underlying health, country of origin, circumstances of travel, and current signs and symptoms. All these factors allow practitioners the unique opportunity of caring for these patients and to be a part of their individual journey.