Immigrants and Immunizations

The United States has more immigrants than any other country in the world.¹ From 1900 to 1930, immigrants made up approximately 12-15% of the US population; in 2020, they accounted for 13.7% of the overall population.¹ The highest percentage on record was 14.8% in 1890, when there were approximately 9.2 million foreign-born individuals living in the US.

Legal Status

Immigrants to the United States have been subject to different acts of regulation by the government since the United States was formed. The 1921 Emergency Quota Act capped the total annual immigration into the US at 350,000.² The Johnson-Reed Act in 1924 further restricted immigration, capping the total number of individuals at 165,000 and creating Nationality quotas at two percent of that nationality present in the 1890 census.² In 1952, the Immigration and Nationality Act removed race as an exclusion for immunization and naturalization, updated the national origins quota, and granted 100 visas per year to individuals coming from Asian countries.²

A 1965 amendment to the Immigration and Nationality Act replaced the quota system with a seven-category preference system.² This system emphasizes family reunification and skilled trades, and is the basis for the immigration system in the country today.

Over 75% of immigrants to the United States have entered the country legally.¹ In 2017, the number of naturalized citizens equaled 20.7 million (45% of legal immigrants), and lawful permanent residents equaled 12.3 million (27%). Temporary visas were granted to 2.2 million people (5%). The remaining 23% of immigrants were unauthorized, and made up of refugees, asylum seekers, and undocumented immigrants.¹

Since the creation of the 1980 Federal Refugee Resettlement Program, the United States has accepted and resettled about three million individuals.^1,2 In 2019, the nation resettled 30,000 individuals from countries like the Democratic Republic of the Congo (12,958), Burma (Myanmar, 4,932), and the Ukraine (4,451).¹ In 2018, 64% of the foreign-born population of the United States live in twenty major metropolitan areas (see Figure 1).¹

Figure 1.

The Metropolitan Areas with the Largest Number of Immigrants, 2018¹

It is believed that up to half of the undocumented immigrants in the country are individuals who have overstayed their visitor, student, or work visas.¹ These individuals obtained lawful documentation and health screenings, and entered the country legally.

Medical Screenings

The Immigration and Nationality Act^3,4 defines an inadmissible alien as someone who:

• Is determined to have a communicable disease of public health significance;

• Failed to present documentation of having received vaccination against vaccine-preventable diseases;

• Has or has had a physical or mental disorder and associated behavior that may pose, or has posed, a threat to the property, safety, or welfare of the alien or others, and which behavior is likely to recur or lead to other harmful behavior; or

• Who is determined to be a drug abuser or addict.

Waivers are available for minors less than ten years who are in the process of being adopted by US citizens, and if a physician has signed an affidavit stating they will see the individual within 30 days of admission for medical evaluation. However, individuals with criminal convictions, who are drug traffickers, or are entering for purposes of prostitution are completely inadmissible.

The Division of Global Migration and Quarantine (DGMQ) provides the medical screening guidelines required by the Immigration and Nationality Act.⁴ All refugees, applicants applying for an immigrant visa, and resident aliens currently living in the United States and applying for an adjustment of their immigration status to permanent resident are required to undergo a medical exam.^4,5 Anyone applying for temporary admission (a non-immigrant visa) may be required to undergo a medical exam at the discretion of the a consular or immigration officer if they have reason to believe an inadmissible health-related condition exists.

The medical exam must consist of a thorough medical history, including a review of any hospitalizations or institutionalizations for mental or physical chronic conditions, a review of illnesses or disabilities, a review of any other records available (police, military, school, employment, etc.), and a review of any history of drug and/or alcohol use, harmful behavior, or psychiatric illness. Individuals must also undergo a physical exam, including a mental status exam, and review of systems.⁵

All individuals wishing to enter the country must also undergo all diagnostic tests required to identify communicable diseases of public health significance. This list includes tuberculosis, syphilis, gonorrhea, and Hansen’s Disease (leprosy), as well as other quarantainable diseases.⁵

Quarantainable communicable diseases are designated by Presidential Executive Order, and include

• Influenza: novel or re-emergent viruses that cause or have the potential to cause a pandemic (e.g. avian H5N1);

• Severe Acute Respiratory Syndromes (e.g. COVID-19, MERS, SARS);

• Viral Hemorrhagic Fevers (e.g. Ebola, Marburg);

• Cholera;

• Yellow Fever;

• Plague;

• Measles;

• Diphtheria;

• Infectious Tuberculosis; and

• Smallpox.

This also includes diseases that are reportable to the World Health Organization (WHO) as Public Health Emergencies of International Concern (PHEIC). This list includes COVID-19, any new-subtype of human influenza type A(H1), wild-type poliomyelitis, SARS, and smallpox, and other disease that require notification through the use of the 2005 IHR algorithm.^5,6

Location

The overall goal of these screenings is to promote and improve the health of the refugee, prevent disease, and familiarize refugees and immigrants with the United States healthcare system. Screenings can be completed overseas and domestically.

First, refugees and immigrants are screened by Panel Physicians in their countries of origin. Panel physicians, a team of over 600 physicians identified by the Department of State, provide pre-departure presumptive treatments (for malaria, intestinal parasites, etc.) and updates to any vaccine series that refugees or immigrants may need.

Once in country, domestic screenings are completed by civil surgeons (a group of over 5,000 physicians selected by United States Citizenship and Immigration Services), state public health departments, and medical providers 30-90 days after an immigrant or refugee arrives in the country.⁵ These screenings check for diseases unique to specific populations and diseases not or rarely seen in the United States (i.e. intestinal parasites, female genital mutilation). They also offer preventative screening, counseling, and testing, and a continuation of vaccine series.⁷

Vaccines for US-Bound Refugees

Routine vaccination of US-bound refugees before travel to the United States is not legally required (note: the current exception to this at the time of writing is the COVID-19 vaccine). Vaccines are recommended to protect an individual’s health, prevent travel delays due to disease outbreaks, and allow more rapid integration into schools after arrival.⁸ As part of the Vaccination Program for US-bound Refugees,⁷ refugees begin the series of Advisory Committee on Immunization Practices (ACIP) recommended vaccines.

Refugees and Visa 93 applicants are offered immunizations depending on age, vaccine history, and eligibility. The vaccine offered must be age-appropriate (as recommended by ACIP for the general population) and must protect against a disease that has the potential to cause an outbreak (i.e. influenza), and/or protect against a disease that has been or is in the process of being eliminated in the United States.⁹ The goal is to provide up to two doses of each vaccine (see Table 1) before individuals enter the United States, depending on the availability and logistics at each overseas site. Valid vaccination records and camp vaccine cards are counted towards this schedule when applicable.

Table 1. Vaccines Offered to Eligible U.S. Bound Refugees⁷.

Age	Vaccines
Birth – Adult	HepB x 2 doses
6 weeks – Less than 15 weeks	Rotavirus x 2 doses
6 weeks – Less than 5 years	Hib x 2 doses PCV x 2 doses
6 weeks – Less than 7 years	DTP x 1 dose
6 weeks – Less than 11 years	Polio x 2 doses (OPV, IPV, or 1 each)
5 years – Adult	COVID-19 x 2
7 years – Adult	Td x 2 doses MenACWY x 1 dose
Over one year – less than 20 years Over one year – those born before 1957	Varicella x 1 dose MMR x 2 doses

Note: Please see source for full information. Hepatitis B (HepB); Hemophilus influenzae (Hib); pneumococcal conjugate vaccine (PCV); diphtheria, tetanus, pertussis (DTP); oral polio vaccine (OPV); inactivated polio vaccine (IPV); tetanus, diphtheria (Td); meningococcal conjugate vaccine with protection against serogroups A, C, W, and Y (MenACWY); measles, mumps, and rubella (MMR).

After a year in the United States, refugees can apply for a change of status to legal permanent resident; at that time individuals are required to be fully vaccinated in accordance with the CDC Technical Instructions for status adjustment.⁹

Conclusion

Despite social media’s messaging to the contrary, there is no evidence that immigrants have been the source of any modern disease outbreaks in the United States.¹⁰ Immigrants and refugees are carefully screened before being granted entry into the United States for any major health condition, and are offered the same vaccines recommended to US citizens every day.