Author(s): Elizabeth Stein, BA

Reviewer(s): Mahri Haider, MD, MPH | Bayle Conrad, Immigration Field Correspondent | Harborview Medical Center

Date Updated: September 9, 2024

Who is required to have a medical examination prior to immigration to the United States? 

All immigrants, refugees and certain non-immigrants, coming to the United States must have a physical and mental examination abroad by a Panel Physician (CDC). The medical examination procedure consists of a physical examination, tuberculous screening (skin test or gamma-interferon release assay in youth/chest x-ray for individuals ≥ 15 years) for tuberculosis, and blood test for syphilis. The vaccination requirements include vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).

Medical spelled in scrabble letters
Photo by Michael Havens (cc license)

Overseas Pre-Departure Medical Screening 

Refugees

In the pre-resettlement context, all refugees must undergo overseas medical screening prior to entry in the United States. Medical treatment prior to this appointment is variable. The purpose of this screening is to detect medical conditions that are inadmissible to the US. These conditions include active TB, untreated Hansen’s disease, untreated syphilis, untreated gonorrhea, physical and mental health disorders with harmful behavior and substance abuse disorders. If one of these medical conditions is detected, the case would not migrate to the US until the condition was treated. The overseas medical screening generally occurs between 3 and 6 months prior to travel to the United States. For those with chronic conditions that could decompensate during travel to the US, the CDC works closely with the International Organization for Migration to ensure these cases to ensure they are stable prior to departure and/or have a medical escort traveling with them. 

Panel physicians appointed by the Division of Global Migration and Quarantine of CDC conduct the examination. The majority of overseas medical examinations are performed by the International Organization for Migration. During the medical exam, panel physicians perform a history and physical examination. Children 2-14 will have only either a tuberculin skin test or gamma-interferon release assay to test for TB and no test for syphilis. Screening for applicants ≥ 15 years includes a test for syphilis and a chest x-ray to screen for tuberculosis. 

Refugees may be administered prophylactic treatment for locally endemic diseases including: 

  • Soil-transmitted helminths (single-dose albendazole) 
  • Strongyloidiasis (2 doses of ivermectin or longer dose of albenzadole if from a Loa-Loa endemic area) 
  • Schistosomiasis (praziquantel) 
  • Malaria (artermether-lumefantrine) 

Asylees

Asylees are persons who meet the definition of a refugee but are already in the United States or are seeking admission at a U.S. port of entry. Therefore, aslyees do not complete the overseas medical screening prior to departure. Those who are living in the United States or are seeking admission at a US port of entry when they apply for asylum are recommended to have a domestic medical exam once they have been granted asylum status. When an asylee applies for adjustment of status (green card application), an I-693 medical examination (including vaccinations) by a civil surgeon is required. Once an asylee has been granted asylum status, their family members may follow to join them in the US, and therefore these family members would undergo the required medical examination overseas, prior to immigration. 

Others

Certain non-immigrants are required to complete an overseas medical screening prior to departure. Undocumented immigrants do not undergo a medical screening prior to entry into the US.

Domestic Medical Screening 

Refugees

Post-resettlement, refugees undergo a domestic medical screening which evaluates current healthcare concerns. A medical screening examination is recommended by the CDC and strongly encouraged by U.S. Office of Refugee Resettlement (ORR). ORR requires medical screenings to be conducted within 90 days of a refugee’s arrival as a condition for funding for the voluntary resettlement agency (VOLAG) that carries out resettlement for the individual. Models for domestic refugee health care delivery are dependent on funding streams specific to the refugee resettlement program in each state. This medical screening appointment takes place at a public health institution or primary care clinic. 

CDC and physician-experts at Pediatric Academic Societies Culture, Ethnicity, and Healthcare Special Interest Group recommend that the physician conduct an extensive history of the patient at this time and assume that the patient has never seen a doctor. Information collected prior to this domestic medical screening exam is extremely variable, even the history collected as part of the pre-departure medical screening. The domestic screening visit is significant so that refugees start their new lives in the U.S. in good health.

Addressing immediate health concerns can be beneficial for refugees who have not had sufficient access to healthcare. Many refugees have not received routine, preventive medical care prior to arrival and this visit should be an opportunity to provide education on preventive health care. It can also help the refugee develop trust in the provider and medical system. It is an opportunity for the refugee to become familiarized with the local health care delivery system and important for establishing long term care continuity within a medical home. Finally, the screening is significant from a public health perspective as conditions might be identified that have consequences for the public such as latent TB and chronic hepatitis B virus infection. 

This appointment occurs soon after arrival. It is recommended that this appointment serve as a screening for TB, mental health screening, and testing for HBV, anemia, and sexually transmitted infections. It should also confirm that the appropriate presumptive anthelminthic therapies were provided prior to departure. Recommendations for this initial domestic appointment suggest that the physician conduct a comprehensive evaluation of the following health domains using a trained interpreter:

  • History
    • Immigration history
    • Birth history
    • Nutritional history
    • Environmental exposure risks
    • Treatment prior to arrival
    • Prior medical records
    • Menarches/LMP
    • Family medical history
    • Social history
    • Educational assessment
    • Substance abuse
    • Sexual history
    • History of trauma or abuse
  • Complete Physical Exam
    • Vision
    • Hearing
    • Blood pressure
    • Pulses
    • Skin
    • Gynecological exam to evaluate presence of female genital cutting
  • Screenings
    • Complete Blood Count (CBC) with differential
    • Lead
    • Tuberculosis
    • Hepatitis B
    • Intestinal Tissue Invasive Parasites (ITIP)
    • Malaria
    • STDs: Syphilis | Chlamydia | Gonorrhea | HIV 

See: Summary Checklist for the Domestic Medical Examination for Newly Arriving Refugees

Often it is difficult to cover all domains of recommended evaluation in one appointment and families may have to come back. 

Asylees

Asylees may broadly present with similar health conditions and concerns as others from their country of origin. Many asylum seekers originate in, or transfer through, countries with public health issues similar to those facing refugees arriving through the U.S. Refugee Admissions Program. Therefore, the CDC recommends that medical providers of asylees apply the same screening and treatment recommendations in the CDC Refugee Domestic Guidelines when performing a medical evaluation of an asylee. For individuals who have been in the United States for more than one year, special attention should be paid to diseases with long latency and associated severe morbidity such as tuberculosis, hepatitis B, and Strongyloides infection. 

Non-Immigrants

Domestic screening medical exams are not embedded into the path of other immigrant groups upon arrival in the United States. 

Accessing Healthcare in the United States 

Following arrival to the United States, access to health insurance and health care is dependent upon immigration status, whether the individual is an adult or child, as well as federal and state level policies. Only U.S. citizens and certain lawfully presented permanent residents (green card holders) qualify for federal health insurance programs. Visitors are responsible for paying for their own medical care. Refugees and those granted asylum are eligible for Medicare/Medicaid insurance for at least 8 months. In certain states, this benefit is available to these populations for longer. In general, undocumented immigrants are not eligible for federal health insurance programs apart from emergency medical care. However, certain US states allow undocumented children or pregnant women to receive Medicaid, and others have expanded Medicaid options to all undocumented immigrants in their state.

Resources and Further Reading