• Use tuberculin skin testing alone or in conjunction with interferon-gamma release assay to screen children younger than 5 years for tuberculosis. A
• Include 2 evaluations for ova and parasites plus a complete blood count with differential when screening refugees for parasitic infections. B
• Screen all adolescent and adult refugees for human immunodeficiency virus infection. A
• Check blood lead levels in all children 6 months to 16 years of age on arrival in the United States B and 6 months later. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
In 2011, 56,384 refugees fleeing persecution in their native countries were admitted to the United States. The largest numbers came from Burma (30.1%), Bhutan (26.6%), and Iraq (16.7%).1 They joined the more than 3 million refugees from all over the world who have resettled in this country since 1975. 1
Refugees arrive in the United States with complex medical issues, including illnesses rarely seen here, mental health concerns, and chronic conditions such as diabetes and hypertension. After arrival, they undergo a domestic refugee medical examination (DRME). This DRME, along with well-planned follow-up, can go a long way toward helping refugees show the proof of vaccination and control of chronic health conditions that are required when they apply for lawful permanent resident status.
The Centers for Disease Control and Prevention (CDC) has published guidelines to help with medical decision making and screening of refugees, but limited information is available on the necessary strategies to address chronic health conditions within the context of the DRME.2 Moreover, differences in refugee experience and health status based on country of origin may demand more detailed, region-specific guidelines.3-9 No standard recommendations address the importance of providing not just initial screening, but comprehensive longitudinal care, as well.
Since 2007, our outpatient practice (MA, KS, GM, PM) has performed the DRME and provided ongoing care for more than 900 refugees resettled in Philadelphia. The practice, which is associated with an urban academic medical center and closely coordinates refugee care with a local resettlement agency, has earned recognition as a Level 3 (top-level certification) patient-centered medical home by the National Committee on Quality Assurance. We offer here a framework for providing comprehensive care to refugees, based on CDC guidelines, available evidence, and our experience.
Prelude: The overseas medical exam
All refugees must undergo an overseas medical examination (OME) no longer than 12 months before resettlement in the United States. Physicians selected by US Department of State consular officials perform the examinations.
The OME includes a medical history, physical examination, and testing to screen for mental illness, drug abuse, syphilis, leprosy, and tuberculosis (TB). Some vaccinations and empiric treatment for parasites also may be provided at the time of the examination.10-12
The OME screens for Class A disorders, which render a refugee ineligible for admission to the United States until treated or stabilized, and Class B conditions, which require close follow-up on arrival (TABLE 1).12 Despite recent steps toward standardization, the quality and thoroughness of OMEs completed at different examination sites still vary substantially.
Overseas medical examination: Class A and B conditions12
|Class A*||Class B†|
|Active or infectious tuberculosis Untreated STI: syphilis, gonorrhea, chancroid, granuloma inguinale, or lymphogranuloma venereum Hansen’s disease (leprosy) Drug or alcohol addiction/abuse Mental illness with harmful behavior||Inactive or noninfectious tuberculosis Treated STI Treated or paucibacillary Hansen’s disease Sustained remission from drug or alcohol addiction or abuse Well-controlled mental illness Pregnancy|
|STI, sexually transmitted infection.|
*Class A disorders render a refugee ineligible for admission to the United States until he or she is treated or stabilized.
†Class B disorders require close follow-up upon the refugee’s arrival in the United States
Arrival in United States is followed by DRME
When refugees arrive in the United States, they are advised to undergo a DRME, which any licensed practitioner may perform, preferably within 90 days. More rapid evaluation is encouraged for medically complex refugees or refugees arriving with Class A or B conditions. Because refugees are eligible for only 8 months of medical assistance, we strongly recommend that the DRME be done promptly.
The CDC publishes guidelines for components of the initial DRME, but state requirements and individual examinations vary widely.2,10,13,14 We outline here the elements of the exam identified by the CDC, supplemented with recommendations based on published evidence and our experiences in caring for refugees.