Migrant, Immigrant, and Refugee Health

Thomas H. Hunter Professor of, International Medicine; Director, Center for Global Health, Division of Infectious Diseases and, International Health; University of Virginia School of Medicine, Charlottesville, VA, USA

Carmage and Martha Walls Distinguished, University Chair in Tropical Diseases; Director, Center for Biodefense and, Emerging Infectious Diseases; Professor and Chair, Department of, Pathology; University of Texas Medical Branch, Galveston, TX, USA

Professor of Medicine, Harvard Medical, School; Professor, Immunology and Infectious, Diseases Department, Harvard School of, Public Health; Chief, Infectious Disease Division; Vice Chair of Research, Department of, Medicine, Beth Israel Deaconess Medical, Center, Boston, MA, USA

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Introduction

The global migration landscape has undergone substantial changes in the past quarter century, and the number of population groups contributing to global mobility is steadily rising. The Human Development Report 2009 by the United Nations Development Program estimates 70 million migrants have moved from developing countries to developed ones and more than 200 million migrants have moved between developing countries. 1 Migration is truly a major social phenomenon, with many complex linkages to economic, trade, social, security, and health policies. In the dynamic relationship between migration and health, immigration has long been recognized as having a large impact on disease epidemiology and the use of health services in migrant receiving nations.2, 3 For example, the impact of immigration on disease epidemiology is demonstrated by the global epidemiology of tuberculosis. Tuberculosis (TB) is a major global cause of infectious disease morbidity and mortality; however, rates of TB in most regions of the developing world are many times higher than those in the developed world (the TB prevalence gap) and are decreasing at a much slower rate. 4 Many migrant-receiving countries in the developed world have had stable or increased migration of persons from regions with high TB prevalence, while at the same time having successfully decreased TB incidence in their native-borne population, further exacerbating the prevalence gap. Consequently, the majority of TB cases in migrant-receiving countries such as the United States and Canada are now being diagnosed in foreign-born populations from high-prevalence source countries5, 6 ( Fig. 127.1 ). This linkage between migration and TB epidemiology becomes more significant when designing solutions for the control and prevention of multidrug-resistant (MDR) TB and the emerging threat of extensively drug-resistant (XDR) TB.7, 8, 9, 10

Number of tuberculosis cases in US-born versus foreign born persons, United States, 1993–2008.

(Data from the Division of Tuberculosis Elimination, Centers for Disease Control and Prevention: www.cdc.gov/tb/statistics.)

Many migrant-receiving countries have prearrival medical examination requirements and protocols for entering migrants, which vary both by the types of populations screened and by the diseases for which examination is required. The health conditions tested through the medical examination procedures required by countries such as Canada, Australia, New Zealand, and the United States are determined on the basis of the risk or danger that these conditions can represent to public health and safety and the additional costs that may be incurred by national public services expenditures.11, 12, 13, 14, 15 In general, these medical examination procedures include a review of the past medical history, a physical examination, and tests that include a chest radiograph and laboratory analyses. The diseases most frequently tested to determine visa eligibility or admissibility of a migrant are infectious diseases such as tuberculosis, sexually transmitted diseases, and mental or behavioral conditions. Immigration regulations in some countries do allow for the consideration of medical waivers to inadmissible health conditions. Although many migrant-receiving countries in Europe either do not require prearrival health evaluations or have fewer requirements and only limited grounds for refusal of admission based on health grounds, most have provisions for notification and inspection if a communicable or serious health condition is recognized or suspected. 16

Us Migration and Health Screening Policies

The number of foreign-born persons living in the United States, almost 38 million in 2007, is greater than ever before in the nation's history representing approximately one-eighth of the total US population. 17 In contrast to the previous twentieth-century US immigration wave, which was dominated by Eastern Europeans who were driven from their countries of origin by such factors as persecution and poverty (so-called “push factors”), the twenty-first century immigration wave, which began in the 1970s, is characterized predominantly by Hispanic followed by Asian migrants who are attracted to the United States for economic opportunities (or “pull factors”). In both waves of migration, migrants have brought with them not only skills and cultural traditions that enriched US economic and social fabric, but also diseases and disease exposures that were different from those existing in US-receiving communities. In addition, twenty-first century migrants are more mobile and remain connected to their countries of birth, typically making several back and forth journeys to visit friends and relatives. 18 New immigrants and refugees, who cross disease prevalence gaps and frequently travel to visit friends and relatives, constitute potentially high-risk populations for translocating communicable diseases of public health significance.

The US Department of Homeland Security has reported more than 175 million nonimmigrant legal admissions, defined as number of entries, not persons, into the United States during 2008. 19 This category includes the approximately 39 million admissions of short-term visitors (tourists, business travelers) and temporary residents (students, specialty workers, diplomats). The majority of these nonimmigrant migrants admitted are not required to undergo health screening prior to US entry. Given the immense numbers of persons crossing US borders and finite resources for evaluation and surveillance, US migrant health screening policy focuses on migrants planning to establish permanent US residence, since this group has the largest potential long-term impact on both disease epidemiology and health care resources utilization. Currently, the US Immigration and Nationality Act (INA) requires that medical screening examinations be performed overseas for all US-bound immigrants and refugees, and in the United States for migrants applying to adjust their visa status to permanent residence (i.e. “green cards”).20, 21 In 2008, the over 1 million immigrants (adjustment of status and new arrivals) and refugees admitted underwent medical screening examinations prior to their admission. The remainder of this chapter covers US medical screening issues for immigrants and refugees. Similar issues and regulations apply across developed and developing countries worldwide. Disease transmission among refugees crowded into camps in resource-limited countries further accentuates the huge importance of international refugee public health preparedness.

Required Overseas Medical Screening Examinations for Us-Bound Immigrants and Refugees

Over 460 000 immigrants and 60 000 refugees arrived in the United States during Fiscal Year 2008. Trends in the number and regions of origin for US-arriving immigrants and refugees have important public health implications in determining the medical evaluation and treatment of these two groups, both overseas and stateside.19, 22 From 2006 to 2008, over 1.3 million immigrants arrived in the United States; the number of arrivals and regions of origin remained relatively stable over this 3-year period ( Fig. 127.2 ). On average, approximately 450 000 immigrants arrived each year, most of these arriving from Asia (majority from China) and the Americas (majority from Mexico), followed by Europe and Africa. From 2006 to 2008, close to 150 000 refugees arrived in the United States; in contrast to immigrants, the number of arrivals and regions of origin have changed markedly over this 3-year period ( Fig. 127.3 ). In 2006, the majority of arriving refugees (45%) were from Africa, 25% from Europe, and only 20% of arriving refugees were from Asia. In contrast, in 2008, almost 75% (approximately 45 000 refugees) arrived from Asia. Trends have important implications for medical evaluation and treatment, both overseas and stateside, as refugees from Africa have relatively high rates of certain diseases, including immunodeficiency virus (HIV) infection, TB, malaria, intestinal helminth infections and other tropical diseases (e.g. schistosomiasis), and likely lack routine vaccinations.23, 24 Similarly, epidemiological information from Southeast Asia, such as reports of artemisinin-resistant Plasmodium falciparum are valuable in alerting on the need to invest in preventive and health promotion activities. 25

US immigrants admitted by region of birth, 1999–2008.