Supplemental Guidance for Performing the Overseas Medical Examination of Refugees and Assisting Refugees with Significant Medical Conditions

Introduction

This guide is a supplement to the Technical Instructions for the Overseas Medical Examination, specifically for U.S.-bound refugees, "follow-to-join refugees," also known as Visa 93 applicants and certain Special Immigrant Visa (SIV) applicants who elect refugee benefits before migration.

The U.S. Refugee Admissions Program (USRAP) is a program to assist refugees applying for U.S. resettlement and is managed by the Department of State in cooperation with the Department of Homeland Security and Department of Health and Human Services. The Centers for Disease Control and Prevention issues Technical Instructions for the Overseas Medical Examination of Immigrants and Refugees, and, together with the Department of State, supports additional health interventions, such as vaccination and parasite treatment programs to promote healthy resettlement.

CDC and the International Organization for Migration (IOM) have established this supplemental guidance for panel physicians conducting the medical examination of U.S.-bound refugees. IOM has a special role in refugee resettlement, including the organization of safe travel (departure and arrival in the U.S.) for refugees, especially those with complex medical conditions, and the transmission of health information from the overseas medical examination and pre-departure interventions securely to CDC, which then transmits the information securely to the receiving health care provider in the United States. The results of the refugee medical examination are used to facilitate placement in the U.S., safe travel, and continuity of health care so that persons with medical conditions receive timely follow-up after arrival in the United States. Medical forms for these applicants should be shared securely with your IOM counterparts who will prepare persons for safe travel and transmit the health data securely to CDC.

The following list describes the major steps in the USRAP health assessment processes for refugees as compared to the immigrant health assessment process. Please use these Supplemental Refugee Health Guidelines and supporting documents as references when performing each of these steps to assist U.S.-bound refugees and V93 "follow-to-join refugees" applicants. Information is also provided for processing of Special Immigrant Visa applicants who elect refugee benefits before migration.

* CDC Technical Instructions for Panel Physicians

** Do not apply for v93 and SIV cases

Acronyms and Definitions

1. Refugee Scheduling and Data Management

Depending on the processing location, refugee medical exams are scheduled by either Resettlement Support Centers (RSC) or IOM Migration Health Division (MHD) staff. While scheduling, IOM will share Department of State (DS) immigration medical forms in a fillable PDF format with your clinic, pre-filled with refugees' photos and biodata. These forms can be completed and signed electronically using the standard PDF software application, Adobe Reader, which can be downloaded here. Supplementary refugee medical forms (SMC, activities of daily living [ADL]) are not pre-filled with refugee biodata and should be completed electronically for eligible refugees as described in the following sections. Completed and signed medical forms must be protected with passwords and shared securely with your RSC and IOM counterparts, along with digital x-rays in DICOM format and any additional scanned medical reports. The forms are imported to the IOM MiMOSA information system and shared with the RSC and U.S. Centers for Disease Control and Prevention (CDC) information systems, making the medical information available for U.S. resettlement agencies, health departments, and healthcare providers. As costs for refugee medical examinations are paid by the U.S. government and reimbursed to panel physicians through IOM, please send the invoices to IOM with the completed medical forms so that IOM can process the payments. To further facilitate data management in USRAP, non-IOM panel sites will receive direct access to the MiMOSA system in the near future.

1.1 Processing of Visa 93 Applicants

A small proportion of USRAP beneficiaries are refugee follow-to-join (Visa 93) applicants, including spouses and unmarried minor children (under the age of 21 years) of the petitioner who is resettled. The vast majority of V93 applicants reside in a country without a permanent U.S. Citizenship and Immigration Services (USCIS) presence. Their petitions are managed by U.S. Embassy consular officers. After the consular officer interview, V93 applicants will be referred to U.S. panel physicians for their required medical examinations. For such applicants, IOM usually cannot generate pre-filled DS medical forms, so panel physicians will have to use the blank fillable DS forms (20) referenced in these guidelines. When completing these forms, it is important to correctly enter refugee biodata, especially the alien number from the embassy referral letter. Like refugees, costs for V93 Visa applicants’ medical examinations are paid for by IOM. Please send the completed medical forms to IOM accompanied by the invoices that IOM needs to process the payments.

1.2 Processing of Special Immigrant Visa Applicants

Afghan and Iraqi recipients of Special Immigrant Visas (SIV) are eligible for the same resettlement assistance and other benefits as refugees admitted under the USRAP. Their petitions are managed by U.S. Embassy consular officers in their countries, and IOM's role in preparing their resettlement typically starts from the time they begin to receive refugee benefits. If you have performed a medical examination for an SIV beneficiary, an IOM SIV focal point will reach out to you and request medical documentation (DS, SMC, ADL forms) that will be added to the USRAP information systems. Please note that, unlike refugee and V93 applicants, costs for SIV medical examinations are not covered by IOM.

2. Refugee Counseling and Consent

This first session of the health assessment should orient refugees to what they can expect during the required medical examination and additional health interventions offered to refugees. The session is intended to allay any anxieties about the assessment and to ensure voluntary informed consent to all the procedures. A nurse, counselor, or health educator may conduct the session, which should explain the objectives and steps of the assessment process, including the tests and interventions that will be done.

After answering any questions the refugees have, the counselor will ask each of the refugees, or the parent or caregiver of a child, if they are willing to sign an informed consent form that is characterized as an agreement between the panel site and the refugees. Refugees who sign this form confirm that they have understood and agree to the health assessment process and to relevant interventions, such as vaccination, and to sharing the results with other agencies involved in their resettlement. Once a refugee signs this form, the health assessment will begin. For more information on the IOM consent form that can be used to create your clinic-specific consent form, please refer to the enclosed documents. It is important to ensure that your consent form covers all elements of the health assessment process the same way the IOM form does.

In many refugee settings, the health assessment process should be completed with the help of an interpreter. If an interpreter is needed, please use properly trained interpreters and ensure that all medical staff have sufficient knowledge on how to work effectively with interpreters. A special training module has been developed by IOM in collaboration with the University of Minnesota (UMN) and is available on the IOM-specific UMN web portal upon request.

3. Refugee Vaccination

Although not mandatory before resettlement, vaccination is strongly recommended for refugees and Visa 93 applicants. Certain vaccines might be required before U.S. resettlement for refugees and V93 applicants in selected countries experiencing outbreaks of vaccine-preventable diseases. The CDC's Division of Global Migration Health and the Bureau of Population, Refugees, and Migration (PRM) of the U.S. Department of State co-fund a vaccination program for USRAP refugees and V93 applicants. The goals of the project are to provide cost-effective interventions to improve refugee health and prevent the importation of vaccine-preventable diseases and to limit the number of vaccinations refugees require after their arrival in the United States. As a panel physician who conducts refugee health assessments, you should offer locally available and age-appropriate vaccines, in accordance with USRAP vaccination program recommendations and in coordination with the RSCs and the IOM team in each region. Please note that only the following list of core vaccines from the DS-3025 form should be used for refugee vaccination unless specifically requested by CDC:

• Pentavalent (DTP-HepB-Hib) or hexavalent (DTaP-IPV-HepB- Hib) combination vaccines
• DTP or DTaP
• Td or Tdap
• MMR
• Polio
• Hep B

This list of vaccines may be modified in coordination with your CDC and IOM counterparts based on the logistics, availability, and cost of vaccines in the country of processing. The below summary describes the main elements of the USRAP refugee vaccination program:

3.1 At All Times

• Monitor the availability of vaccines and keep a sufficient stock to ensure supply is uninterrupted
• Maintain the cold chain required for vaccine storage in accordance with the CDC Vaccine Storage and Handling
• Keep IOM and CDC informed of vaccine shortages or any outbreaks of communicable diseases that affect or could potentially affect refugees hosted in your country

3.2 Before Vaccination

• When scheduling an exam, ask refugees to bring their (or their children's) vaccine records when they come to the clinic
• Review vaccine records and document historical doses in the DS-3025 form if doses are determined to be valid (enter doses sequentially under the historical vaccine dose columns).
• Conduct hepatitis B surface antigen testing using testing kits endorsed by CDC
• Perform urine pregnancy testing for all female refugees¹ between 15 and 50 years of age, inclusive, before both dose 1 and dose 2 of any live vaccine
• Provide counseling and distribute the IOM vaccine information brochure to each USRAP refugee or family.
• Screen each refugee for contraindications to vaccination using the enclosed immunization contraindication checklist
• Obtain informed consent using a USRAP-specific consent form developed by your clinic

3.3 During Vaccination

• Perform vaccination in accordance with the USRAP Vaccination Schedule
• Observe refugees for 15 minutes after vaccination

3.4 After Vaccination

• Document administered vaccines on the fillable DS-3025 form (in "given by panel" column).
• Provide each refugee with a hard copy of the completed DS-3025 form
• Refer refugees to government vaccination clinics for vaccines only available there
  • Instruct refugees to send copies of the vaccination records to you to update their DS-3025 forms and share them with IOM.
• Document and report any adverse effects following immunization (AEFI) using the AEFI reporting form (13) referenced in this document
• Send electronic copies of the DS-3025 form and AEFI reporting form (if needed) securely to IOM to be uploaded into MiMOSA
• Submit invoices to your IOM focal point with refugee biodata/vaccine details and any updates on vaccine costs if different from the previously agreed upon prices

Please also refer to the USRAP Vaccination Manual and your country-specific guidelines coordinated with CDC. In case of questions, please contact your CDC and/or IOM counterparts.

4. Resettlement Needs Assessment

The immigration medical examination serves to detect, diagnose, and treat when needed, inadmissible health-related conditions, including active tuberculosis, untreated syphilis or gonorrhea, Hansen’s disease, physical or mental disorders associated with harmful behaviors, and substance use. Another objective of medical examinations for U.S.-bound refugees is to identify refugees with SMC and to assess and document their resettlement, travel, and medical follow-up needs. To meet this objective, a comprehensive physical examination, use of trained interpreters during the examination, and review of available medical documentation are crucial. The following list shows SMC groups to which a refugee may belong and may therefore require additional assistance from all agencies involved in the resettlement process.

• Pregnant refugees
• Refugees with significant mental illnesses or developmental delays
• Refugees with acute severe malnutrition
• Refugees requiring expedited resettlement because of their life-threatening health condition
• Refugees with travel assistance requirements (e.g., medical escort, oxygen, indwelling catheter, nasogastric tube)
• Refugees with significant mobility problems requiring wheelchair, stretcher, or special accommodation
• Refuges requiring urgent medical follow-up within one week after arrival
• Refugees requiring extensive surgery or treatment (e.g., renal dialysis, complex congenital cardiac conditions)
• Refugees with special schooling or employment needs

4.1 Refugee SMC Form

The SMC form is used to document special needs of refugees with complex medical conditions. Please complete the SMC form for eligible refugees at the end of the immigration medical examination and share this form with the RSC or your IOM focal point. The SMC form is mainly being used by non-medical staff and facilitates a refugee’s transportation and placement needs after arrival. The form should include a list of the person’s health conditions to help non-medical staff better understand the assistance required (Figure 1).

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For each medical condition in this section of the form, please indicate the degree of disability and any adaptations, and provide relevant details in the remarks section.

4.2 Completing SMC section

Hearing – Explain what the refugee can and cannot hear and how this condition affects his/her ability to study, work, or perform daily activities. Also indicate what adaptations have been implemented, such as use of a hearing aid, sign language, or lip reading. An SMC form is not required for medium hearing loss that does not affect schooling, employment, or activities of daily living (ADL).

Vision – Provide details on the actual disability. To qualify as blind, a refugee's visual acuity must be 20/200 (6/60) or worse in the better eye while wearing corrective lenses. An SMC form is not required for simple refractive errors.

Learning/Development – Include observed developmental delays and describe any known or observed learning limitations that may affect post-arrival schooling or work.

Communication – Detail any communication impairment and adaptations (e.g., speaks single words only or uses sign language) and specify whether the impairment is caused by a particular physical defect or by a mental health condition.

Mobility – To determine appropriate transportation, accommodation, and ADL assistance, describe each mobility limitation and the underlying cause, ability for self-care, devices used (e.g., wheelchair), and whether assistance in ADL is required. Please indicate if the person has his/her own wheelchair/other supporting devices or whether such wheelchair/devices should be provided by their resettlement agency upon arrival.

Trauma/Injury – Indicate the type of trauma/injury and provide relevant details on any extra assistance required.

Mental Health Condition – This category is important not only for indicating severity and details of a mental health condition but also for helping RA arrange follow-up services upon arrival, something which can take significant time. Whenever possible, please indicate post-arrival medical follow-up, assistance, and psychosocial support needs, as well as other required arrangements, including any need for a caregiver.

Other Conditions – Although mild to moderate and well-controlled chronic conditions (e.g., hypertension, chronic obstructive pulmonary disease [COPD], diabetes) do not require an SMC form and should be documented on the immigration medical forms only, the same conditions, when poorly controlled or of a severe degree, do require an SMC form to ensure earlier medical follow- up upon arrival. Your clinical judgment should help decide what conditions represent SMCs.

4.3. Documenting Resettlement Needs

The SMC form helps all agencies involved in the resettlement of refugees with significant medical conditions to collect and provide details otherwise not covered by the traditional immigration medical examination forms. The following actions can significantly facilitate a refugee's safe travel, overall resettlement process, and integration upon arrival:

• Suggesting expedited processing to the RSC for refugees with life-threatening conditions that will benefit from expedited resettlement and urgent medical interventions upon arrival.
• Describing travel requirements for IOM to arrange appropriate and safe transportation for a refugee with a complex medical case all the way from his/her current place of residence to the final destination (detailed in Section 5).
• Detailing post-arrival needs for medical follow-up, including timing and duration, type of provider, and type of medical facility (Figure 2). Individuals needing follow-up include those with Class A conditions with waivers for continuing tuberculosis treatment or controlling a mental health condition.

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*Please note: "Immediately" means hospitalization upon arrival, and "In 6 Months" should not be selected because all refugees should be seen within 90 days after arrival (will be replaced with "In 3 Months")

• Describing medication needs and existing medication supplies to help the RA to plan for medication refills. Please note that in most cases a medical appointment is required to obtain a prescription for a medication refill.

4.4 Documenting ADL Support

RA should receive timely and accurate information on any post-arrival requirements that can affect placement of refugees with medical needs in the United States. This information is particularly important for arranging proper housing, schooling, employment, and ADL support for refugees with special needs as reflected in Figure 3.

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For any refugee potentially requiring ADL support, please evaluate their ADL, rate the performance of each skill or function, and complete an ADL form. The ADL assessment gives information on activities impacted by disability due to mental or physical conditions. The final ADL information should include the following elements:

• Whether the refugee is capable of independently performing the self-care task
• The degree of impairment/functional burden due to the refugee's functional limitations
• Support needs, including details on how these needs should be addressed upon arrival to the United States, specifying whether the caregiver is already part of the household or has to be employed

4.5 Documenting Travel Requirements

Air travel may worsen a refugee's health condition by combining high altitude, long flight times, the airplane cabin environment (e.g. low humidity, reduced oxygen partial pressure), and stress. Therefore, some refugees with SMCs require special travel arrangements (e.g., oxygen, medical escorts). Please request special travel arrangements as needed (Figure 4); the RSC and IOM will facilitate your requests during pre-departure arrangements and travel. Moreover, please note that certain conditions detailed in Section 8 should lead to travel deferral until the condition has been evaluated and stabilized and arrangements made to mitigate risks during travel.

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* FD–final destination; POE–port of entry only; LPM-liters per minute; EDD – estimated delivery date

Medical Escorts

Escorts may be assigned to refugees who cannot travel by air unaccompanied because of their need for medical assistance. In general, any person who meets any of the criteria below will require a medical escort. Whether the escort is a doctor or nurse will depend on the condition’s severity and the evaluating physician’s opinion. Some examples of people requiring medical escorts are the following:

• Persons with significant medical conditions which are likely to require significant treatment during travel or present a meaningful risk of clinical deterioration during travel, but which are stable and are not severe enough to prevent travel as described by International Air Transport Association (IATA) medical guidelines (1).
• Persons who require medical devices during travel, including supplementary oxygen, intravenous catheters, indwelling urinary catheters, and nasogastric tubes. All such persons require a medical escort.
• Persons with a recent history of events, such as trauma, surgery, or seizures, which increase the risk of travel. Such persons should not travel within the minimum time post-event as described by Air Travel Guidelines (1-3).
• Persons with behavioral, cognitive, or intellectual impairment who require supervision or assistance in their daily living activities
• Persons with stabilized significant psychiatric illness requiring an appropriately trained medical escort
• Frail elderly persons who do not have adequate family support

Operational (non-medical) Escorts

This type of escort should be assigned for other categories of travelers, such as:

• Healthy unaccompanied minors
• Persons who require assistance with mobility but who are otherwise clinically well
• Persons who have physical impairments (such as vision disability) who require assistance with travel but who are otherwise clinically well

Mobility Arrangements

Assistance for a refugee during travel may include various types of wheelchair access, three-seat seating on the airplane (usually not available for domestic flights in the United States), or a stretcher. The decision trees in Figures 5 and 6 should assist your decision-making on arrangements for refugees with limited mobility. For any refugee requiring a wheelchair, it is important to specify whether he/she already has a wheelchair and plans to bring it to the United States or if one should be provided after arrival.

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Supplementary Oxygen

If supplementary oxygen is needed, oxygen requirements during travel should be fully described on the SMC form, including in-flight and ground requirements and administration instructions (e.g., intermittent or continuous, how many liters per minute [lpm] should be delivered). Many airlines accept only portable oxygen concentrators (POC), so it is important to indicate the preferred delivery type (continuous or pulse oxygen delivery). Special coordination must take place for in- flight oxygen flow requirements of over 3 lpm continuous because a POC cannot provide this. It is also important to note whether the patient will require oxygen on the ground, because IOM and the RA will need to arrange it.

Dialysis

Dialysis treatment schedule is important to indicate on the SMC and DS forms. Nephrologist evaluation and relevant laboratory tests should be included. Any refugee undergoing regular dialysis requires extensive coordination before departure to ensure safe travel within the travel window. A dialysis session should take place less than 24 hours before a refugee’s international flight, and another dialysis session should follow upon arrival at the final destination. A medical escort is required in such cases to ensure the refugee’s safe travel.

Pregnancy

IOM cannot transport pregnant refugees with a gestational age beyond 34 weeks and 6 days. Therefore, for pregnant refugees in their last trimester, or when gestational age cannot be reliably defined, the pre-departure evaluation should include an ultrasound examination to estimate gestational age. For pregnant refugees with multiparous or complicated pregnancies, this cutoff is reduced to below 32 weeks and 6 days. A fitness-to-travel certificate indicating gestational age and estimated delivery date (EDD) should always be provided to a pregnant refugee (please refer to the IOM FTT form (10) referenced in this document). Please consider these women’s specific health needs in the context of the resettlement process and provide counseling with the help of the IOM counseling flip chart (8).

5. SMC Referrals and Management

Upon completion of the medical examination, appropriate counseling should be provided to all refugees with significant medical conditions. This counseling should include basic health education on the diagnosed conditions, and review of the recommended follow-up, pre-departure, travel, and post-arrival arrangements, also detailed in the IOM counseling flip chart (8).

• Details of the medical condition(s), recommended medical referrals, and treatment
• How IOM/other agencies facilitate resettlement of refugees with significant medical conditions
• The importance of keeping all medical documents
• Expected pre-departure and travel arrangements
• Immediate post-arrival medical follow-up arrangements
• The importance of getting an 8-week medication supply before departure (split between carry-on (2 weeks) and checked luggage)
• Advice on accessing primary, specialist, and emergency health care before and after arrival to the United States

To the extent possible, please explore medical services and support programs available to refugees in your country and refer to them when appropriate. In the absence of available free services, please explore other alternatives to address health conditions that may result in refugees not being fit to travel, and coordinate with IOM focal points. If a medical referral is required to reconfirm resettlement needs of a refugee, please coordinate it with your RSC and IOM counterparts and have them approve the referrals and the estimated cost in advance.

For SMC cases meeting any of the following criteria, a monthly follow-up and management plan (on-site and/or remote follow-up) is typically needed:

• Fitness to travel is in doubt as a result of recent illness, hospitalization, injury, surgery, or instability of an acute or chronic medical condition
• Special travel arrangements are required, such as medical escort, oxygen, stretcher, dialysis
• Known pregnancy
• Newly diagnosed medical condition requiring ongoing medication

Please document detailed pre-departure evaluation and follow-up plans for such cases on the SMC form and share them with your IOM focal points. Please also ask refugees to inform your clinic (or RSC/IOM directly) about any significant changes in their medical condition. It is very important for IOM to receive medical updates and share updated SMC forms with its resettlement counterparts whenever significant changes occur at any point before a refugee’s departure. A subset of refugees with life-threatening health conditions that cannot be addressed through a regular process should be considered for expedited resettlement on medical grounds. Inform IOM/RSC, and activate the medical expedite protocol via the SMC form (check YES for “Recommend expedite process on medical ground” in the first section of the form). Always provide detailed explanation in the additional comments section on the last page of the SMC form.

6. Pre-departure Evaluation

Pre-departure evaluation (PDE) is typically conducted within 1 to 3 weeks before departure for selected refugees with significant medical conditions whose fitness to travel needs to be reconfirmed or who require special arrangements for their travel (described in Section 5). The following components are included in the pre-departure evaluation:

• Medical history review and comprehensive physical examination
• Specialist review as indicated to ensure fitness to travel and advice on travel requirements
• Oxygen saturation measurement for persons with
  • Cardiac or respiratory SMCs
  • Anemia
  • Shortness of breath on exam
• Hemoglobin measurement for persons with SMCs that pose a health risk during air travel:
  • Pregnancy
  • Moderate to severe malnutrition
  • Anemia identified at initial examination or at PDE
  • Reduced oxygen saturation (if unknown cause)
• Blood glucose level for persons with diabetes
• Other investigations as coordinated with IOM

Always compare the results of the pre-departure evaluation with the initial medical exam results and document the results on all relevant refugee medical forms, including the DS, SMC, and ADL forms. Airline-specific medical form, e.g. Medical Information for Fitness to Travel (MEDIF or MEDA), may also need to be completed for refugees with specific travel needs because of their medical conditions, and returned to IOM at least 2 weeks before travel to ensure necessary coordination and update USRAP information systems.

7. Pre-embarkation (Fitness-to-travel) Check

IOM may ask that you organize pre-embarkation checks (PEC) for all U.S.-bound refugees departing from your country within 72–24 hours before their departure. This check is intended to ensure that all refugees are fit to travel, do not have communicable diseases of public health concern, and will arrive at their final destinations in stable condition. It also helps to ensure that appropriate arrangements have been made for any person needing travel assistance. The following elements should be performed during the PEC:

• Review refugee medical forms, SMC forms, and other relevant medical reports, exploring whether there have been any changes to the refugee's medical condition since last evaluation.
• Confirm list of current medications, dosages, and available supply, updating SMC forms as needed.
• Measure and review vital signs.
• Measure oxygen saturation for patients with anemia, cardiac and/or pulmonary conditions, shortness of breath on exam.
• Perform a physical examination.
• For pregnant refugees, confirm that gestational age has not passed maximum allowed for travel and that a certificate of fitness to fly with pregnancy is provided.
• Counsel refugees with specific travel and post-arrival needs.
• Update SMC and DS forms—include test results, treatments, and follow-up needs.
• Share the results with IOM, informing them about any changes and any deferrals required.

Please document PEC results and details on any additional investigations or treatment on the IOM Pre-departure Medical Procedures (PDMP) forms and share them with IOM on the same day the PEC is completed.

8. Travel Deferrals

Any significant medical condition that is unstable, unevaluated, or known to pose a significant risk of deterioration during flight should lead to travel deferral until the condition has been evaluated and stabilized, and arrangements have been made to mitigate risks during travel. Please notify IOM immediately about any refugees who are not fit to travel.

• Communicable diseases (including COVID-19 exposure, symptoms, or positive test result – see Annex II)
• Anemia with hemoglobin less than 7.5 g/dl
• Thrombocytopenia with platelets <30,000cells/uL
• Sickle cell crisis – recent (within last 9 days)
• Myocardial infarction within last 7 days
• Cardiac failure – decompensated
• Unstable angina pectoris
• Cerebral infarction within last 14 days
• Deep vein thrombosis (DVT) or other thromboembolic disorders – active, acute
• Respiratory disease with breathlessness at rest or markedly poor exercise tolerance
• Fractures – unstable/untreated
• Hemorrhage – recent, gastrointestinal
• Jaw fracture with fixed wiring
• Surgery within previous 10 days, depending on type
• Acute and/or suppurative otitis media that has not been adequately treated
• Sinusitis – severe
• Pneumothorax – suspected or confirmed
• Pregnancy with gestational age 34 weeks or above (32 weeks if multiparous or complicated pregnancy)
• Epilepsy or seizure disorder – uncontrolled
• Unstable psychiatric disorders (including ongoing substance abuse)
• Unpredictable or aggressive behavior
• Uncontrolled pain or distress
• Condition likely to cause discomfort or offense to other passengers (e.g., open, foul-smelling wound)

9. Presumptive Treatment

To decrease the prevalence of selected intestinal parasite and malaria infections among U.S.-bound refugees, CDC has developed presumptive treatment guidelines for IOM physicians and non-IOM clinics assisted by IOM operations. The presumptive treatment activities outlined in these guidelines should only be implemented upon request of CDC/IOM and are typically done at the time of PECs. All Middle Eastern, Asian, African, Latin American, and Caribbean refugees, with exceptions noted in the hyperlinked CDC Presumptive Treatment Guidelines, should undergo the following interventions at the time of their pre-embarkation check:

• Pregnancy test for all female refugees¹ from 15 to 50 years old
• Single dose of albendazole
• One dose of ivermectin (if available/licensed in your country)

In addition, refugees departing from sub-Saharan Africa should receive artemisinin-based combination therapy for malaria and praziquantel for schistosomiasis. All presumptive treatment should be provided as directly observed therapy and documented on the refugees’ – PDMP forms. Additional details on the presumptive treatment process and eligible groups are described in these links:

10. Medical Documentation

Timely documentation of medical examination findings, medical referrals, significant medical conditions (SMC) follow-up updates, pre-departure evaluations, and travel and immediate post- arrival needs is crucial for ensuring that resettlement of refugees with SMC is organized in the safest way possible and that necessary healthcare arrangements are made before arrival to the United States. In addition to requiring documentation of the initial results of the immigration medical examination on the DS, SMC, and ADL medical forms in accordance with CDC Technical Instructions and USRAP refugee health guidelines, the resettlement process requires that medical updates for refugees undergoing external evaluations, additional follow-up visits, and other evaluations be included in the DS-3026 remarks section.

The updates should be included in chronological order with a clear heading and date (e.g., 17 Jan 2019 – Cardiologist Evaluation, 20 Jan 2019 – Pre-departure Follow-up Visit), starting from oldest to most recent, so that the individual's clinical course over time can be followed clearly. Please also include dates for lab/imaging/other diagnostic testing results. Relevant information should be consistent on all medical forms after each update (e.g., if cardiologist evaluation summarized on

the DS form recommended oxygen for travel, this recommendation should also be added to the SMC and MEDIF/MEDA forms). Please refer to the list below of items that should be included in the DS-3026 form as soon as they become available and reflected as needed on the SMC and DS forms.

Key components from all medical updates, relevant for non-medical staff of resettlement agencies (RA) who will receive refugees after their arrival to the United States, should always be summarized under the SMC form’s additional comments section. Do not copy and paste all DS form remarks into the additional comments section but rather adapt it to the audience as needed, limiting the amount of medical information shared with the non-medical audience.

11. Health Assessment and Vaccination Cost Reimbursement

Upon request of PRM and CDC, and in close coordination with U.S. embassies for V93 cases, IOM reimburses panel physicians for medical examination and vaccination costs upon receipt of their invoice and supporting documents, in accordance with the agreed-upon prices detailed in the panel physicians’ U.S. Embassy contracts or in supplementary agreements with IOM. IOM typically requires the following supporting documents to facilitate the reimbursement process:

• Panel site invoice in the agreed-upon format
• U.S. Embassy contract with the panel site with detailed prices
• Additional IOM contract/letter exchange if applicable
• For V93 cases – embassy's referral letter(s) confirming V93 case status
• Completed and electronically signed DS medical forms in fillable PDF format, including DS-3025 form with all administered vaccines properly

IOM also requires additional justification of any service rendered that exceeds the fee agreed with the U.S. Embassy or was not coordinated with IOM in advance.

12. References and Documents

Resources

1. IATA Medical Manual 12th Edition (2020)
2. British Airways Health Your Patient and Air Travel: A Guide to Physicians
3. WHO guidance for air travel by persons with pre-existing medical conditions and special needs
4. CDC Guidelines for Overseas Presumptive Treatment of Strongyloidiasis, Schistosomiasis, and Soil- Transmitted Helminth Infections
5. CDC Overseas Refugee Health Guidelines: Malaria
6. CDC Vaccine Storage and Handling Toolkit
7. IOM/UMN Medical Interpreter Training Module

IOM Resources (available in different languages at IOM portal)

1. Counselling flip chart
2. IOM consent form
3. Pregnancy fitness-to-travel form
4. Pregnancy brochure
5. Vaccine Information Statements
6. AEFI reporting form
7. Immunization contraindication checklist
8. Hep B brochure
9. Hep B testing protocol
10. USRAP vaccination schedule
11. Stock management card
12. IOM invoice template
13. Fillable DS, SMC, ADL, and PDMP forms
14. USRAP refugee health videos

Annex I. USRAP SMC Checklists

These checklists complement CDC TIs and IOM Refugee Health Guidelines to help panel physicians prepare for resettlement of refugees with selected medical conditions that may affect their travel and placement needs.

While the checklists outline a suggested process for SMC cases, each patient's situation may be unique. Therefore, the final workup and referral plan is subject to the Panel Physician's clinical judgement in close coordination with the IOM medical team.

Congenital Heart Disease or Congestive Heart Failure

Hypertension

COPD and other conditions with continuous O2 Needs

Disorders with Psychotic Features/Behavioral Issues

Seizure Disorder / Epilepsy

Cerebral Palsy; Paraplegia; Hydrocephalus

Insulin-dependent Diabetes

Sickle Cell Disease, Severe Anemia

Bleeding Disorders (e.g., Hemophilia, Platelet Disorders)

ESRD Requiring Dialysis

Portal Hypertension, Esophageal Varices

Pregnancy