Letters to the Editor

Screening and Immunizations for Refugees to the United States


Am Fam Physician. 2018 Aug 1;98(3):141-142.

Original Article: Primary Care for Refugees: Challenges and Opportunities

Issue Date: July 15, 2017

Available online at: https://www.aafp.org/afp/2017/0715/p112.html

To the Editor: We would like to thank Drs. Mishori, Aleinikoff, and Davis for reviewing the challenges and opportunities for refugees seen in primary care settings. We agree that refugees often face barriers to care as a result of cultural, language, and socioeconomic factors. We would respectfully like to provide clarification on a few points mentioned in the article.

The article states that the pre-resettlement examination is performed overseas, following technical guidelines from the Centers for Disease Control and Prevention with oversight from the U.S. State Department and the International Organization for Migration. It also states that documentation from this examination is available to state and local health departments through the National Notifiable Diseases Surveillance System (http://www.cdc.gov/nndss/nedss.html). In fact, documentation from the overseas medical examination is provided to state and local health officials through the Electronic Disease Notification system (https://www.cdc.gov/immigrantrefugeehealth/Electronic-Disease-Notification-System.html). This is a web-based system that notifies state or local health officials when all refugees (regardless of examination findings) and immigrants who are at risk of tuberculosis arrive in their jurisdictions.1 Furthermore, panel physicians with the International Organization for Migration conduct examinations in many countries and manage resettlement logistics, but they do not provide oversight for the medical examination.

Table 3 states that hepatitis B screening should be performed for refugees from countries with greater than 2% prevalence. However, guidelines specify a prevalence rate of 2% or greater. It should be noted that most eligible refugees receive predeparture treatment for soil-transmitted helminths, schistosomiasis, Strongyloides, and malaria before arrival in the United States.2

Lastly, in Table 3, the action column for immunizations recommends that physicians order varicella zoster virus (VZV) immunoglobulin G (IgG) and hepatitis B surface antibody tests before vaccinating. We believe the authors meant that it is reasonable to check VZV IgG before administering the VZV vaccine. A positive VZV IgG result indicates previous infection, so the vaccination is not needed. We would agree with this approach. However, we were confused by the suggestion to check hepatitis B surface antibody test results before vaccinating. Most refugees are checked for hepatitis B infection before departure by screening for hepatitis B surface antigen. When that test result is negative, the vaccine series is initiated overseas. If testing has not been performed previously, it should be done after arrival, regardless of the vaccine history (as indicated by the authors). The hepatitis B surface antibody test can be used to indicate immunity by vaccination, but only in a completely immunized person. On its own, in a partially vaccinated or unvaccinated person, it is not particularly helpful. A positive hepatitis B surface antibody test result with a negative anti–hepatitis B core antibody result must be interpreted with caution in a recently or partially immunized person.3

Editor's Note: This letter was sent to the authors of “Primary Care for Refugees: Challenges and Opportunities,” who declined to reply.

Author disclosure: No relevant financial affiliations.


1. Lee D, Philen R, Wang Z, et al. Disease surveillance among newly arriving refugees and immigrants—Electronic Disease Notification System, United States, 2009. MMWR Surveill Summ. 2013;62(7):1–20.

2. Centers for Disease Control and Prevention. Immigrant and refugee health: treatment schedules for presumptive parasitic infections. https://www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/interventions/interventions.html. Accessed December 7, 2017.

3. Centers for Disease Control and Prevention. Immigrant and refugee health: screening for hepatitis during the domestic medical examination. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/hepatitis-screening-guidelines.html#modalIdString_CDCTable_0. Accessed December 7, 2017.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


May 2022

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article