Refugee Health Quarterly
Vol. 14
A Refugee Health update from the Minnesota Department of Health
Jan. 2015
Greetings from the Refugee Health Program
Happy New Year! It’s that time of year when we reflect on
where we have been, where we are, and where we would
like to be in 2015. Most importantly, it’s a time to be
grateful for the partnerships we have with local public
health, passionate providers in the refugee screening
clinics, dedicated resettlement agency staff, and
community members working to advance refugee
health—your partnership, help, and flexibility made 2014
another successful year. Thank you!
This past year, we welcomed new staff to the Refugee
Health Program, as well as student workers and interns
who have allowed us to sustain and grow many of our
activities and objectives. We are looking forward to the
new projects to come in 2015.
This edition highlights several interesting activities, including
an initiative to make overseas vaccination records available in
the statewide immunization registry, the Minnesota
Immunization Information Connection (MIIC). In the provider
update, we revisit immunizations since they are a key part of
refugee health screening and the resettlement process. In our
LPH/VOLAG spotlight we provide an update on the
Affordable Care Act and the tremendous work by our partners to improve the MNsure enrollment process for refugees,
asylees, parolees, victims of trafficking, and other immigrants
eligible for Medical Assistance (MA). Finally, we are preparing
for the eighth annual LPH/VOLAG forum on Jan. 29.
We wish you a wonderful 2015. We’re excited for the
opportunities this New Year brings!
Local Public Health/VOLAG Forum - Jan. 29, 2015
The Eighth Annual Local Public Health and Voluntary
Resettlement Agency forum will be held on Jan. 29, 2015.
The theme is, “All on the Same Team: Refugee Health in
Minnesota,” and promises to be a full day of networking,
presentations, and discussion about meeting the
ongoing health-related needs of our new refugee
arrivals—together!
This year the forum will focus on key resources (e.g.,
transportation and health care homes), metro and rural
resettlement issues, disability services, refugee mental
health needs and access, and a presentation about a visit
to a refugee camp and other places of interest in Thailand.
This forum is an important time for all who work closely with
refugees, particularly in their first few months after arrival,
to come together to share their knowledge, learn about
resources, generate ideas, and meet the other players—the
team—involved in the collective work of refugee resettlement.
Find more details about the forum at:
www.health.state.mn.us/divs/idepc/refugee/forum.html.
Contact Ellen Frerich at [email protected] or
651-201-5827 if you have questions.
Diverse Media Project
The Diverse Media Project is a collaborative project
between refugee health, immunization, and
communications staff at MDH. Advertisements on an
array of immunization topics are placed in diverse
community newspapers, websites, and radio shows.
Recent ads have covered topics such as flu vaccine and
travel immunizations. Some advertisements are also
translated into other languages. This project will continue
throughout 2015. Please contact Danushka Wanduragala
with questions at [email protected].
Travel immunization
advertisement in Spanish
Flu advertisement in English
Refugee Health Program
625 Robert Street North
St. Paul, MN 55164-0975
1-877-676-5414, 651-201-5414
www.health.state.mn.us/refugee
Page 1
Provider Update: Revisiting Immunizations
Immunizations are a key part of refugee health screening
and the resettlement process. They:
• Protect both the individual and the community
against vaccine-preventable disease,
• Are required for school enrollment, and
• Are required for adjustment of status (application for
green card).
The Refugee Health Program tracks vaccines given
during the refugee health screening exam. Providers in
Minnesota are doing excellent work. In 2013, 97 percent
of refugee health screenings included vaccination.
Here are some reminders and tips on how to accurately
assess which immunizations have already been given and
which are needed.
Immunization schedule principles:
• Only vaccine doses that have been documented in
writing or recorded electronically should be counted as
valid. In some instances history of disease is allowed if
supported by serological testing. The General
Recommendation on Immunizations describes when
it might be appropriate to test for immunity. You can
access that document at: www.cdc.gov/mmwr/pdf/
rr/rr6002.pdf (see page 27). However, revaccination is
generally recommended.
• Use the respective U.S. Recommended Immunization
Schedules for Children and Adolescents and for Adults
to compare the refugee’s immunization documentation
to the recommended schedule. For the current
schedules go to: www.cdc.gov/vaccines/schedules/
hcp/index.html, or call 651-201-5503 or 1-800-6573970 to order your own copies.
• Ensure that documented doses meet the minimum
age and minimum interval requirements according
to U.S. immunization schedules. This is particularly
important because different countries follow different
schedules. A quick guide for checking minimum ages
and intervals can be found at: www.cdc.gov/vaccines/
pubs/pinkbook/downloads/appendices/A/ageinterval-table.pdf.
• Errors of documentation may occur (e.g., dates of
vaccination that precedes a person’s birth). It is not
acceptable to assume that a documented dose
was miswritten if the date occurs before a birth
date or is given too soon. If the documented date
does not meet the minimum age or interval, it
cannot be counted.
• Use the Minnesota immunization registry, called
Minnesota Immunization Information Connection
(MIIC), to guide you in predicting future vaccination
needs.
Refugee immunization information sources:
We receive overseas medical paperwork through the CDC
database called Electronic Disease Notification (EDN). This
information is generally uploaded and available to the RHP
within two to five business days of a refugee’s arrival, and
forwarded to local public health who sends it to the
screening clinic. It includes immunizations given immediately
before the refugee left his or her camp. These immunizations
will begin to be uploaded into MIIC by MDH for primary
refugee arrivals in 2015. (See page 3 for more details.) They
will continue to be available to providers in paper format as
part of the overseas paperwork. Please continue to document
the vaccines given and titers drawn by your clinic through
your existing protocol.
Immunizations listed in the CDC EDN paperwork are
occasionally subject to administrative errors; for example,
paperwork on several arrivals in 2014 documented
immunizations given before the individual’s birth date or
immunizations that did not meet minimum time intervals in
a series. Such immunizations must be considered not given,
and should be reported to MDH ([email protected])
for follow-up with our overseas partners.
Additional medical paperwork available through the
resettlement agencies (VOLAGs) is accessible at the time of
arrival, but may omit immunizations given close to the time
of departure. Finally, a refugee may carry personal
documentation of immunization, which should then be
assessed by the provider for completeness.
Additional information for adjustment of status:
Refugees are eligible to adjust their status one year after their
U.S. arrival. For refugees, proof of immunization is the only
required health assessment. For asylees and other
immigration categories, it is one of the required assessments.
Occasionally, refugees or partners may have questions about
which vaccines are needed for the adjustment of status
examinations (also called I-693 after the form involved). For
context, those vaccination requirements (which are adapted
from ACIP recommendations) can be found here: www.cdc.
gov/immigrantrefugeehealth/exams/ti/civil/vaccinationcivil-technical-instructions.html#tbl1.
Please note that vaccination waivers for adjustment of status
must follow the USCIS procedure and must be blanket
waivers (applicants cannot waive only one vaccination) based
on sincere moral convictions or religious beliefs. Please see
www.uscis.gov/news/questions-and-answers/vaccinationrequirements. Refugees should seek expert guidance on
this process, which is beyond the scope of the MDH RHP or
refugee health screening.
Page 2
Refugee Health Data: Overseas Immunization Records Coming to MIIC
During recent years, an increasing number of refugees
have been receiving immunizations before departing for
the U.S. (Figure 1). In 2004, 50 percent of primary refugee
arrivals to Minnesota had received at least one vaccination
overseas, compared to 76 percent in 2013. To ensure that
the vaccine history is available to health care providers and
schools in a timely manner, the Refugee Health Program is
planning an initiative to make these overseas vaccination
records available in the statewide immunization registry, the
Minnesota Immunization Information Connection (MIIC),
shortly after a refugee’s arrival.
We typically receive overseas immunization records
within 5-10 days of arrival to Minnesota. Upon this
notification, RHP staff would:
1.Create a MIIC record for new refugees with
documentation of overseas vaccinations
In January 2015, we will send a survey to seven school
districts that regularly enroll newly arrived refugees. The
survey will assess their current practices for enrolling new
refugee students and allow them to provide feedback and
comments on this project.
We hope to begin this initiative in early 2015 and will
continue to keep LPH, school districts, and screening clinics
informed of our progress. Educational and training materials
will be created to provide detailed instructions on this new
process.
If you have any questions, please contact Kailey Nelson at
[email protected]. For more information on MIIC,
go to www.health.state.mn.us/miic.
2.Enter all overseas vaccines available on their
overseas medical exam
3.Provide the MIIC Identification Number to the
local public health (LPH) jurisdiction where the
refugee is residing. The refugees will also be
searchable by all MIIC users, using name, birth
date, and/or gender.
In July 2014, we reached out to 19 LPH
jurisdictions that commonly receive primary
refugee arrivals and assessed their current protocol
for processing vaccination records provided on the
overseas medical exam. The survey also addressed
questions and comments, and we will be
meeting with four of the largest refugee-receiving
counties to discuss this initiative in more detail.
Figure 1. Percent of Primary Refugee Arrivals to Minnesota with
Documentation of ≥1 Overseas Vaccination, 2004-2013
*Other includes East Asia/Pacific, Eastern Europe, Latin America/Caribbean,
North African/Middle East, and Western Europe.
Local Public Health/VOLAG Spotlight: ACA and Refugees
Newly arrived refugees face many challenges when
resettling in Minnesota, but thanks to a collaborative
effort by a host of partners, refugees have a bit easier
time lining up state assistance with their health insurance.
Many of these new Minnesotans arrived with identified
health needs and risk factors, making timely insurance
enrollment even more critical. However, until recently,
refugees, asylees, Cuban entrants, and victims of
trafficking eligible for Medical Assistance (MA) faced a
variety of obstacles to completing the necessary
paperwork and documentation to receive state
assistance for health insurance. For example, those who
had not been assigned social security numbers could
not apply online and had to submit paper forms, along
with proof of identification. Refugees also faced lengthy
delays in processing paper applications. These problems
hindered refugees’ ability to access crucial health services,
including clinical care and medication. Refugee health
screenings were delayed significantly.
In response to these challenges, resettlement agencies, local
public health, clinics and elected officials, along with the
Minnesota Department of Health, worked with the Minnesota
Department of Human Services (DHS) to find solutions. On
July 21, 2014, DHS implemented a workaround, routing
primary refugee MA applications to a designated team within
MNsure. This process has dramatically cut processing times
and improved accuracy. DHS is continuing to take steps to
ensure payment for services provided to MA-pending
refugees prior to July 21. A separate Personal Master Index
(PMI) number has been created for each person who had the
wrong activation date, to cover the gap period. Providers can
request this PMI through DHS and submit claims for services.
The workaround has been successful for primary refugees.
Partners continue to work on developing the best plan for
facilitating the MA application process for asylees, Cuban
entrants, victims of trafficking and, refugees migrating from
other states.
Page 3