ȱ
––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘Ȭ
Ž•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
‘Šȱǯȱ ŠŠ•ȱ
—Š•¢œȱ’—ȱ ––’›Š’˜—ȱ˜•’Œ¢ȱ
ž‘ȱ••Ž—ȱŠœŽ–ȱ
™ŽŒ’Š•’œȱ’—ȱ ––’›Š’˜—ȱ˜•’Œ¢ȱ
Š¢ȱŗŞǰȱŘŖŖşȱ
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŝȬśŝŖŖȱ
   ǯŒ›œǯ˜Ÿȱ
ŚŖśŝŖȱ
ȱŽ™˜›ȱ˜›ȱ˜—›Žœœ
Pr
epared for Members and Committees of Congress

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
ž––Š›¢ȱ
Under current law, foreign nationals not already legally residing in the United States who wish to
come to the United States generally must obtain a visa and submit to an inspection to be admitted.
They must first meet a set of criteria specified in the Immigration and Nationality Act (INA) that
determine whether they are eligible for admission. Moreover, they must also not be deemed
inadmissible according to specified grounds in the INA. One of the reasons why a foreign
national might be deemed inadmissible is on health-related grounds. The diseases that trigger
inadmissibility in the INA are those communicable diseases of public health significance as
determined by the Secretary of Health and Human Services (HHS).
The recent outbreak of the 2009 H1N1 virus (commonly called “Swine Flu”) has generated
attention in Congress and the media, particularly with its relationship to foreign travel. With
Mexico reportedly being the likely source country of this strain of influenza, and its spread to a
number of areas across the United States, questions have been raised on travel restrictions to the
United States, particularly in regard to foreign nationals. Potential issues for Congress are three-
fold: (1) are current health-related grounds for exclusion sufficient to ensure public safety in
regards to contagious diseases; (2) would increased restrictions on foreign travel (even
temporarily) inflict more economic harm than benefit; and (3) are the resources provided for
frontline agencies charged with screening foreign travelers sufficient to identify potentially
infected travelers?
From an immigration standpoint, infectious disease outbreaks place the greatest procedural and
resource pressures on Customs and Border Protection (CBP), an agency within the Department of
Homeland Security (DHS). CBP is charged with screening admissions of all travelers at land, sea,
and air ports of entry (POE), and CBP Officers screened approximately 409 million individuals in
FY2008 for admissions into the United States. CBP works in conjunction with the Centers for
Disease Control and Prevention (CDC) to monitor travelers and attempt to contain any diseases
that may be spread by travelers coming from abroad. CDC, in conjunction with CBP, operates 20
quarantine stations and has health officials on call for all ports of entry. DHS has established its
role in case of a pandemic outbreak through a memorandum of understanding with other agencies
and in The National Strategy for Pandemic Influenza.
Various federal statutes and legal questions may arise should a response to an influenza pandemic
require limiting the use of transportation-related infrastructure, which includes, but is not limited
to airports, seaports, and land ports of entry. Constitutional concerns, especially those related to
the “right to travel” may also be implicated by decisions impacting transportation-related
infrastructure.
In recent years health-related grounds for exclusion has also been a congressional concern for
other contagious diseases. In addition to the H1N1 outbreak, these diseases have included
tuberculosis (TB). This report will be updated as circumstances warrant.

˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
˜—Ž—œȱ
Introduction ..................................................................................................................................... 1
Health-Related Grounds for Exclusion ........................................................................................... 2
Legislative History .................................................................................................................... 2
Communicable Diseases ........................................................................................................... 3
Waivers of the Health Grounds........................................................................................... 5
Vaccination Requirements .................................................................................................. 6
Port of Entry Policies and Procedures ............................................................................................. 7
General CBP Procedures ........................................................................................................... 7
The Centers for Disease Control and Prevention................................................................ 9
Emergency Procedures............................................................................................................ 10
Select Contagious Diseases ........................................................................................................... 10
H1N1 Virus ..............................................................................................................................11
Border Closing.................................................................................................................. 12
Tuberculosis (TB) ................................................................................................................... 13

Š‹•Žœȱ
Table A-1. CDC Quarantine Stations by City and Location.......................................................... 14

™™Ž—’¡Žœȱ
Appendix A. CDC Quarantine Stations......................................................................................... 14
Appendix B. CDC Technical Guidance......................................................................................... 15

˜—ŠŒœȱ
Author Contact Information .......................................................................................................... 16

˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
—›˜žŒ’˜—ȱ
Under current law, foreign nationals not already legally residing in the United States who wish to
come to the United States generally must obtain a visa and submit to an inspection to be
admitted.1 They must first meet a set of criteria specified in the Immigration and Nationality Act
(INA) that determine whether they are eligible for admission. Moreover, they must also not be
deemed inadmissible according to specified grounds in the INA. One of the reasons why a foreign
national might be deemed inadmissible is on health-related grounds.2
The recent outbreak of the 2009 H1N1 virus (commonly called “Swine Flu”) has generated
attention in Congress and the media, particularly with its relationship to foreign travel. With
Mexico reportedly being the likely source country of this strain of influenza, and its spread to a
number of areas across the United States, questions have been raised on travel restrictions to the
United States, particularly in regard to foreign nationals. While grounds for exclusion based on
health-related criteria already exist in the Immigration and Nationality Act (INA), some have
questioned whether these provisions are sufficient to deal with the current situation, as well as
potential future pandemics. Potential issues for Congress are at least three-fold: (1) are current
health-related grounds for exclusion sufficient to ensure public safety in regards to contagious
diseases; (2) would increased restrictions on foreign travel (even temporarily) inflict more
economic harm than benefit; and (3) are the resources provided for frontline agencies charged
with screening foreign travelers sufficient to identify potentially infected travelers?
Statutorily, three departments—the Department of State (DOS), the Department of Homeland
Security (DHS) and the Department of Justice (DOJ)—each play key roles in administering the
law and policies on the admission of aliens.3 DOS’s Bureau of Consular Affairs (Consular
Affairs) is the agency responsible for issuing visas, DHS’s Citizenship and Immigration Services
(USCIS) is charged with approving immigrant petitions, and DHS’s Bureau of Customs and
Border Protection (CBP) is tasked with inspecting all people who enter the United States. DOJ’s
Executive Office for Immigration Review (EOIR) has a significant policy role through its
adjudicatory decisions on specific immigration cases.

1 Authorities to except or to waive visa requirements are specified in law, such as the broad parole authority of the
Attorney General under § 212(d)(5) of the Immigration and Nationality Act (INA) and the specific authority of the Visa
Waiver Program in § 217 of the INA.
2 Other grounds for exclusion include: criminal history; security and terrorist concerns; public charge (e.g., indigence);
seeking to work without proper labor certification; illegal entry and immigration law violations; ineligible for
citizenship; and aliens previously removed. For more information, see CRS Report RL32256, Visa Policy: Roles of the
Departments of State and Homeland Security
, by Ruth Ellen Wasem.
3 Other departments, notably the Department of Labor (DOL), and the Department of Agriculture (USDA), play roles
in the approval process depending on the category or type of visa sought, and the Department of Health and Human
Services (HHS) sets policy on the health-related grounds for inadmissibility discussed below.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŗȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
With certain exceptions,4 aliens seeking admission to the United States must undergo separate
reviews performed by DOS consular officers abroad as well as CBP inspectors upon entry to the
United States.5 These reviews are intended to ensure that applicants are not ineligible for visas or
admission under the grounds for inadmissibility spelled out in the Immigration and Nationality
Act (INA).6 These criteria are: health-related grounds; criminal history;7 security and terrorist
concerns; public charge (e.g., indigence); seeking to work without proper labor certification;
illegal entry and immigration law violations; ineligible for citizenship; and aliens previously
removed. The health-related grounds are further broken down into four categories: having a
communicable disease, lacking required vaccinations, presenting a physical or mental disorder,
and evidencing drug abuse or addiction.8
Ž’œ•Š’ŸŽȱ ’œ˜›¢ȱ
The statutory language permitting the exclusion of aliens on the basis of health or communicable
diseases date back to the Immigration Act of 1891. “Persons suffering from a loathsome or a
dangerous contagious disease” were added to the grounds of exclusion, and the 1891 Act also
required a medical inspection of all aliens arriving at ports of entry.9 When the various
immigration and citizenship laws were unified and codified as the Immigration and Nationality
Act of 1952 (INA), the health-related grounds were 7 of 31 grounds for exclusion.10 One of these
7 health-related grounds specified that aliens “afflicted with any dangerous contagious disease”
would be excluded from the United States.
The Immigration Amendments Act of 1990 streamlined and modernized all of the grounds for
inadmissibility into nine broad categories. At that time, Congress recodified the health-related
ground for inadmissibility to include any alien “who is determined (in accordance with
regulations prescribed by the Secretary of Health and Human Services) to have a communicable
disease of public health significance.”
In 1996, the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA)
amended the INA to require prospective immigrants to demonstrate that they have been
vaccinated against certain “vaccine-preventable” diseases. More specifically, §341 of the IIRIRA

4 Certain classes of aliens are not required to obtain a visa to enter the United States and are therefore exempt from the
consular review process. For example, under the visa waiver program (VWP), nationals from certain countries are
permitted to enter the United States as temporary visitors (nonimmigrants) for business or pleasure without first
obtaining a visa from a U.S. consulate abroad. See INA § 217; 8 U.S.C. § 1187. For additional background on the
VWP, see CRS Report RL32221, Visa Waiver Program, by Alison Siskin.
5 For background and analysis of alien screening and visa issuance policy, see CRS Report RL31512, Visa Issuances:
Policy, Issues, and Legislation
, by Ruth Ellen Wasem.
6 INA § 212(a); 8 U.S.C. § 1182(a).
7 For a full discussion of this ground, see CRS Report RL32480, Immigration Consequences of Criminal Activity, by
Yule Kim and Michael John Garcia.
8 INA § 212(a)(1)(A).
9 Act of March 3, 1891; 26 Stat. 1084.
10 For a complete analysis of the pre-1990 laws and policies, see U.S. Congress, House Committee on the Judiciary,
Grounds for Exclusion of Aliens under the Immigration and Nationality Act: Historical Background and Analysis,
committee print, prepared by the Congressional Research Service, 100th Cong., 2nd sess., September 1988, Ser. No. 7.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
Řȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
created a new basis of inadmissibility in §212(a) for failing to present evidence of vaccination
against nine “vaccine-preventable diseases,” including mumps, measles, rubella, polio, tetanus
and diphtheria toxoids, pertussis, influenza type B and hepatitis B.
Much of the policy debate since 1990, however, has centered on HIV/AIDS.11 In 1993, Congress
amended the health-related grounds for inadmissibility by adding the phrase: “which shall include
infection with the etiologic agent for acquired immune deficiency syndrome.”12 In 2008, § 305 of
P.L. 110-293, the Tom Lantos and Henry J. Hyde United States Global Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, eliminated the language in
the INA that statutorily barred foreign nationals with HIV/AIDS from entering the United States.
This revision does not, however, entitle foreign nationals with HIV/AIDS to receive visas to enter
the United States. The HHS reportedly has begun the rulemaking process to remove HIV from
this list. On September 29, 2008, the DHS announced the publication of a final rule that grants
consular officers the authority to grant nonimmigrant visas to otherwise eligible applicants who
are HIV-positive and meet certain requirements. Visas issued under the final rule do not publicly
identify any traveler as HIV-positive. The HIV-waiver final rule applies to foreigners who are
HIV-positive and seek to enter the United States as visitors for up to 30 days.
˜––ž—’ŒŠ‹•Žȱ’œŽŠœŽœȱȱ
The INA renders inadmissible foreign nationals infected with a “communicable disease of public
health significance.13 While the INA does not define “communicable disease of public health
significance” directly, it does task the Secretary of Health and Human Services (HHS) to define
the term by regulation. The relevant regulation’s definition expressly lists eight diseases as a
“communicable disease of public health significance”: HIV infection; chancroid; gonorrhea;
granuloma inguinale; infectious leprosy; lymphogranuloma venereum; active tuberculosis;14 and

11 INA § 212(a). The fiscal year 1987 Supplemental Appropriations Act included in §518 the following requirement:
“On or before August 31, 1987, the President, pursuant to his existing power under section 212(a)(6) of the
Immigration and Nationality Act, shall add human immunodeficiency virus infection to the list of dangerous contagious
diseases contained in title 42 of the Code of Federal Regulations.” Simultaneously with the vote, HHS published a final
rule adding AIDS to the list of “dangerous contagious diseases” in Title 42 of the Code of Federal Regulations, and a
proposed rule to replace AIDS on this list with HIV infection. Regulations implementing the statutory requirement
were published by the HHS, effective August 31, 1987.

12 P.L. 103-43, the National Institutes of Health Revitalization Act of 1993, § 2007(a). The 1993 legislation was
enacted in response to controversy over an announcement by the William Jefferson Clinton Administration that the
HHS Public Health Service regulations would be revised to remove HIV infection and six other diseases from a list of
diseases for which aliens could be excluded from the United States, leaving only infectious tuberculosis on the list. A
similar amendment to the regulations had been proposed in January 1991, by the George H.W. Bush Administration,
and had also been controversial. In both cases, the deletion of HIV infection from the list of excludable diseases caused
the most concern. (June 10, 1993; 107 Stat. 210).
13 INA § 212(a)(1), 8 U.S.C. § 1182(a)(1) (Any alien who is determined (in accordance with regulations prescribed by
the Secretary of Health and Human Services) to have a communicable disease of public health significance…is
inadmissible.).
14 The prevalence of active tuberculosis among foreign nationals has been a concern for many years. On January 23,
1991, HHS published a proposed rule in which infectious tuberculosis would have been the only communicable disease
listed. That rule was suspended May 29, 1991, largely because of the controversies of leaving HIV/AIDS off the list. In
addition, processing of Hmong refugees located in Thailand was temporarily halted in 2005 to ensure that the refugees
had completed treatment for infectious tuberculosis before they came to the United States. See “State Department Halts
Travel of Hmong Refugees to U.S.; Institutes Enhanced Medical Screening,” Interpreter Releases, vol. 82, no. 7
(February 14, 2005).
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
řȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
infectious syphilis.15 However, this list is neither exclusive nor exhaustive because the regulatory
definition also includes other diseases incorporated by reference to a Presidential Executive
Order.16 The relevant executive order lists: cholera; diphtheria; infectious tuberculosis; plague;
smallpox; yellow fever; viral hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, South
American, and others not yet isolated or named); severe acute respiratory syndrome (SARS); and
“[i]nfluenza caused by novel or reemergent influenza viruses that are causing, or have the
potential to cause, a pandemic.”17
Furthermore, the regulatory definition also includes communicable diseases that may pose a
“public health emergency of international concern.”18 A disease rises to this level, and thus
qualifies as a “communicable disease of public significance,” if the CDC Director, after
evaluating (1) the seriousness of the disease, (2) whether the emergence of the disease was
unusual or unexpected, (3) the risk of the spread of the disease in the United States, and (4) the
transmissibility and virulence of the disease,19 determines that “a threat exists for [the disease’s]
importation into the United States” and the disease “may potentially affect the health of the
American public.”20
The Centers for Disease Control and Prevention (CDC) in HHS take the lead in protection against
communicable diseases among foreign nationals who come to the United States. The CDC are
responsible for providing the technical instructions to civil surgeons and panel physicians who
conduct medical examinations for immigration purposes. Foreign nationals who are applying for
visas at U.S. consulates are tested by in-country physicians who have been designated by the
State Department. The physicians enter into written agreements with the consular posts to
perform the examinations according to HHS regulations and guidance. Foreign nationals in the
United States who are adjusting to legal permanent resident (LPR) status are tested by civil
surgeons designated by USCIS.
A medical examination is required of all foreign nationals seeking to come as legal permanent
residents and refugees, and may be required of any alien seeking a nonimmigrant visa or
admission at the port of entry. Foreign nationals are generally tested at their own expense, though
the costs for refugees are covered by the U.S. government. If there is reason to suspect an
infection, applicants for temporary admission as nonimmigrants (such as tourists, business
travelers, temporary workers, and foreign students) are tested at the discretion of the consular
officer or admitting CBP inspector. Children under 15 years of age are required to have a general
physical examination and provide proof of immunizations, but they are not required to have the
chest x-rays, blood tests, or HIV anti-body test.21

15 42 C.F.R. § 34.2(b).
16 42 C.F.R. § 34.2(b)(2).
17 Exec. Order. No. 13295, 68 FR 17255 (April 4, 2003) as amended by Exec. Order. No. 13375, 70 FR 17299 (April 1,
2005).
18 42 C.F.R. § 34.2(b)(3).
19 See 42 C.F.R. §34.3(d)(2) (factors used to determine whether a communicable disease poses a public health
emergency of international concern).
20 42 C.F.R. § 34.2(b)(3). See also Annex 2 of the revised International Health Regulations
http://www.who.int/csr/ihr/en.
21 U.S. Department of State Bureau of Consular Affairs, Frequently Asked Questions—Immigrant Visa Interview
Medical Examination
, http://travel.state.gov/visa/immigrants/info/info_3745.html#_What_should_the.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
Śȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
Policies and procedures established over the years by the CDC spell out the obligations of the
physicians who are designated to conduct the medical examination to meet the statutory
requirements of the INA. According to the CDC’s technical guidance for the physicians
performing the medical examination, they are required to make an assessment of the foreign
national that includes a medical history, a review of other available records, a physical
examination, and required diagnostic tests ( more detailed information on these requirements are
available in Appendix B).22 Afterwards, CDC guidance says, the panel physician completes the
DS-2053 form if the visa is being processed by consular officers abroad, or the civil surgeon
completes I-693 form if the status adjustment is being processed by USCIS adjudicators within
the United States. In general, the medical reports are valid for one year.
Mere presence of one of the designated diseases does not always lead to exclusion. After a visa
applicant is found to be afflicted with tuberculosis, for example, the consular officer or USCIS
adjudicators is to request the medical examiner to determine whether the tuberculosis is Class A
(infectious), Class B-1 (clinically active, not infectious) Class B-2 (not clinically active) or Class
B-3 (old or healed tuberculosis). A foreign national diagnosed with Class B-1 tuberculosis, is not
automatically ineligible for LPR visa purposes; nor is a foreign national diagnosed with Class B-
1, B-2, or B-3 tuberculosis automatically ineligible for nonimmigrant (temporary) visa
purposes.23
Š’ŸŽ›œȱ˜ȱ‘Žȱ ŽŠ•‘ȱ ›˜ž—œȱ
The INA gives the Secretary of Homeland Security24 the discretionary authority to waive some of
the health-related grounds for inadmissibility under certain circumstances.25 For example, foreign
nationals infected with a communicable disease of public health significance can still be issued a
waiver and admitted into the country if they are the spouse, unmarried son, unmarried daughter,
minor unmarried lawfully adopted child, father, or mother of a U.S. citizen, alien lawfully
admitted for permanent residence, or an alien issued an immigrant visa, or is a VAWA self-
petitioner.26 Waivers are also available, under certain circumstances, for those inadmissible for
lacking proper vaccination27 and for those who have a physical or mental disorder.28 The
Secretary may also waive the application of any of the health-related grounds for inadmissibility
if she finds it in “the national interest” to do so.29
The Department of State Visa Office reports that a total of 832 potential LPRs were initially
denied a visa in 2008 on the basis of a communicable disease of public health significance (e.g.,
cholera, infectious tuberculosis, HIV/AIDS).30 However, 437 people obtained waivers or

22 INA § 222(f) provides that if an immigrant visa is not issued, all medical eligibility forms will be treated as
confidential.
23 9 FAM § 40.11 N.5.2.
24 The text actually names the Attorney General, but the passage of the Homeland Security Act of 2002 transferred the
waiver power to the Secretary of Homeland Security.
25 INA § 212(g), 8 U.S.C. § 1182(g).
26 INA § 212(g)(1), 8 U.S.C. § 1182(g)(1).
27 INA § 212(g)(2), 8 U.S.C. § 1182(g)(2).
28 INA § 212(g)(3). 8 U.S.C. § 1182(g)(3).
29 INA, § 212(d)(13)(B)(i).
30 In FY2008, a total of 291,792 immigration applications were found ineligible under grounds for exclusion in the
INA. However, during the same fiscal year 184,457 applications overcame the grounds for exclusion.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
śȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
overcame an initial denial based upon a communicable disease and were granted LPR visas in
2008.31 Comparable data from the Department of Homeland Security have not been made
available.
When waivers are given to nonimmigrants, it is done on a case-by-case basis for up to 30 days,
for such reasons as visiting a family member, short-term treatment, or attending conferences. The
Department of State Visa Office reports that a total of 219 potential nonimmigrants were denied a
visa in 2008 on the basis of a communicable disease of public health significance.32 Also in 2008,
187 people obtained waivers or overcame an initial denial based upon a communicable disease
and received a nonimmigrant visa.33 Comparable data from the Department of Homeland Security
have not been made available.
ŠŒŒ’—Š’˜—ȱŽšž’›Ž–Ž—œȱ
As stated above, the INA renders inadmissible foreign nationals who are not vaccinated against
vaccine-preventable diseases.34 Vaccinations are statutorily required for mumps, measles, rubella,
polio, tetanus, diphtheria, pertussis, influenza type B and hepatitis B. Vaccinations against other
diseases may also be required if recommended by the Advisory Committee for Immunization
Practices (ACIP), an advisory committee to the CDC.35 Those vaccinations against other diseases
the ACIP have added are: hepatitis A, human papillomavirus, meningococcal, pneumococcal,
rotavirus, varicella, zoster, and the annual influenza vaccine.36 Most visas denied on this basis are
overcome when evidence of the vaccination is presented.37
If the panel physician or civil surgeon believes that a vaccination record is fraudulent, the visa
applicant is handled in the same way as someone who has failed to present a vaccination record.
The vaccination requirement may be waived when the foreign nation receives the vaccination, the
civil surgeon or panel physician certifies that the vaccination would not be medically appropriate,
or if the vaccination would be contrary to the foreign national’s religious or moral beliefs.38

31 U.S. Department of State Bureau of Consular Affairs, 2008 Report of the Visa Office, Washington , DC, 2009,
Appendix Table XX.
32 In FY2008, a total of 2,083,726 nonimmigrant applications were found ineligible under grounds for exclusion in the
INA. However, during the same fiscal year 538,129 applications overcame the grounds for exclusion.
33 U.S. Department of State Bureau of Consular Affairs, 2008 Report of the Visa Office, Washington , DC, 2009,
Appendix Table XX.
34 INA § 212(a)(ii).
35 Id.
36 See CDC Immigration Requirements: Technical Instructions for Vaccination, Table 1 (2007). On April 8, 2009, the
CDC issued a notice with comment period that minor modifications would be made to the vaccination requirements
under the Immigration and Nationality Act. For more information, see Centers for Disease Control and Prevention,
Department of Health and Human Services, “Criteria for Vaccination Requirements for U.S. Immigration Purposes,”
74 Federal Register 15986-15987, April 8, 2009.
37 U.S. Department of State Bureau of Consular Affairs, 2008 Report of the Visa Office, Washington , DC, 2009,
Appendix Table XX.
38 INA § 212(g)(2).
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
Ŝȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
˜›ȱ˜ȱ—›¢ȱ˜•’Œ’ŽœȱŠ—ȱ›˜ŒŽž›Žœȱ
From an immigration standpoint, infectious disease outbreaks place notable procedural and
resource pressures on U.S. Customs and Border Protection. The mission of CBP is to protect the
borders of the United States by preventing, preempting, and deterring threats against the U.S.
through ports of entry and by interdicting illegal crossing between ports of entry. CBP’s mission
integrates homeland security, safety, and border management in an effort to ensure that goods and
persons cross the borders of the U.S. in accordance with applicable laws and regulations, while
posing no threat to the country.39 There are 327 official ports of entry in the United States,
including 15 preclearance offices in Canada, Ireland, and the Caribbean. As it performs its official
missions, CBP maintains two overarching and sometimes conflicting goals: increasing security
while facilitating legitimate trade and travel.40 Highlighting this challenge, CBP is charged with
screening admissions at land, sea, and air ports of entry (POE), and CBP Officers screened
approximately 409 million individuals in FY2008 for admissions into the United States, of which
94 million arrived by aircraft.41 In addition to the large demand for inspections, many ports of
entry suffer from staffing shortages, spatial constraints, and a general lack of resources to fully
execute the agency’s mission.42
From CBP’s perspective, the most significant challenge in screening for infectious diseases
comes at the land border. The vast majority of admissions into the United States occur at the land
border, where local and regional economies are dependent upon the movement of goods and
people across the border to maintain economic viability. Even without medical screening or other
special circumstances, land borders can build up inspection lines that are several hours long due
to the high demand for crossings and inadequate infrastructure at most POEs to accommodate
such crossings.
Ž—Ž›Š•ȱȱ›˜ŒŽž›Žœȱ
At official ports of entry, CBP officers are responsible for conducting immigration, customs, and
agricultural inspections on entering aliens.43 In the case of a foreign national being inspected, the

39 The priority of CBP is to prevent terrorists and their weapons from entering the United States, and to support related
homeland security missions affecting border and airspace security. CBP is also responsible for apprehending
individuals attempting to enter the U.S. illegally; stemming the flow of illegal drugs and other contraband; protecting
U.S. agricultural and economic interests from harmful pests and diseases; protecting American businesses from theft of
their intellectual property; regulating and facilitating international trade; collecting import duties; and enforcing U.S.
trade laws. U.S. Congress, House Committee on Appropriations, Department of Homeland Security Appropriations
Bill, 2009
, report to accompany H.R. 6947, 110th Cong., 2nd sess., September 18, 2008, H.Rept. 110-862 (Washington:
GPO, 2008), p. 29.
40 U.S. Customs and Border Protection, Performance and Accountability Report, Fiscal Year 2008, Washington, DC,
December 2008, p. 6.
41 Ibid..
42 For example, see U.S. Government Accountability Office, Various Issues Led to the Termination of the United
States-Canada Shared Border Management Pilot Project
, GAO-08-1038R, September 4, 2008, p. 4.
43 For more information, see CRS Report RS21899, Border Security: Key Agencies and Their Missions, by Chad C.
Haddal. Between official ports of entry, the U.S. Border Patrol (USBP)—a component of CBP—enforces U.S.
immigration law and other federal laws along the border. As currently comprised, the USBP is the uniformed law
enforcement arm of the Department of Homeland Security. Its primary mission is to detect and prevent the entry of
terrorists, weapons of mass destruction, and unauthorized aliens into the country, and to interdict drug smugglers and
other criminals. In the course of discharging its duties the USBP patrols over 8,000 miles of U.S. international borders
(continued...)
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŝȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
officer may ask questions, verify documents and perform various other inspection activities to
determine whether any of the grounds for inadmissibility under the INA applies to the foreign
national. Violators of any of these grounds may be detained, charged, or offered voluntary
removal depending upon the circumstances of a given case.
The CBP Inspector’s Field Manual states that CBP officers are responsible for observing all
travelers for obvious signs and symptoms of quarantinable and communicable diseases, such as
(1) fever, which could be detected by a flushed complexion, shivering, or profuse sweating; (2)
jaundice (unusual yellowing of skin and eyes); (3) respiratory problems, such as severe cough or
difficulty breathing; (4) bleeding from the eyes, nose, gums, or ears or from wounds; and (5)
unexplained weakness or paralysis.44 Additionally, a person is considered to be ill in terms of
foreign quarantine regulations when symptoms meet the following criteria:
1. Temperature of 100 degrees Fahrenheit or greater which is accompanied by one
or more of the following: rash, jaundice, glandular swelling, or which has
persisted for 2 days or more.
2. Diarrhea severe enough to interfere with normal activity or work.45
However, CBP officers are not medically trained or qualified to physically examine or diagnose
illness among arriving travelers.
According to a Government Accountability Office (GAO) report,46 there are three general
scenarios in which CBP officers encounter ill persons who are in need of medical attention or
who may pose a public health threat:
• In the most common scenario, CBP officers encounter an individual who
discloses that he/she needs medical attention for various health reasons.
• CBP officers suspect an individual may need medical attention or may pose a
public health risk to others (e.g., individual exhibits obvious signs and symptoms
of illness, such as fever, weakness, or both, as observed by officers).
• CBP officers encounter an individual who is an exact match to a public health
alert in Treasury Enforcement Communications System (TECS II)47 and may
pose a public health risk to others.

(...continued)
with Mexico and Canada and the coastal waters around Florida and Puerto Rico. For more information on the Border
Patrol, see CRS Report RL32562, Border Security: The Role of the U.S. Border Patrol, by Chad C. Haddal.
44 U.S. Department of Homeland Security, Inspector’s Field Manual, Chapter 17, Section 9, Washington, DC, March
2006.
45 Ibid.
46 U.S. Government Accountability Office, Public Health and Border Security: HHS and DHS should Further
Strengthen Their Ability to Respond to TB Incidents
, GAO-09-58, October 2008, pp. 49-50.
47 TECS II is a computerized information system designed to identify suspected violators of federal law, as well as a
communications system permitting message transmittal between certain Federal, national, state, and local law
enforcement agencies. Immigration inspectors use the Interagency Border Inspections System (IBIS) at ports of entry to
verify and obtain information on aliens presenting themselves for entry into the United States. IBIS is a broad system
that sits on TECS II and interfaces with other databases as well. Because of the numerous systems and databases that
interface with IBIS, the system is able to obtain such information as whether an alien is admissible, an alien’s criminal
information, and whether an alien is wanted by law enforcement.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
Şȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
The GAO report additionally states that in all three scenarios, CBP protocols require officials, at a
minimum, to isolate the person while notifying officials at CDC and, depending on the
circumstance, to contact the designated local public health authorities (e.g., hospitals and
emergency medical personnel).48 Each port of entry, according to GAO, is supplied with personal
protective equipment, including masks and gloves, and inspecting officers must use this
equipment in dealing with travelers suspected of having communicable or quarantinable illnesses,
as well as while handling the individuals’ documents and belongings. CBP officers are
responsible for coordinating with CDC to provide assistance in identifying arriving individuals
from areas with known communicable disease outbreaks.
‘ŽȱŽ—Ž›œȱ˜›ȱ’œŽŠœŽȱ˜—›˜•ȱŠ—ȱ›ŽŸŽ—’˜—ȱ
The Centers for Disease Control and Prevention in HHS take the lead in protection against
communicable diseases and is responsible for providing the technical instructions to civil
surgeons and panel physicians who conduct medical examinations for immigration. CDC officials
are not present at the border on a day-to-day basis, but there are quarantine stations located in a
number of international airports and near a few land ports of entry (for a full list, see Appendix
A
). However, these stations constitute a small fraction of the 327 ports of entry operated by CBP.
As a result, the CDC, through their Division of Global Migration and Quarantine (DGMQ),49 is to
train CBP inspectors to watch for ill persons and items of public health concern.50 CDC is to
approve the physicians used at the ports of entry, and the tests are to be performed in consultation
with and in accordance with CDC guidance. CDC officials are to be stationed at the border during
immigration emergencies and other periods when public health may be threatened. But even
though steps have been taken to fortify ports of entry with medical staff, even fully staffed
quarantine stations are not in a position to perform routine health screening on all passengers
crossing the border as a standard operating procedure.51

48 Ibid. If the incident occurs at a port of entry collocated with a quarantine station, CBP officials are instructed to
notify the CDC official at the quarantine station on-site. However, all ports of entry have access to on-call medical
personnel.
49 The mission of DGMQ is to reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, and
other globally mobile populations, and to prevent the introduction, transmission, and spread of communicable diseases
through regulation, science, research, preparedness, and response. DGMQ is comprised of three branches: the
Quarantine and Border Health Services Branch, the Geographic Medicine and Health Promotion Branch, and the
Immigrant, Refugee, and Migrant Health Branch. Each branch has its own mission that aligns with DGMQ’s
overarching mission. The Quarantine and Border Health Services Branch’s mission is to protect the health of the public
from communicable diseases through science, partnerships and response at U.S. ports of entry. The mission of the
Geographic Medicine and Health Promotion Branch is to characterize the health risks associated with international
travel and develop ways to reduce the associated morbidity and mortality. The mission of the Immigrant, Refugee, and
Migrant Health Branch mission is to promote and improve the health of immigrants, refugees, and migrants, and
prevent the importation of infectious diseases and other conditions of public health significance into the United States
by these groups.
50 According to ExpectMore.gov: “CDC works closely with CBP to train the CBP officers to incorporate these
responsibilities into their daily activities. The quarantine stations rely not only on CBP but also on airline crews and
ship masters to identify ill passengers. Officers of CBP and the U.S. Coast Guard (USCG) have statutory responsibility
“to aid in the enforcement of quarantine rules and regulations.” The CDC Quarantine Stations are technically
responsible for inspecting all imports of animals under their authority to ensure that the animals do not display signs of
communicable disease. In practice, however, this responsibility usually is carried out by CBP veterinary and animal
health inspectors on behalf of the Quarantine Core.”
(http://www.whitehouse.gov/omb/expectmore/detail/10009087.2008.html)
51 Through an interagency agreement between the Department of Health and Human Services and the Department of
Homeland Security, the Division of Immigration Health Services (DIHS) provides healthcare to undocumented
(continued...)
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
şȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
–Ž›Ž—Œ¢ȱ›˜ŒŽž›Žœȱ
When a health-related emergency occurs that impacts travelers entering and exiting the United
States, certain emergency procedures are to be enacted. The National Strategy for Pandemic
Influenza (NSPI) clarifies that: “Lead departments have been identified for the medical response
(Department of Health and Human Services), veterinary response (Department of Agriculture),
international activities (Department of State) and the overall domestic incident management and
Federal coordination (Department of Homeland Security). Each department is responsible for
coordination of all efforts within its authorized mission, and departments are responsible for
developing plans to implement [the NSPI].”52
In practice, should emergency actions be required at the border in response to an outbreak of
disease, there are several steps that CBP may take. Initially, CBP, in conjunction with other
relevant agencies such as CDC, would conduct a risk assessment to determine necessary
procedures as well as the best possible distribution of manpower and other resources to
effectively manage the emergency. One possible step would be to increase its medical screening
at ports of entry. Such a measure would involve working with CDC to bring in medical personnel
that would screen individual travelers at the ports of entry inspection areas.53 Another possible
step would be to increase its stockpiles of antiviral drugs and/or redistribute these drugs to
targeted CBP field offices. Such a redistribution would generally be based upon the risk
assessment conducted by CBP and information provided by the medical community.
Ž•ŽŒȱ˜—Š’˜žœȱ’œŽŠœŽœȱ
Although all diseases carry implications for international travel, a few contagious diseases have
garnered notable public attention. Two of these diseases are discussed in the sections below. The
diseases discussed were selected largely due to the significant congressional attention they
received in the context of immigration policy.54

(...continued)
migrants in the custody of Immigration and Customs Enforcement (ICE) residing in Service Processing Centers (SPC)
and Contract Detention Facilities (CDF). DIHS, however, plays virtually no role in regard to inspection of travelers or
screening of legal immigrants and nonimmigrants. For more information on DIHS, see CRS Report RL34556, Health
Care for Noncitizens in Immigration Detention
, by Alison Siskin.
52 National Strategy for Pandemic Influenza, p. 10.
53 CBP would only implement such a measure under an emergency procedure due to the large amount of medical
resources that would be diverted to ports of entry, the notable slowing of the inspections process that would result, and
the additional pressures it would place on already limited inspection spaces at ports of entry (Testimony of Secretary of
Homeland Security Janet Napalitano in U.S. Congress, Senate Committee on Homeland Security and Governmental
Affairs, Swine Flu: Coordinating the Federal Response, 111th Cong., 1st sess., April 29, 2009, Washington: GPO,
2009). For more information on legal issues related to emergency procedures at the border, see CRS Report R40560,
The 2009 Influenza A(H1N1) Outbreak: Selected Legal Issues, coordinated by Kathleen S. Swendiman and Nancy Lee
Jones.
54 Although each disease received notable public attention, Avian Flu and Severe Acute Respiratory Syndrome (SARS)
are not included in this discussion. These diseases were not included because their impact on the United States was
minimal, the diseases have currently been contained, and each had little or no impact on immigration and port of entry
inspection policies and procedures.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŗŖȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
ŗŗȱ’›žœȱ
On April 29, 2009, the World Health Organization (WHO) raised its influenza (“flu”) pandemic
alert level to Phase 5, one level below declaring that a global influenza pandemic was underway.55
The WHO increased the pandemic flu alert level in response to the spread of a new strain of
influenza A subtype H1N1 virus. The novel flu virus was first identified in two children in
Southern California in late April 2009. Health officials quickly confirmed that many of the
illnesses in Mexico involved the same new flu strain. Since then, a growing number of single or
clustered cases of illness have been identified across the United States, Canada, and several other
countries. As of May 5, 2009, 1,124 cases meeting the WHO criteria for confirmation have been
confirmed in 21 countries in North America, Europe, Asia, and Oceania. These include more than
400 U.S. cases, as well as cases in multiple states in Mexico and provinces in Canada. The
majority of the WHO confirmed cases are in Mexico, the United States, and Canada.56
The global spread of this virus is attributable to transnational travel of individuals infected in a
source country and the subsequent infection of other individuals in the arriving country. CBP
officers have been instructed to conduct “passive lookouts” for individuals exhibiting symptoms
of illness. However, medical questioning or thermal scanning for elevated body temperature of all
passengers is not being conducted (as is the case in countries such as Australia).57 However, in
response to the outbreak, CDC issued a notice on April 27, 2009, recommending that American
citizens avoid all nonessential travel to Mexico.58
The H1N1 outbreak has prompted federal agencies to conduct response and mitigation actions.
CDC reported that as of May 1, 2009, supplies from CDC’s Division of the Strategic National
Stockpile (SNS) were being sent to all 50 states and U.S. territories to help them respond to the
outbreak. Secretary of Homeland Security, Janet Napalitano, stated on April 30, 2009, that the
Federal Government had stockpiled 50 million courses of two types of antiviral drugs—Tamiflu
and Relenza. These stockpiles were in addition to the states’ stockpiles of 23 million courses and
the Department of Defense stockpiles numbering in the millions. The Secretary also stated that
antiviral courses from the national stockpiles were being moved to states that have confirmed
incidents of the virus.59 CDC also reported that the Federal Government and manufacturers have
begun the process of developing a vaccine against this new virus.60 Moreover, gloves and masks
and other similar equipment were being provided to employees at ports of entry. President Obama

55 According to WHO, “the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to
finalize the organization, communication, and implementation of the planned mitigation measures is short.” (World
Health Organization (WHO), Pandemic Influenza Preparedness and Response: A WHO Guidance Document, April
2009, p. 32, http://www.who.int/csr/disease/influenza/pipguidance2009/en/index.html)
56 For additional and updated information, see CRS Report R40554, The 2009 Influenza A(H1N1) “Swine Flu”
Outbreak: An Overview
, by Sarah A. Lister and C. Stephen Redhead.
57 HSDailyWire.com, Airport Flu Scanners as Global Health Alert Increases, May 1, 2009,
http://hsdailywire.com/single.php?id=7885.
58 U.S. Department of State, “Travel Alert: 2009 H1N1 Influenza,” press release, April 28, 2009,
http://travel.state.gov/travel/cis_pa_tw/pa/pa_3028.html.
59 U.S. Department of Homeland Security, “Remarks by Secretary Napolitano at Today’s Media Briefing on the H1N1
Flu Outbreak,” press release, April 30, 2009, http://www.dhs.gov/ynews/releases/pr_1241140344050.shtm.
60 Centers for Disease Control and Prevention website, available at http://www.cdc.gov/h1n1flu/.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŗŗȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
has requested $1.5 billion in supplemental funding from Congress to aid the response to the H
1N1 virus outbreak.61
˜›Ž›ȱ•˜œ’—ȱ
Some critics of the Administration’s current approach to the handling of the H1N1 flu outbreak
have called for DHS to consider closing the border between the United States and Mexico in
order to prevent the continuing spread from the source country.62 Both the President and the
Secretary of Homeland Security have rejected this proposed course of action, noting that
circumstances do not warrant such a response. The Administration generally has contended that a
border closure would not achieve its intended purpose since the virus has already spread to the
United States. Moreover, when asked what types of conditions related to the H1N1 flu virus
would warrant closing the border, the interim Deputy Director for Science and Public Health at
the Centers for Disease Control and Prevention, Rear Admiral Anne Schuchat, testified: “I don’t
think there are any.”63 These general positions were reiterated by the Secretary of Homeland
Security at a press conference on April 30, 2009.64 Thus, it seems unlikely that the Administration
would consider closing the border due to the spread of the H1N1 virus.65
Closing the United States border with Mexico would be a massive logistical undertaking that
most experts believe would cause “economic devastation,” particularly in the southwest United
States. According to the U.S. Department of Commerce, in 2008 Mexico was the second largest
export market for U.S. goods ($151.5 billion) and the third largest import market ($215.9
billion).66 GAO reported that legitimate travel between the United States and Mexico contributes
to over $1 billion in bilateral trade on a daily basis.67 In practical terms, such action would
necessitate CBP shifting its non-essential personnel to support law-enforcement functions in the
Southwest. The Federal Aviation Administration, the U.S. Coast guard, and numerous other
agencies would have to be called upon to coordinate air and sea traffic and prevent any incoming
traffic that originated in Mexico. Additionally, national guard troops might be called upon to
assist in controlling the 1,933-mile-long land border to prevent surreptitious crossings and
maintain law and order. Due to the large number of resources such an effort would require, the
manpower and equipment to perform these functions would be partially drawn from other border
areas and ports of entry. This shift would likely have a negative effect on the flow of commerce,
as well as create increased security risks. Thus, there is a strong probability that closing the
border to Mexico would have a detrimental impact on travelers from other countries arriving at
ports of entry outside the southwest United States.

61 Liz Robbins and Donald G. McNeil Jr, “Asking for More Funding, U.S. Steps Up Flu Response,” The New York
Times
, April 29, 2009, sec. Health, http://www.nytimes.com/2009/04/29/health/29flu.html?_r=1&ref=politics.
62 Comments of Sen. John McCain in U.S. Congress, Senate Committee on Homeland Security and Governmental
Affairs, Swine Flu: Coordinating the Federal Response, 111th Cong., 1st sess., April 29, 2009 (Washington: GPO,
2009).
63 Kasie Hunt, “Homeland Secretary Sees No Reason to Close Border with Mexico,” CongressDaily, April 29, 2009.
64 U.S. Department of Homeland Security, “Remarks by Secretary Napolitano at Today’s Media Briefing on the H1N1
Flu Outbreak,” press release, April 30, 2009, http://www.dhs.gov/ynews/releases/pr_1241140344050.shtm.
65 For legal issues related to closing the border, see CRS Report R40560, The 2009 Influenza A(H1N1) Outbreak:
Selected Legal Issues
, coordinated by Kathleen S. Swendiman and Nancy Lee Jones.
66 U.S. Department of Commerce (2008).
67 U.S. Government Accountability Office, Border Security: State Department is Taking Steps to Meet Projected Surge
in Demand for Visas and Passports in Mexico
, GAO-08-1006, July 2008, p. 1.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŗŘȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
ž‹Ž›Œž•˜œ’œȱǻǼȱ
In recent years, tuberculosis (TB) has prompted greater concerns with health and screening
officials in the United States, due in part to the development of drug resistant strains of the
disease.68 These developments have caused agencies such as the CDC to implement instructions
and preparedness plans for screening and handling travelers to the United States infected with TB.
Additional concerns were raised in Spring 2007 when two individuals with drug-resistant TB
disease were requested flagged by HHS for CBP interdiction. Despite this call for interdiction,
both individuals were able to enter the United States through ports of entry. These incidents
resulted in a reassessment of federal coordination and response regarding TB and other
contagious diseases.69 Despite renewed efforts by federal agencies, TB remains an ongoing public
health threat from foreign travelers.
The majority (57%) of tuberculosis cases diagnosed in the United States are diagnosed in persons
born outside the United States.70 It is not clear, however, what percentage of this population
would have been symptomatic of the disease at the time of their arrival at a port of entry. An
estimated 2 billion people—one-third of the world’s population—are infected with
Mycobacterium (M.) tuberculosis, the bacterium that causes TB, approximately 9 million of
whom have transmissible TB disease.71 Medical screening for tuberculosis is legally required of
refugees and applicants of U.S. immigration in order to receive a visa and enter the United States.
However, CBP does not currently have any special provisions outside of its general procedures
for TB screening at ports of entry.


68 For more information on tuberculosis, see CRS Report RL34144, Extensively Drug-Resistant Tuberculosis (XDR-
TB): Emerging Public Health Threats and Quarantine and Isolation
, by Kathleen S. Swendiman and Nancy Lee Jones.
69 According to a GAO report: “In the spring of 2007, HHS requested DHS’s assistance in attempting to interdict at the
border two individuals with drug-resistant TB disease so that they could direct them to treatment. According to HHS
documents, in May 2007, one of these individuals, a U.S. citizen, traveled abroad against advice from physicians.
When state and local health officials were unable to find this person and serve him with a written order not to travel,
they requested help from HHS. While he was traveling abroad, HHS located him and attempted to direct him to
treatment. HHS then contacted DHS for assistance. However, while HHS and DHS were determining a course of action
to attempt to prevent him from traveling further by airplane, he once again traveled. Furthermore, as the departments
were working to intercept him at the U.S. border, he was able to reenter the country because a U.S. Customs and
Border Protection (CBP) officer, in violation of CBP policy, ignored a computerized alert in CBP’s border screening
and inspection system to detain him. In a separate incident, a Mexican citizen with drug-resistant TB who had a prior
history of nonadherence to treatment crossed the U.S.-Mexico border approximately 20 times during April and May
2007. HHS and DHS worked together to try to prevent him from crossing the border, but attempts to identify him in
DHS databases failed on several occasions. According to HHS officials, both individuals were eventually located and
received treatment, and none of the people who might have been in contact with these individuals were reported to have
contracted TB.”(U.S. Government Accountability Office, Public Health and Border Security: HHS and DHS Should
Further Strengthen Their Ability to Respond to TB Incidents, GAO-09-58, October 2008, p. 2-3).
70 Information available at ExpectMore.gov, http://www.whitehouse.gov/omb/expectmore/detail/10009087.2008.html.
71 U.S. Government Accountability Office, Public Health and Border Security: HHS and DHS Should Further
Strengthen Their Ability to Respond to TB Incidents
, GAO-09-58, October 2008, p. 1.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŗřȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ
™™Ž—’¡ȱǯ ȱžŠ›Š—’—ŽȱŠ’˜—œȱ
Table A-1. CDC Quarantine Stations by City and Location
City Location
Anchorage, AK
Ted Stevens Anchorage International Airport
Atlanta, GA
Hartsfield-Jackson Atlanta International Airport
Boston, MA
Logan International Airport
Chicago, IL
O'Hare International Airport
Dallas/Ft. Worth, TX
Dallas/Ft. Worth International Airport
Detroit, MI
Detroit Metro Airport
El Paso, TX
CDC El Paso Quarantine Station
Honolulu, HI
Honolulu International Airport
Houston, TX
George Bush Intercontinental Airport
Los Angeles, CA
Los Angeles International Airport
Miami, FL
Miami International Airport
Minneapolis, MN
Minneapolis-St. Paul International Airport
Newark, NJ
Newark Liberty International Airport
New York, NY
John F. Kennedy International Airport
Philadelphia, PA
Philadelphia International Airport
San Diego, CA
CDC San Diego Quarantine Station
San Francisco, CA
San Francisco International Airport
San Juan, PR
Luis Muñoz Marin International Airport
Seattle, WA
Seattle-Tacoma International Airport
Washington, DC
Dulles International Airport
Source: CRS presentation of information posted on CDC website, available at http://www.cdc.gov/ncidod/dq/
quarantine_stations.htm.
Notes: Information is current as of May 1, 2009.

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ŗŚȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
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™™Ž—’¡ȱǯ ȱŽŒ‘—’ŒŠ•ȱ ž’Š—ŒŽȱ
As previously discussed, policies and procedures established over the years by the CDC spell out
the obligations of the physicians who are designated to conduct the medical examination to meet
the statutory requirements of the INA. According to the CDC’s technical guidance72 for the
physicians performing the medical examination, they are required to make the following
assessments of the foreign nationals seeking visas:
• a medical history, obtained by the civil surgeon or a member of the physician’s
professional staff, from the applicant (preferably) or a family member, which
includes: 1) a review of all hospitalizations; 2) a review of all institutionalizations
for chronic conditions (physical or mental); 3) a review of all illnesses or
disabilities resulting in a substantial departure from a normal state of well-being
or level of functioning; 4) specific questions about psychoactive drug and alcohol
use, history of harmful behavior, and history of psychiatric illness not
documented in the medical records reviewed; and, 5) a review of chest
radiographs and treatment records if the alien has a history suggestive of
tuberculosis.
• a review of any other records that are available to the physician (e.g., police,
military, school, or employment) that may help to determine a history of harmful
behavior related to a physical or mental disorder and to determine whether
illnesses or disabilities are present that result in a substantial departure from a
normal state of well-being or level of functioning.
• a review of systems sufficient to assist in determining the presence and the
severity of Class A or Class B conditions. The physician should ask specifically
about symptoms that suggest cardiovascular, pulmonary, musculoskeletal, and
neuropsychiatric disorders. Symptoms suggestive of infection with any of the
excludable communicable diseases (tuberculosis, HIV infection, syphilis,
chancroid, gonorrhea, granuloma inguinale, lymphogranuloma venereum, and
Hansen’s disease) should also be sought.
• a physical examination, including an evaluation of mental status, sufficient to
permit a determination of the presence and the severity of Class A and Class B
conditions. The physical examination is to include 1) a mental status examination
that includes, at a minimum, assessment of intelligence, thought, cognition
(comprehension), judgment, affect (and mood), and behavior.
• a physical examination that includes, at a minimum, examination of the eyes,
ears, nose and throat, extremities, heart, lungs, abdomen, lymph nodes, skin and
external genitalia.
• all diagnostic tests required for the diagnosis of the diseases identified as
communicable diseases of public health significance and other tests identified as
necessary to confirm a suspected diagnosis of any other Class A or Class B
condition.

72 U.S. Department of Health and Human Services Centers for Disease Control, Technical Instructions for Medical
Examination of Aliens
, June 12, 1991, as revised in July 1992.
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ŗśȱ

––’›Š’˜—ȱ˜•’Œ’ŽœȱŠ—ȱ œœžŽœȱ˜—ȱ ŽŠ•‘ȬŽ•ŠŽȱ ›˜ž—œȱ˜›ȱ¡Œ•žœ’˜—ȱ
ȱ

ž‘˜›ȱ˜—ŠŒȱ —˜›–Š’˜—ȱ

Chad C. Haddal
Ruth Ellen Wasem
Analyst in Immigration Policy
Specialist in Immigration Policy
chaddal@crs.loc.gov, 7-3701
rwasem@crs.loc.gov, 7-7342






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