Vaccination Requirements

and Form I-693

Mary Naughton, MD, MPH

Immigrant, Refugee and Migrant Health Branch (IRMH)
Division of Global Migration and Quarantine (DGMQ)
National Center for Emerging and Zoonotic Infectious Diseases
U.S. Centers for Disease Control and Prevention
Atlanta, Georgia
cdcqap@cdc.gov

National Center for Emerging and Zoonotic Infectious Diseases

Division of Global Migration and Quarantine
 Outline

 Legal requirement for immigrant vaccination

 Process to determine which vaccines each
applicant must show proof of having received
 “Recent” changes
 Influenza vaccine types
 Pneumococcal vaccination for applicants ≥ 65 years
of age more complex
 Special populations
 References and contact information
 Objectives
 Know algorithm for selecting and ordering age-
appropriate vaccines for adjustment of status applicants

 Recall basic knowledge about 3 types of influenza

vaccine

 Demonstrate basic familiarity with new pneumococcal

vaccine requirements for applicants ≥ 65 years of age

 Explain how refugees and K-visa holders differ from

other applicants presenting for an adjustment of status
exam
 Vaccination Requirements for U.S.
Immigration: 1996
 The U.S. Congress amended the Immigration and
Nationality Act (INA) by adding to the health-related
grounds of inadmissibility Proof of Vaccination
Requirements for Immigrants

 Any person who seeks an immigrant visa or adjustment

of status for permanent residence must show proof of
having received vaccination against vaccine-preventable
diseases
 As recommended by the Advisory Committee for
Immunization Practices (ACIP)
 Prior to December 14, 2009
Required Vaccinations

According to the INA, immigrants were

required to show proof of having received all
vaccinations that the ACIP recommended for
persons living in the United States
 2009 Vaccination Criteria
The vaccine must be an age-appropriate
vaccine recommended by the ACIP for the
general U.S. population, AND for vaccines not
named in the INA:
The vaccine must protect against a
disease that has the potential to
cause an outbreak
At least one
of the The vaccine must protect against a
following: disease that has been eliminated in
the U.S. OR is in the process of
elimination in the U.S.
 Required Age-appropriate Vaccines
for Applicants Adjusting Status

 Diphtheria, tetanus,  Hepatitis A

pertussis*  Hepatitis B*
 Polio*  Meningococcal
 Measles, mumps, rubella*  Varicella
 Rotavirus  Pneumococcal
 Haemophilus influenzae  Influenza**
type B**
Note: List does not include
herpes zoster or human
* Named in the INA papillomavirus vaccine
** INA states “influenza type B”
 Classification of Vaccines
Live Attenuated
 Measles, mumps,  Rotavirus
rubella  Varicella
 Oral polio (OPV)  Intranasal influenza

Inactivated
 Diphtheria, tetanus, pertussis  Hepatitis B
 Polio (IPV)  Meningococcal
 Haemophilus influenzae type B  Pneumococcal
 Hepatitis A  Influenza
 Components of Vaccination Evaluation

 Fraud prevention measures

 Verify identity of applicant
 Review previous vaccination records (if available)
• Self-reported vaccine doses NOT acceptable
• Check records for evidence of fraud

 Knowledge of Vaccination TI
 Age-appropriate vaccines
 Contraindications and precautions
 Decision Process for Determining
Applicant’s Vaccination Needs

 Determine age

 Review medical history and vaccination records

 Review TI Vaccination Table to determine the vaccines for 
which the applicant is required to show proof of vaccination

 Review ACIP schedule and read footnotes for age‐
appropriate required vaccines
 Contraindications, precautions, and catch‐up doses

 Assess laboratory needs
Vaccination Table in
2009 Vaccination
Technical
Instructions
for Civil Surgeons

Adapted from ACIP

recommendations

Must be used in conjunction with

current ACIP schedules
ACIP-recommended Immunization Schedule for Persons
Aged 0 through 18 years – United States, 2016
 Color-coding of Immunization Schedules

 Yellow — range of recommended ages for all persons

 Green — range of recommended ages for catch-up

 Purple — range of recommended ages for certain

high-risk groups

 Blue — not applicable to civil surgeon exam*

 White — no recommendation

*Not official name of category (blue category applies only to meningococcal vaccine)
 Which colored bars on the ACIP
schedule must the civil surgeon use
when assessing the vaccination needs
of adjustment of status applicants?
Which colored bars on the ACIP schedule must
the civil surgeon use when assessing the
vaccination needs of adjustment of status
applicants?

Answer:

Yellow-- range of recommended ages for all persons

Green-- range of recommended ages for catch-up

 How to Use the ACIP Schedules
for the Adjustment of Status Examination

 On the ACIP schedule
 Find the age range (column) of the applicant

 For each vaccine (row) that is age‐appropriate on the TI 
Vaccination Table, identify which vaccines have a
 Yellow bar (all persons) in the applicant’s age range or  a
 Green bar (catch‐up vaccination) in the applicant’s age 
range 
 Continue process to determine if these vaccines should be 
administered
 How to Use the ACIP Schedules
for the Adjustment of Status Examination, Cont’d.

 Do not require applicant to receive vaccine if, for 
applicant’s age, bar is purple on the ACIP schedule, 
which means administer only if applicant has a high‐
risk indication
May recommend vaccine to applicant if applicant falls into 
risk category, but do not require administration of, or 
payment for, vaccination as part of the adjustment of 
status examination
ACIP-recommended Immunization Schedule for Persons
Aged 0 through 18 years – United States, 2016
ACIP-recommended Adult Immunization
Schedule – United States, 2016
Adult Immunization
Schedule Footnotes
 CDC Vaccine Schedules
(Child and Adult) App

http://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html
 Vaccine Contraindications
Any vaccine Severe allergic reaction

Live-attenuated
vaccines
Pregnancy* and severely
• MMR** immunocompromised conditions
• Varicella
• Intranasal
influenza (LAIV)
Encephalopathy within 7 days of
Pertussis pertussis vaccination

*See www.cdc.gov/vaccines/pubs/preg-guide.htm
**Should avoid becoming pregnant for 4 weeks after vaccination
Not Contraindications to Vaccine Administration

 Mild-to-moderate local reactions to previous dose of

vaccine
 Mild acute illness (e.g., low-grade fever, upper
respiratory infection, diarrhea)
 Recovering from illness
 Antimicrobial therapy
 Tuberculin skin test*

*All vaccines can be given on the same day as a TST or any time after
TST is applied. If MMR, varicella, or live-attenuated (intranasal)
influenza vaccine is administered before TST, at least 4 weeks is
recommended before giving TST.
 Not Contraindications
to Vaccine Administration, Cont’d.
 Pregnant or immunosuppressed persons in the
household*
 Breastfeeding, for vaccines required for civil
surgeon exam
 Preterm birth
 Family history of adverse events
*Health care workers who care for severely immunocompromised
persons who are isolated because of immunocompromise, should
NOT receive live-attenuated influenza vaccine (LAIV). If the workers
receive LAIV, they should refrain from care of severely
immunocompromised persons for 7 days.
 Vaccine Precautions
 Any vaccine
 Moderate or severe acute illness (e.g., high-grade
fever)

 Td/Tdap, meningococcal, and influenza vaccines

 Prior Guillain-Barré syndrome

 Rotavirus vaccine
 Prior intussusception
 Rhesus-based vaccine associated with
intussusception in 1999 no longer on market
 Vaccine Precautions, Cont’d.
 DTP/DTap vaccine
Any of the following after a previous dose of DTP/DTap
vaccine
 Fever of 40.5oC (105oF) or higher within 48 hours
 Persistent crying for >3 hours within 48 hours
 Convulsions w/ or w/o fever within 3 days

 If a vaccine is not administered due to a

precaution, mark “contraindicated” on DS-3025
form
Adverse Reactions After Vaccination

Local Systemic
 Pain, swelling,  Fever, malaise,
redness at headache
injection site  Nonspecific
 Common with  May be
inactivated unrelated to
vaccines vaccine
 Usually mild
and self-limited
 Spacing of Live* Vaccines
 If live vaccines are not given simultaneously, they
must be spaced apart by at least 4 weeks

 May arise if applicant has recently been vaccinated

elsewhere with any live parenteral vaccine or LAIV

 If live vaccine not given because time interval < 4

weeks, mark “insufficient time interval” on I-693 form
 Also mark “insufficient time interval” on I-693 form if
vaccine series not completed at the time of the civil
surgeon examination

* Parenteral vaccine or live attenuated influenza vaccine (intranasal)

 Vaccines: Practical Issues

 Only one dose of each vaccine series is required

for adjustment of status examination

 OK to give multiple simultaneous vaccines

 No maximum number of vaccines per visit
 Use separate body sites
 No mixing in same syringe unless licensed for such
 Vaccines: Practical Issues, Cont’d.
 Form I-693
 Every row should have at least one check mark
 Physician should not sign until after vaccines are
administered

 Almost every applicant will require a blanket

waiver
 Influenza Vaccine
The Vaccination Technical Instructions and
Updates for Civil Surgeons require immigrant
applicants of which age group(s) to show proof of
having received influenza vaccine?

a. 6 months -18 years

b. 50 years of age and older
c. 6 months -18 years; 50 years of age and older
d. 65 years of age and older
e. 6 months of age and older
Can influenza vaccine be given
to persons with an egg allergy?
 Yes!

• Which types?
– Inactivated influenza vaccine (IIV) if “hives-
only” allergy
– Recombinant influenza vaccine (RIV)
 Footnotes: Influenza Vaccination
if Egg Allergy
• Persons aged 6 months or older, including pregnant
women and persons with a hives-only allergy to eggs,
can receive the inactivated influenza vaccine (IIV). An
age-appropriate IIV formulation should be used.

• Adults aged 18 to 49 years can receive the

recombinant influenza vaccine (RIV) (FluBlok). RIV
does not contain any egg protein.
 Matching Influenza Vaccine Types
A. Inactivated influenza vaccine (IIV)
B. Live-attenuated influenza vaccine (LAIV)
C. Recombinant influenza vaccine(RIV)

Does not contain egg

_ Appropriate for persons 2 through 49 years of age only
Appropriate for persons 6 months of age and older
Should not be administered to persons under 18 years old

Should not be administered if a child 2 through 17 years of

age is taking aspirin or an aspirin-containing product
Should not be administered if there is a history of
asthma or wheezing in a child aged 2 through 4 years of age
Influenza Vaccine Types: READ FOOTNOTES
 Inactivated influenza vaccine (IIV)
 Injectable
 Appropriate for persons 6 months of age and older

 Live-attenuated influenza vaccine (LAIV)

 Intranasal
 Appropriate for healthy, non-pregnant persons 2 through 49
years of age only
 Multiple contraindications and precautions

 Recombinant influenza vaccine (RIV)

 Injectable
 Appropriate for persons 18 years of age and older
 No egg protein
 Pneumococcal Vaccination for Applicants
≥ 65 Years of Age: READ ALL FOOTNOTES

 Types
 PCV-13 = Pneumococcal conjugate vaccine
 PPSV-23 = Pneumococcal polysaccharide vaccine

 ACIP now recommends administering one dose of PCV-13 in

addition to one dose PPSV-23, at or after age 65 (but cannot
give PCV-13 and PPSV-23 simultaneously)

 Applicants ≥ 65 years old are required to show proof of

vaccination with one dose of at least one of the two vaccines,
administered at or after age 65
 Pneumococcal Vaccination for Applicants
≥ 65 Years of Age: READ ALL FOOTNOTES, Cont’d.

 If documentation of both vaccines lacking, give PCV-13

 PCV-13 and PPSV-23 administration must be separated

by 1 year
 If one year has not elapsed, mark “insufficient time interval” on
Form I-693 and comment in “Remarks”

 PPSV-23 doses must be separated by 5 years

 Applies if previous PPSV-23 dose(s) given before age 65
• If received PCV-13 at or after age 65 and is not yet 5 years from
previous PPSV-23 dose, mark “insufficient time interval” for
PPSV-23 on Form I-693 and comment in “Remarks”
Vaccination Record of I-693 Form
 Vaccination Record of I-693 Form
 If any of the boxes under “Not Medically
Appropriate” are checked, the first box below
must be checked
 Vaccination Record of I-693 Form
 If the applicant requires but refuses vaccines,
and therefore cannot show proof of vaccination,
the last box below must be checked

 This applicant is inadmissible (Class A)

 Vaccination Waivers
 Blanket waiver categories (no application)
 Not age appropriate
 Contraindicated
 Insufficient time interval
 Not fall (flu) season (influenza vaccine only)

 Individual waiver categories (requires

application)
 Religious conviction regarding all vaccines
 Moral conviction regarding all vaccines
 Applicant Education and Record

 Applicant education
 If a vaccine series is incomplete, advise to complete series
with another provider (series completion not necessary to
sign Form I-693)

 Provision of records
 Provide copy of Vaccination Record directly to each
applicant
• Original record goes to USCIS
• Applicant needs own copy for school or other requirements
o Prevents needless re-vaccination

o Prevents repeat record requests

 Refugees
 Refugees not required to receive vaccines
during panel physician examination abroad

 However, many refugees now undergo

vaccination abroad
 Voluntary
 Using ACIP schedules
 Guidelines differ from Vaccination TI (requirements) for
• Civil Surgeons
• Panel Physicians
 Second doses are often given abroad
 Refugees, Cont’d.

 Only refugees entering the United States with a

Class A condition (with waiver) are required to
undergo a repeat immigration medical exam with
a civil surgeon

 Refugees usually vaccinated by health

departments, blanket designated as a civil
surgeon by USCIS for refugee vaccination
alone, but you may encounter in your
practice
 K Visa Applicants (Nonimmigrants)

 K Visa applicants
 Fiancé or spouse of U.S. citizen
 Children of fiancé or spouse of U.S. citizen

 May receive vaccines abroad or civil surgeon

may need to administer as part of the
adjustment of status exam in the United States

 Must fulfill requirement of showing proof of

vaccination in order to adjust status
Vaccines: References
 2009 Technical
Instructions for
Vaccination for Civil
Surgeons
 http://www.cdc.gov/immigran
trefugeehealth/exams/ti/civil/
vaccination-civil-technical-
instructions.html

 ACIP Vaccination
Schedules for Health
Care Professionals
 http://www.cdc.gov/vaccin
es/schedules/hcp/index.ht
ml
Vaccines: References, Cont’d.

 CDC Pink Book

Epidemiology and
Prevention of Vaccine-
Preventable Diseases
www.cdc.gov/vaccines/Pubs/
pinkbook/
13th Edition (2015)

 Vaccination guidelines for

pregnant women
www.cdc.gov/vaccines/pubs/
preg-guide.htm
 How Civil Surgeons
Can Contact CDC
 Email address: cdcqap@cdc.gov

 CDC answers inquiries about Technical Instructions

 CDC is not able to answer questions about

• Form I-693, except specific medical or classification
questions

• Becoming a civil surgeon (civil surgeon designation)

and Form I-910 (USCIS)
 Thank You

Questions?

For more information please contact Centers for Disease Control and
Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.

National Center for Emerging and Zoonotic Infectious Diseases

Division of Global Migration and Quarantine
Vaccine Administration Area