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Afghan Clinical Guidance
Center of Excellence in Newcomer Health
Background
In August 2021, the Department of Homeland Security (DHS) led Operation Allies Welcome (OAW), an initiative to resettle Afghans to the United States (U.S.) who were evacuated after the fall of the Afghan government. In Phase 1 of OAW, Afghans were initially evacuated to transit locations overseas and then to eight military bases in the U.S., called “safe havens”. Evacuees had varying immigration statuses which included Humanitarian Parolee and Special Immigration Visa holder (SIV). By March 2022, Afghan nationals living at safe havens were resettled to states across the U.S., and the safe haven sites in the US closed. This marked the end of OAW Phase 1, during which 74,190 Afghans were resettled to the U.S. (OIG-22-78: The DHS Unified Coordination Group for Operation Allies Welcome Coordinated Afghan Resettlement but Faced Challenges in Funding and Authority).
Phase 2 of OAW took place from February to September 2022. During Phase 2, Afghans applied from overseas to come to the U.S. through the SIV program or the US Refugee Admissions Program (USRAP). Afghans resettled through these pathways traveled directly to their new locations of residence and were supported by resettlement agencies: Afghan Arrivals under the U.S. Refugee Admissions Program.
Starting in September 2022, people from Afghanistan have been welcomed to the U.S. as part of Operation Enduring Welcome (OEW): Afghan Arrivals under Enduring Welcome. Most arrivals coming through OEW have SIV holder or refugee status and are traveling directly from overseas transit sites where their immigration processing and overseas medical examinations take place. Overseas medical examination information is available via the CDC’s Electronic Disease Notification system (EDN) for these newcomers.
The arrival pathway of Afghan newcomers impacts whether they completed pre-arrival immigration medical screenings and received overseas vaccinations. These statuses also affect post-arrival health requirements, benefits eligibility, and pathways to permanent residency (Table 1). For benefits eligibility, including for the domestic medical exam, refer to Table 2.
- Afghan Arrivals under the U.S. Refugee Admissions Program
Refer to Afghan Arrivals under Enduring Welcome section. - CDC: Dear colleague letter (March): OAW Phase 2 medical examinations (PDF)
Update on the Phase 2 Afghan newcomers arriving from overseas and medical examinations; Mar. 28, 2022. - DHS: Operations Allies Welcome
Benefits and eligibility
Afghan Humanitarian Parolees arriving after 09/30/2023 are no longer eligible for Office of Refugee Resettlement benefits, including the domestic medical exam, unless they meet family reunification criteria. Details about benefit eligibility may be found in the following links.
- HHS Office of Refugee Resettlement: Afghan Assistance Resources
- Afghan Humanitarian Parolees and Unaccompanied Afghan Minors Eligible for ORR Benefits and Services: Policy Letter 22-01 (PDF)
Benefit eligibility is complex. Please review the policy letters referenced in the table for details and clarification.
| Immigration Status | Medical screening requirement prior to resettlement | Vaccination requirement prior to resettlement | Eligible for ORR-funded benefits* | Civil surgeon and form I-693 required for adjustment of status |
|---|---|---|---|---|
| Refugee | Overseas, per CDC Technical Instructions, CDC: Overseas Refugee Health Guidance | Vaccination Program for U.S.-bound Refugees and Visa 93 Applicants | Yes | Yes, at time of adjustment of status to lawful permanent resident I-693 may be completed by health department as blanket designated civil surgeon. |
| SIV (granted overseas) | Overseas, per CDC Technical Instructions, CDC: Overseas Refugee Health Guidance | Vaccination Program for U.S.-bound Refugees and Visa 93 Applicants | Yes | N/A – this exam is completed pre-arrival for SIV applicants. |
| SIV (applying from within the U.S.) | On US Safe Haven (military bases) between August 2021 to March 20223:
| On U.S. Safe Haven between August 2021 to March 2022: Vaccination with MMR, Varicella, IPV, COVID-19 vaccination and age-appropriate vaccines, as available | Yes | Yes, if requested by USCIS. NOTE: exam must be completed by a designated civil surgeon NOT a health department with blanket designation. If applicant had a completed form I-693 from a U.S. military base, this form is valid for 2 years from date of civil surgeon signature |
| Afghan Humanitarian Parolee | On U.S. military bases between August 2021 and March 20223:
| On U.S. Safe Haven between August 2021 to March 2022: Vaccination with MMR, Varicella, IPV, COVID-19 vaccination and age-appropriate vaccines, as available | Maybe. Refer to ORR's DCL 24-01 to determine eligibility | No, Afghan Humanitarian Parole status does not currently provide a pathway to lawful permanent residency. In May 2023, DHS announced a pathway to re-parole eligible Afghan nationals: DHS Announces Upcoming Re-parole Process for Afghan Nationals. Individuals granted humanitarian parole may apply for another status. |
| Asylee | No | No | Yes | Yes, at the time of adjustment of status to lawful permanent resident |
| Temporary Protected Status (TPS) | No | No | No | No, TPS status does not provide a pathway to lawful permanent residency. Individuals granted TPS may apply for another status. |
*Includes medical assistance if other eligibility requirements met, including income and residency. If not eligible for Office of Refugee Resettlement (ORR) benefits, please refer to county services for assistance in applying to other benefits.
1 Individuals who resettle through Operation Allies Welcome may have a combination of statuses including: SIV (completed overseas), SIV (applying within the US), Afghan Humanitarian Parolee, Asylee and Temporary Protected Status.
2 Individuals who resettle through Operation Enduring Welcome may have a combination of statuses including: SIV (completed overseas), refugees, and asylees.
3 The medical screening requirement at the US safe havens was implemented at each base individually so there may be variation in the dates of implementation or completeness.
| Afghan Parolee Status | ORR Eligibility Requirements |
|---|---|
| PRIMARY: Afghan Parolee |
|
| RELATIVE: Spouse or child of Afghan Parolee |
|
| RELATIVE: Parent or legal guardian of unaccompanied child |
|
Brief overview for clinicians caring for Afghan new arrivals
Best practices and cultural considerations
Proper use of a medical interpreter is essential
Preferred languages among Afghan evacuees include Dari or Pashto (unrelated to Dari and Farsi). Less common languages include English, Hazaragi (related to Farsi), Uzbek, and others. Dari and Farsi are dialects of the Persian language; however, patients who speak Dari may or may not understand Farsi depending on their region of origin and education. Even within Afghanistan, there is regional variation in vocabulary and accent in each of these languages. Orienting interpreters to a family’s or individual’s city/province of origin can improve communication. Refer to the Translators Without Borders: Farsi and Dari Language Factsheet (PDF) for more information.
Cultural background resources
- Afghan Refugee and Humanitarian Parolee Health Profile
History, cultural beliefs, health concerns and priorities, health care and access, and more to consider when caring for or assisting Afghan refugees and humanitarian parolees. - Afghan Health Initiative
- Cultural Orientation Resource Exchange: Afghan Backgrounder
Introductory information about sponsorship, refugee populations, and resources to use with newcomers. - Center of Excellence in Newcomer Health: Afghan newcomers
- NIH: Recently arrived Afghan Refugee Parents' Perspectives About Parenting, Education and Pediatric Medical and Mental Health Care Services
Potential health conditions
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Condition-specific guidance
- AAP: Blood Lead Levels Among Afghan Children in the US 2014-2016
- Afghan Evacuees Health Resources: Medical FAQs for Health Care Providers
Cholera, COVID, diphtheria, leishmaniasis, lice, malaria, measles, pertussis, polio, scabies, typhoid, varicella and behavioral health - Center of Excellence in Newcomer Health: Webinars
Webinars recorded with Afghan topics- Afghan Humanitarian Arrivals: Leishmaniasis and Malaria
- Afghan Arrivals: Pre- and post-natal care
- Afghan Humanitarian Arrivals: Post resettlement stressors, coping strategies, and the Afghan Symptom Checklist
- Strategies for responding to the psychosocial needs of Afghan communities
- Guidelines on Maternal Lead Screening for Immigrants and Refugee
- ECCMID research highlights diptheria outbreaks among migrants in Europe
Health screening and care
- CareRef: Clinical Assessment for Refugees
CareRef is a tool that guides clinicians through conducting a routine post-arrival medical screening of a newly arrived refugee to the U.S. The output of this tool is based on the current CDC Domestic Refugee Screening Guidance. CareRef recommends screening tests and other preventive care based on the demographic and geographic factors that contribute to risk. - Afghan Evacuees Health Resources
University of Minnesota and Minnesota Department of Health partnership to develop a coordinated resettlement response to Afghan new arrivals. - CDC Guidance for the U.S. Domestic Medical Examination for Newly Arriving Refugees
- CDC: Interim Clinical Guidance for Providers Caring for Newcomers from Afghanistan (PDF)
Update Alert with recommendations for leishmaniasis, lead, and malaria; Dec. 20, 2021. - Switchboard: Understanding US Domestic Medical Screening for Refugees and Other Newcomers
An overview of domestic medical screening exam and reasons to complete all components of the exam. - PolicyLab: Refugee Health Care in the United States
A review of common models of refugee health care and tools to standardize care for all refugees.
Household health and safety
- Afghan Evacuees Health Resources: Household Health and Safety FAQs for Communities hosting Afghans
Medical guidance to prepare for and promote household health and safety when hosting Afghan refugee families and individuals.
Health profiles
- Afghan Refugee and Humanitarian Parolee Health Profile
History, cultural beliefs, health concerns and priorities, health care and access, and more to consider when caring for or assisting Afghan refugees and humanitarian parolees. - Centers of Excellence in Newcomer Health Colorado Infographics: New Arrival Health Overviews
- New Arrival Health Overview: Afghanistan, 2009-2019
- Afghan Health Profiles and Screening Guidance from arrivals to Washington State and Maryland, 2015-2021: Adults (PDF) | Pediatrics (PDF)
- Afghan Infographic from the Colorado Center of Excellence in Newcomer Health on Afghan arrivals, 2009-2019
- PLOS Medicine: Health of Special Immigrant Visa holders from Iraq and Afghanistan after arrival into the United States using Domestic Medical Examination data, 2014–2016: A cross-sectional analysis
SIV holders
For general health information on newly arrived SIV holders please see the following publications:
- Kumar GS, Pezzi C, Wien S, et al. Health of Special Immigrant Visa holders from Iraq and Afghanistan after arrival into the United States using Domestic Medical Examination data, 2014- 2016: A cross-sectional analysis. PLoS Med. 2020;17(3):e1003083. Published 2020 Mar 31.
- Kumar GS, Wien SS, Phares CR, Slim W, Burke HM, Jentes ES. Health profile of adult special immigrant visa holders arriving from Iraq and Afghanistan to the United States, 2009-2017: A cross-sectional analysis. PLoS Med. 2020;17(5):e1003118. Published 2020 May 13. doi:10.1371/journal.pmed.1003118
- Wien SS, Kumar GS, Bilukha OO, Slim W, Burke HM, Jentes ES. Health profile of pediatric Special Immigrant Visa holders arriving from Iraq and Afghanistan to the United States, 2009- 2017: A cross-sectional analysis. PLoS Med. 2020;17(3):e1003069. Published 2020 Mar 17. doi:10.1371/journal.pmed.1003069
Translated resources
- CDC: Health Education and Communication Tools
Translated Resources about Infectious Diseases and other Health topics from CDC in Dari, Pashto and Urdu - CDC's Response to Afghan Evacuees
Infectious disease resources in Dari and Pashto - NRC-RIM: Curated Health Resources
Wide variety of topics in Dari, Pashto, and Farsi - NRC-RIM: COVID-19 Resources for Afghan New Arrivals
- Afghan Health Initiative: Lead Prevention Program
Public Service Announcements in Dari, Pashto and English from King County, WA - American College of Emergency Physicians: Quick Communication Guide for Afghan Patients (PDF)
Communication guide for medical conditions and medications translated into Dari and Pashto - Immunize.org: Vaccine Information Statements
Translated into Dari and Pashto - Centers of Excellence in Newcomer Health Colorado: Translated Materials
Acknowledgements
Lead authors: Elizabeth Dawson-Hahn, Katherine Yun, Janine Young, Shoshana Aleinikoff, Jasmine Matheson, Mahri Haider, Ellen Frerich, Sarah Kuech, Blain Mamo
Contributors include members of the Minnesota Department of Health Center of Excellence in Newcomer Health’s Afghan Clinical Guidance Workgroup and the Washington State Department of Health Refugee and Immigrant Health Program.
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