Last week, the Department of Homeland Security announced new layers of enhanced entry screening procedures at five major U.S. airports.
With the outbreak of Ebola in West Africa, and the first death by Ebola in the United States, many are asking how the U.S. government screens incoming foreign visitors for health purposes. Here are some facts about the health screening process.
Can the United States deny admission to foreign visitors who pose health risks?
Yes. Under Section 212 of the Immigration and Nationality Act, any foreign national 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 and may be denied entry.1 As of August 2014, the following diseases can prevent someone from entering the United States:2
- Granuloma inguinale
- Infectious leprosy
- Lymphogranuloma venereum
- Active tuberculosis
- Infectious syphilis
- Infectious tuberculosis
- 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
- Other influenza viruses that are causing or could cause a pandemic, such as H1N1.
However, it must be noted that returning Americans cannot be denied entry, although they may be referred to public health officials where there is medical reason to do so.3
How does the United States screen for individuals who might be inadmissible on health-related grounds?
Most foreign nationals who wish to travel to the United States (including those from all countries in Africa) must first apply for a visa at a United States Embassy or Consulate. During this process, the State Department consular officers ask questions relating to the health of the applicant, and if there are suspicions of health concerns; will refer the applicant to local physicians authorized by the State Department to conduct health examinations for immigration purposes.4
Visitors who are already in possession of a valid visa (visas may be valid for several years after issuance) or who do not require a visa to travel to the United States (such as nationals of the 38 countries in the Visa Waiver Program) are screened by U.S. Customs and Border Protection (CBP) Officers upon arrival, and may be referred to contracted physicians in the United States for screening as appropriate.5
In addition, the Centers for Disease Control (CDC) and CBP work with countries where there are outbreaks of serious communicable diseases, as well as airlines and foreign airports, to screen travelers prior to departure for potential diseases that may prevent their entry.6
How are CBP officers trained to spot travelers who might be ill?
CDC provides guidance and training to CBP officers on what to look for and ask travelers with regard to potential health problems.7 This guidance is regularly updated when breakouts of significant diseases happen around the world, such as with the SARS epidemic in 2003 or the H1N1 virus outbreak in 2009. The training includes questions to ask the travelers about risk factors for diseases (such as travel locations and encounters with anyone who is sick) as well as physical signs and/or symptoms to look for. Additionally, CDC maintains 20 quarantine stations at most major international airports as well as at the major land border ports of entry near San Diego, California and El Paso, Texas.8
CBP, in coordination with CDC, also can place health-related “lookouts” in the CBP border inspection system, when there has been identification of a potentially infected person ahead of travel, such as in cases of a potential or known “carrier.” These individuals are usually tracked through the public health database known as the Do Not Board (DNB) list.9
How well does this screening work?
CBP Officers encounter millions of travelers each day from around the world. For most travelers, the inspection process takes less than a minute. CBP personnel, although trained by CDC, are not physicians or qualified medical experts and can only identify the most obvious symptoms of disease. Unfortunately, many infectious diseases show no signs or symptoms for days and sometimes weeks. Ebola, for example, has a 21-day incubation period but is not contagious until symptoms appear.10 CBP does conduct risk-based screening of travelers from or to areas where there are outbreaks of disease. CBP may ask additional questions and it has the authority to refer individuals to an authorized physician for additional screening before admitting the traveler.
In 2013, there were 174 million foreign travelers admitted to the United States and millions more returning United States citizens. CBP found just over 204,000 of those foreign travelers inadmissible for any reason. Those found inadmissible on health-related grounds make up a small fraction of those who were denied entry.11
For this reason, CDC and DHS officials have stated that they prefer to work with countries where outbreaks occur to screen travelers prior to departure, where CDC teams work with local health officials, the World Health Organization (WHO) and non-governmental organizations to screen and identify those who may be sick before travel. In addition, the United States, Canada and Mexico work very closely through their public health agencies on preparedness and response to pandemics, through the North American Plan for Animal and Pandemic Influenza (NAPAPI).12
Can we stop all incoming flights and travelers from Ebola-stricken countries?
The United States does have the authority to deny transit and landing rights to foreign airlines in the United States or order U.S. airlines to not fly to or from certain areas for national security or other purposes. However, because there are very few direct flights from the Ebola-stricken West African countries to the United States each day, most African travelers transit through other countries first.13 Therefore, the United States has little means to stop travel from Africa directly without disrupting travel from other major international hubs. Most travelers from Africa arrive through some of the busiest international airports in the country; any additional screening procedures for arriving passengers could cause delays and impact many other passengers, so care must be taken in how to effectively target those most likely to be a risk.
Additionally, CDC and WHO officials have stated that travel bans would not be the right response. In an op-ed this week, CDC Director Tom Frieden asserted that travel bans would actually make it more difficult to address the outbreak because it would obstruct international aid and relief, drive affected patients deeper underground, and prevent U.S. citizens and other healthy travelers from returning home.14
So what is the U.S. government doing to prevent Ebola from coming here?
On Thursday, the Department of Homeland Security announced new layers of enhanced entry screening procedures at five major U.S. airports: John F. Kennedy International Airport (NY), Dulles International Airport (D.C.), Newark Liberty International (NJ), Chicago’s O’Hare International Airport (IL), and Hartsfield-Jackson Atlanta International Airport (GA). These five airports receive 94 percent of all travelers from the Ebola-affected countries, Guinea, Liberia, and Sierra Leone. Travelers will be escorted to a screening area where officials will look for symptoms and take their temperature. Other data will also be collected, such as contact information and location for the next 21 days.15 Exit screening is also taking place at airports in the affected countries.
1 INA Section 214(a)(1)(A)(i).
2 Wassem, Ruth Ellen, “Immigration Policies and Issues on Health-Related Grounds of Exclusion,” Congressional Research Service, August 14, 2014.
3 Lister, Sarah A, “Safe at Home? Letting Ebola-Stricken American Return,” Congressional Research Service, August 5, 2014.
4 State Department, The Immigrant Visa Process: Medical Examinations http://travel.state.gov/content/visas/english/immigrate/immigrant-process/interview/prepare/medical-examination.html; Siskind, Gregory, “The ABC’S of Immigration: Health-Related Grounds of Inadmissibility,” http://www.lexisnexis.com/practiceareas/immigration/pdfs/web475.pdf
5 Wassem, pg. 8
6 CDC, Screening of Travelers at Airports, http://www.cdc.gov/vhf/ebola/pdf/screening-of-travelers-at-airports.pdf
7 Wassem, pg. 8
8 CDC Quarantine Stations http://www.cdc.gov/quarantine/quarantinestationcontactlistfull.html
9 CDC, Travel Restriction and Intervention Activities, http://www.cdc.gov/quarantine/quarantineisolation.html; Federal Air Travel Restrictions for Public Health Purposes, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5737a1.htm
10 CDC, Ebola Signs and Symptoms, http://www.cdc.gov/vhf/ebola/symptoms/index.html
11 Office of Immigration Statistics, Nonimmigrant Admissions (2013) http://www.dhs.gov/sites/default/files/publications/ois_ni_fr_2013.pdf; Immigration Enforcement Actions (2013), http://www.dhs.gov/sites/default/files/publications/ois_enforcement_ar_2013.pdf ; State Department, Immigrant and Nonimmigrant Visa Ineligibilities, http://travel.state.gov/content/dam/visas/Statistics/AnnualReports/FY2013AnnualReport/FY13AnnualReport-TableXX.pdf
14 Frieden, Tom, “Why I don’t support a travel ban to combat Ebola outbreak,” October 9, 2014 http://www.foxnews.com/opinion/2014/10/09/cdc-chief-why-dont-support-travel-ban-to-combat-ebola-outbreak/
15 CDC press release http://www.cdc.gov/media/releases/2014/p1008-ebola-screening.html