Medical Risks for Internationally Adopted Children

Varicella vaccine should be given to those without a history of varicella disease or documentation of 2 doses of varicella vaccine. Most adult family members and caretakers will need to be immunized with hepatitis B vaccine, since it has only been routinely given since If the adopted child is from a polio-endemic area, family members and caretakers should ensure they have completed the recommended age-appropriate polio vaccine series. A one-time inactivated polio booster for adults who have completed the primary series in the past is recommended if they are traveling to these areas and can be considered for adults who remain at home but who will be in close contact caring for the child.

Prospective adoptive parents and any children traveling with them should receive advice on travel safety, food safety, immunization, malaria chemo-prophylaxis, diarrhea prevention and treatment, and other travel-related health issues, as outlined elsewhere in this book.

Instructions on car seats, injury prevention, food safety, and air travel apply equally to the adoptive child, so the travel health provider should also be familiar with and provide information on these child-specific issues. All immigrants, including children adopted internationally by US citizens, must undergo a medical examination in their country of origin, performed by a physician designated by the Department of State.

The medical examination is used primarily to detect diseases or risk behaviors that may make the immigrant ineligible for a visa. Prospective adoptive parents should not rely on this medical examination to detect all possible disabilities and illnesses. Laboratory results from the country of origin may be unreliable. This examination should not replace the evaluation that is recommended once the child comes to the United States. Additional information about the medical examination and the vaccination exemption form for internationally adopted children are available on the Department of State website at http: The adopted child should have a medical examination within 2 weeks of arrival in the United States or earlier if the child has fever, anorexia, diarrhea, vomiting, or other medical concerns.

Items to consider during medical examination of an adopted child include the following:. In addition, all children should receive a developmental screening by a clinician with experience in child development to determine if immediate referrals should be made for a more detailed neurodevelopmental examination and therapies. Concerns raised during the preadoption medical review may dictate further investigation. The current panel of tests for infectious diseases recommended by the American Academy of Pediatrics AAP for screening internationally adopted children is as follows:.

International adoption: Health issues for families

These screens may include Chagas disease serologic tests, malaria smears, or serologic testing for schistosomiasis, strongyloidiasis, and filariasis. Gastrointestinal parasites are commonly seen in international adoptees, but the prevalence varies by birth country and age. The highest rates of infection have been reported from Ukraine and Ethiopia and increase with older age. Giardia intestinalis is the most common parasite identified. Three stool samples collected in the early morning, 2—3 days apart and placed in a container with preservative are recommended for ova and parasite analysis.

Only 1 of these samples needs to be analyzed for Giardia antigen and Cryptosporidium antigen. Although theoretically possible, transmission of intestinal parasites from internationally adopted children to family and school contacts has not been reported; however, good hand hygiene is recommended to prevent infection. Stool samples should be cultured for enteric bacterial pathogens for any child with fever and bloody diarrhea. Unlike refugees, internationally adopted children are not treated for parasites before departure.

HAV serology IgG and IgM should be considered for all internationally adopted children to identify children who may be acutely infected and shedding virus and to make decisions regarding HAV immunization. In and early , multiple cases of hepatitis A secondary to exposure to newly arrived internationally adopted children were reported in the United States.

Some of these cases involved extended family members who were not living in the household. Identification of acutely infected toddlers new to the United States is necessary to prevent further transmission. If a child is found to have acute infection, HAV vaccine or immunoglobulin can be given to close contacts to prevent infection. In addition, it is cost effective to identify children with past infection with serologic testing since they would not need to receive the HAV vaccine.

All internationally adopted children should be screened for HBV infection with serology for hepatitis B surface antigen HBsAg and hepatitis B surface antibody to determine past infection, current infection, or protection due to vaccination. Children found to be positive for HBsAg should be retested 6 months later to determine if the child has a chronic infection.

Results of a positive HBsAg test should be reported to the state health department. HBV is highly transmissible within the household. All members of households adopting children with chronic HBV infection must be immunized and should have follow-up antibody titers to determine whether levels consistent with immunity have been achieved. They should be vaccinated for hepatitis A if they are not immune. They should also have a consultation with a pediatric gastroenterologist.

Repeat screening at 6 months after arrival should be done on all children who initially test negative for HBV surface antibody.

International adoption: Health issues for families

Routine screening for hepatitis C virus HCV should be done, since most children with HCV infection are asymptomatic, screening for risk factors is not possible, effective treatments are available, and close follow-up of infected patients is needed to identify long-term complications. Antibody testing with an EIA should be done for screening.

Children with HCV infection should be referred to a gastroenterologist for further evaluation, management, and treatment. Screening for Treponema pallidum is recommended for all internationally adopted children. Initial screening is done with both nontreponemal and treponemal tests. Treponemal tests remain positive for life in most cases even after successful treatment and are specific for treponemal diseases, which include syphilis and other diseases such as yaws, pinta, and bejel that can be seen in some countries.

HIV screening is recommended for all internationally adopted children. If PCR testing is done, 2 negative results from assays administered 1 month apart, at least one of which is done after the age of 4 months, are necessary to exclude infection. Children with HIV infection should be referred to a specialist. Some experts recommend repeating the screen for HIV antibodies 6 months after arrival if the initial testing is negative.

Screening for Chagas disease should be considered for children arriving from a country endemic for Chagas disease. The risk of Chagas disease varies by region within endemic countries. Although the risk of Chagas disease is likely low in adopted children from endemic countries, treatment of infected children is effective. Serologic testing when the child is aged 9—12 months will avoid possible false-positive results from maternal antibody. If a child tests positive for Chagas disease, the child should be referred to a specialist for further evaluation and management. Routine screening for malaria is not recommended for internationally adopted children.

However, thick and thin malaria smears should be obtained immediately for any febrile child newly arrived from a malaria-endemic area see Chapter 3, Malaria. All internationally adopted children should be screened for tuberculosis TB after arriving in the United States. Internationally adopted children are at 4—6 times the risk for TB than their US-born peers. TST results must be interpreted carefully for internationally adopted children; guidelines may be found in the bibliography.

In addition, they appear to be more specific than the TST for Mycobacterium tuberculosis infection in children who have had BCG vaccination. A chest radiograph and complete physical examination to assess for pulmonary and extrapulmonary TB are indicated for all children with positive TB screening results. Hilar lymphadenopathy is a more sensitive finding for TB in young children than are pulmonary infiltrates or cavitation. A repeat TST 3—6 months after arrival is recommended for children who initially test negative. Additional information is available at www.

If active disease is found, every effort should be made to isolate the organism and determine sensitivities, particularly if the child is from a region of the world with a high rate of multidrug-resistant TB see Chapter 3, Tuberculosis. After the adoption, the infectious diseases consultant may be asked to assess the adequacy of the child's vaccination record from the birth country and to assist in screening, evaluation, and management of infectious diseases.

Since , nearly , children from other countries have been adopted by American families. More than 21, children have arrived in ; all indications suggest that this number will continue to increase [ 1 ]. Since , the top 4 birth countries have consistently been Russia, China, South Korea, and Guatemala. Kazakhstan, Ukraine, Romania, and Vietnam have also been frequent birth countries in the past decade. The living circumstances of children before adoption vary greatly. Most such children reside in orphanages, where they may experience malnutrition, emotional and physical neglect, environmental deprivation, and exposure to infectious diseases.

Children in South Korea, and sometimes those in Guatemala, are notable exceptions, because most reside in foster care before adoption. Regardless of country of origin, internationally adopted children have often experienced many perinatal complications, including low birth weight, prematurity, no prenatal care, and prenatal exposure to drugs and alcohol.

International adoption medicine, a relatively new specialty in pediatrics, has emerged to address the specific health care needs of these children after arrival in the United States and of their prospective parents before the adoption [ 2 ].

Medical Issues in Adoption

One of the primary concerns of international adoption medicine is the evaluation of international adoptees for infectious diseases, as for other immigrant children [ 3—14 ]. Rather, the list of infectious diseases identified in international adoptees is relatively short and is consistent from country to country. It includes tuberculosis, hepatitis B and C, HIV infection, syphilis, intestinal infections with parasites, enteric bacteria, or Helicobacter pylori , skin infections especially scabies , and the occasional vaccine-preventable disease.

The infectious diseases consultant contributes greatly to the care of international adoptees, both before and after arrival in the United States, by interpreting preadoptive medical and vaccine records, offering travel advice, and providing care for infectious diseases after arrival. This review will discuss these topics; details about specific infections and their management can be found in standard references. Other concerns of international adoption medicine, including growth and developmental delays, microcephaly, rickets, anemia, lead poisoning, emotional and behavioral issues, school problems, and precocious puberty, have been recently reviewed elsewhere [ 10 , 15 ].

All children placed for international adoption undergo medical evaluations in their birth countries. Prospective parents often consult a physician for assistance in interpreting the sometimes arcane terminology in these reports e. These diagnoses rarely denote the presence of chronic or worrisome conditions.

Some children have had multiple hospitalizations for infections; frequently, this is done to minimize the spread of contagious diseases rather than because the child was seriously ill. Laboratory testing for infectious diseases. Occasionally, hepatitis C test results are also provided. The timing and accuracy of these results are questionable: Maternal history and other risk factors are rarely noted. Adoptive parents should therefore be cautioned that negative test results do not guarantee the absence of these conditions. It is rarely advisable to repeat these tests in the birth country: These tests, along with other recommended screening tests table 1 , should therefore be repeated when the child arrives in the United States.

Occasionally, more sophisticated blood tests e. Unfortunately, the accuracy and validity of such results are also uncertain. Most adoptive parents travel to receive their child; in some countries notably Russia , parents must travel twice to complete legal formalities. Occasionally, parents bring older children or other family members on these trips. The infectious diseases consultant may be asked to provide travel medicine advice for these individuals. Traveling adults should have updated vaccinations for polio; tetanus; measles, mumps, and rubella; varicella; hepatitis B accelerated schedule, if needed ; and others, as needed [ 18—20 ].

Child travelers should receive all age-appropriate vaccines; for some destinations, an accelerated vaccine schedule is suggested [ 3 ]. Receipt of destination-specific vaccines such as typhoid and hepatitis A vaccines may sometimes be advisable. Basic advice regarding hygiene, traveler's diarrhea, malaria prophylaxis if needed , and travel safety are also helpful, especially for inexperienced travelers. The health risks for accompanying children should be carefully discussed with parents, including hygiene, contact with street dogs, and traffic [ 3 , 21 ].

Helpful, up-to-date, country-specific vaccine and other recommendations for travelers are available at Web sites for the Centers for Disease Control and Prevention http: Adoptive families sometimes encounter difficult situations related to infectious diseases. For example, the recent severe acute respiratory syndrome SARS epidemic in Asia affected many adopting families. In the initial phases of the SARS outbreak, some adoptive parents ignored the WHO warnings about travel to China in their eagerness to receive their children; several adoptive parents and children were hospitalized with suspected SARS upon return to the United States none of the cases were proven.

Adoptive parents frequently request recommendations for medications to bring on their trip for the newly adopted child. Parents should be reassured that most illnesses can be satisfactorily managed by the child's local physicians using available medications. A few items may be useful, however, if the child becomes ill while in transit, such as antibiotics e. It may also reassure traveling parent s to have appropriately-sized sterile needles and syringes on hand and a physician's letter to minimize problems at border crossings , although these are widely available at low cost and without a prescription in most birth countries.

One of the chief concerns of prospective parents is that their newly adopted child will be infected with HIV. Some of the clinical features of HIV infection, institutionalization, and malnutrition overlap. For example, developmental delay, failure to thrive, opportunistic infections e. HIV infection may thus mistakenly be attributed to environmental causes if appropriate testing is not done [ 15 ]. Despite widespread concern about HIV infection in international adoptees, the actual risk is low.

In 7 studies that described a total of children adopted by persons in the United States, Australia, and France, no child with HIV infection was identified, although 3 had transient antibodies to HIV [ 4 , 8 , 13 , 16 , 23—25 ]. Moreover, of children adopted during the period of — who were evaluated in 17 international adoption clinics, only 12 children 0. The actual proportion of HIV-infected adoptees is likely to be less than this, because this survey included only children who were evaluated in specialized clinics.

Many internationally adopted children come from areas of high or moderate prevalence. Virtually all children are tested for hepatitis B infection before adoption. With few exceptions e. Few differences are found between countries although hepatitis B is now rare among South Korean adoptees, reflecting the successful national hepatitis B vaccination program [ 30 ]; higher rates were found among Romanian adoptees in the early s. Some international adoptees have unusually severe hepatitis B, possibly because multiple exposures to the virus, concomitant malnutrition, or infection with certain viral genotypes may augment disease expression [ 31—33 ].

HBV is readily transmissible through ordinary household contact [ 34—38 ]. Antibody titers to HBV should be assessed in all members of households in which newly adopted children are found to be carriers, and exposure precautions for unimmunized individuals e. Although disclosure of the child's status to schools and day care facilities is not mandated [ 3 ], specific recommendations for individual families should be discussed. Newly arrived children should be tested at the time of arrival for hepatitis B surface antigen HBsAg , core antibody, and surface antibody HBsAb [ 3 ]; experts suggest retesting again 6 months later.

Children found to have HBsAg should undergo additional testing, including liver function tests i. Except in infants in whom antibody may represent maternal antibody, children with isolated hepatitis B core antibody may be recovering from acute HBV infection, be distantly immune with nondetectable levels of HBsAb, have a false-positive core antibody result, or have a false-negative result for HBsAg i.

Liver ultrasound and consultation with a gastroenterologist are recommended for children with elevated transaminase levels. These HBV strains have undergone mutations in the major hydrophilic loop of surface antigen amino acids 98— and have reduced reactivity in conventional diagnostic assays. Hepatitis C is also found worldwide, with distinct genotypes found in different geographic regions. Young age at the time of infection—especially in cases of vertical transmission—may protect individuals, to some extent, from an adverse outcome [ 41 ].

Screening recommendations for hepatitis C are somewhat unclear. Most authors recognize that the risk of infection is low [ 13 ]. The Red Book does not recommend routine testing, except in those children who have received blood products, children whose mothers used drugs during pregnancy [ 3 , 14 ], and children from China, Russia, eastern Europe, and Southeast Asia [ 3 ]. However, because these risk factors are rarely known with certainty, screening all arrivals for hepatitis C antibodies by ELISA seems prudent [ 27 ].

In 6 studies including 1 unpublished study of infectious diseases risks for international adoptees from many countries, only 26 children 1. In some cases, these were children with maternal antibodies; such antibodies may persist for 12—15 months after birth. Hepatitis C may be difficult to diagnose. False-negative test results occur early in the course of disease. Thus, positive results should be confirmed by recombinant immunoblot assays, which have better sensitivity and specificity.

While you’re there

No antibody tests distinguish between acute, chronic, or resolved infection, nor do they distinguish between maternal antibody or infection-induced antibody. Moreover, the natural history of the disease in perinatally infected individuals is incompletely understood. However, PCR tests are costly and not well-standardized.

The rates of false-negative and false-positive results may be unacceptably high: Screening new arrivals for Hepatitis A is rarely necessary, except to assess the need for hepatitis A immunization in children with hepatitis B or C and in children older than 12—15 months of age to allow disappearance of maternal antibodies who reside in areas of endemicity. Most internationally adopted children are screened for congenital syphilis in their birth countries and are treated if infection is found. Nevertheless, a small number of children arrive in the United States each year with undiagnosed, untreated congenital syphilis.

In our clinic, cases in children from China and central American countries have been the most common.

We have also seen 1 school-aged child from Bulgaria arrive with unrecognized, untreated syphilis; a history of sexual abuse was elicited. Congenital syphilis is endemic in Russia and in other countries of the former Soviet Union. Generally, this condition is well-managed medically, although details of treatment are often lacking. Typical dental malformations are occasionally seen even when adequate treatment has been provided. Other medical or neurological complications have not yet been reported in this group of children.

Children with a history of treated congenital syphilis should undergo careful serial evaluations [ 3 ] until they are 12 months of age. Ophthalmologic and audiologic evaluations should be performed, as well as screening for neurological and developmental disorders. Detailed recommendations for the evaluation and treatment of children with positive results of serological screening tests on arrival can be found in the Red Book [ 3 ]. Children whose test results are negative and whose histories do not indicate syphilis need no further evaluation. The prevalence varies depending on country of origin [ 5 , 8 , 11 , 13 , 14 , 23—25 , 29 ]; South Korean children, for example, are rarely infected.

Giardia lamblia is the most frequently identified pathogen, but others that are often found include Entamoeba histolytica, Dientamoeba fragilis, Ascaris lumbricoides, Trichuris trichiura , hookworms, and Strongyloides stercoralis. Some children are infected with multiple parasites; in our clinic, 1 child from India was infected with 7 different parasites.

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Children who are infected with intestinal parasites are more likely than their noninfected peers to have growth delay and to be anemic. Some infected children may also have impaired cognitive function unrelated to anemia ; eradication of parasites is sometimes accompanied by improved neuropsychiatric function [ 47—50 ]. More obvious symptoms of infestation include diarrhea, flatulence, odoriferous stools, abdominal pain, and failure to thrive.

Assessment of symptoms may be difficult because of language barriers and the young ages of many of the children [ 14 ]. Regular, formed stools do not exclude the possibility of parasitic infection. All new arrivals should be screened for intestinal parasites. Use of 3 samples improves detection rate [ 14 ]. The use of immunoassays for detection of Giardia antigen alone is inadequate. Follow-up samples should be obtained after treatment to verify eradication and to screen for additional parasites. Parasites are sometimes missed during the initial screening of stool samples; retesting is advisable if symptoms appear later.

Only some parasites induce eosinophilia especially hookworm and Strongyloides, Ascaris , and Toxocara species. Therefore, absence of eosinophilia does not preclude parasitic infection. Children with unexplained eosinophilia after initial stool screening should be reevaluated, and less common parasitic causes of eosinophilia e.

International Adoption

Specific serological tests are available for schistosomiasis, strongyloidiasis, filariasis, echinococcosis, and toxocariasis. In children with persistent eosinophilia and no obvious diagnosis, empirical treatment with a broad-spectrum anthelmintic usually albendazole [ 52 ] is reasonable [ 51 ]. Other explanations should be sought if the eosinophil count does not return to normal [ 52 ]. Some sources have suggested that Giardia infection need not be treated. In this population, however, treatment is generally indicated because of the high risk of spread within the family and other contacts e.

Some less familiar parasites may cause confusion when reported by the laboratory. Under ordinary circumstances, Blastocystis hominis, Entamoeba coli, Entamoeba hartmanii, Entamoeba polecki, Entamoeba dispar, Cryptosporidium species, Microsporidium species, Cyclospora species, Isospora species, Iodamoeba buetschlii , and Endolimax nana are considered nonpathogens and do not require treatment.

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Bacterial enteric pathogens and H.