Cynthia R. Howard, Chandy C. John

Overview

The number of internationally adopted children arriving annually to the United States has averaged 21,449 children in the past 4 years. These children accounted for 1.85% of all legal immigrants and approximately 10% of all legal pediatric immigrants in 2006 and 2007. The demography of international adoption is in constant flux, and the epidemiology of diseases in this population of children shifts as a consequence.

In 2007, the most common countries of origin for internationally adopted children were China, Guatemala, Russia, Ethiopia, South Korea, Vietnam, Ukraine, and Kazakhstan (Map 7-1). The numbers of children coming from Vietnam and Ethiopia increased 409% and 69%, respectively, during 2006–2007, and in 2007, Vietnam and Ethiopia were represented for the first time in the top six countries of origin. In 2007, 40% of internationally adopted children were <1 year of age, 43% were 1–4 years of age, and 17% were ≥5 years of age. Sixty-one percent were female.

International adoptees are usually underimmunized and are at increased risk for infections such as measles and hepatitis A, due to often-crowded living conditions, malnutrition, lack of clean water, and exposure to endemic diseases that are not common in the United States. The major challenges in health care regarding international adoptees include—

• Absence of a medical history
• Unavailability of biological family history
• Questionable reliability of immunization records
• Variation in pre-adoption living standards
• Different disease epidemiology in countries of origin
• Increased risk for developmental delays

(From United States Department of Homeland Security. Yearbook of Immigration Statistics: 2007. Washington, D.C.: U.S. Department of Homeland Security, Office of Immigration Statistics; 2008.)

Travel Preparation for Adoptive Parents and Their Families

Prospective adoptive parents should be encouraged to consider the following for themselves and other family members:

• A pre-travel visit is strongly recommended for prospective adoptive parents.
• Family members who remain at home, including extended family, and child care providers should also be current on their routine immunizations, as recommended by the Advisory Committee on Immunization Practices (ACIP).
• Protection against measles, hepatitis A, and hepatitis B must be ensured for everyone who will be in the household or providing child care for the adopted child.
• Adults <65 years of age who are due for a tetanus booster should receive the diphtheria, tetanus and acellular pertussis (DTaP) vaccine.
• A one-time inactivated polio booster also is recommended for adults.

Overseas Medical Examination of the Adopted Child

All immigrants, including infants and children adopted internationally by U.S. citizens, and all refugees entering the United States must undergo a medical examination in their country of origin, performed by a panel physician designated by the U.S. Department of State.

• The medical examination is used primarily to detect certain serious contagious diseases that may be the basis for visa ineligibility.
• Prospective adoptive parents should be advised not to rely on this medical examination to detect all possible disabilities and illnesses. Laboratory results from the country of origin may also be unreliable.
• The medical examination consists of a brief physical examination and a medical history, a chest radiograph examination for tuberculosis, and blood tests for syphilis and HIV are required for immigrants ≥years of age. Immigration applicants <15 years old are tested only if there is reason to suspect any of these diseases.

The U.S. Department of State website provides additional information about the medical examination at http://adoption.state.gov/about/how/health.html and the vaccination exemption form for internationally adopted children at http://travel.state.gov/pdf/ DS-1981.pdf (PDF).

Follow-Up Medical Examination after Arrival in the United States

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 or vomiting (Table 7-6). Further evaluation will depend on—

• the country of origin,
• the age of the child,
• previous living conditions,
• the number of times a child has been moved from one residence to another (e.g., home, hospital, orphanages, and adoptive families),
• nutritional status,
• developmental status,
• the adoptive family’s specific questions, and
• any concerns raised during a pre-adoption medical review.

In one study, >50% of newly arrived adopted children had an undiagnosed medical condition, and of these, >50% were diagnosed as an infectious disease.

Screening for Infectious and Noninfectious Diseases

The current panel of tests recommended by the American Academy of Pediatrics (AAP) for screening of infectious diseases is outlined in Table 7-7.

Gastrointestinal Parasites

Gastrointestinal parasites have been found in up to 51% of internationally adopted children. Giardia intestinalis is the most common parasite identified. The highest rates of infection have been reported from Russia, Eastern Europe, and China.

Hepatitis A

Serology has proven useful in identifying the young infant or child from a hepatitis A virus-endemic area who may be asymptomatic yet is acutely infected and is shedding virus, with the potential to infect others. In 2007 and early 2008, multiple cases of hepatitis A secondary to exposure to a newly arrived internationally adopted child were reported in the United States.

Hepatitis B

Hepatitis B surface antigen has been reported in 1%–5% of newly arrived adoptees, depending on the country of origin and the year that the study was conducted. The hepatitis B virus (HBV) is highly transmissible within the household. All members of households adopting children who are HBV carriers must be immunized and should have follow-up antibody titers to determine if levels consistent with immunity have been achieved. Children found to be hepatitis B surface antigen-positive should receive additional tests and consultation with a pediatric gastroenterologist.

Hepatitis C

Hepatitis C serologic screening is recommended for children from China, Russia, Eastern Europe, and Southeast Asia. Depending on history of prevalence in the country of origin, receipt of blood products, and maternal drug use, hepatitis C screening of children from other areas may be indicated.

HIV

Clinical symptoms of malnutrition, long-term institutionalization, and acquired immunodeficiency may overlap, but positive HIV antibodies in children <18 months of age may reflect maternal antibody, but not infection. Assaying for the virus by HIV DNA with PCR will confirm the diagnosis of HIV in the infant or child. Some experts recommend HIV DNA PCR for any infant <6 months old on arrival. In children >6 months of age, two negative assays for HIV DNA administered 1 month apart are necessary to exclude infection.

Malaria

Smears should be obtained on all children arriving from areas endemic for malaria and for any newly arrived child who has a fever. The child with fever should have three sets of malaria smears at least 12 hours apart before excluding the diagnosis.

Tuberculosis

Internationally adopted children are at four to six times the risk for tuberculosis than their U.S.-born peers.

• The tuberculin skin test (TST) of purified protein derivative is indicated for all children >3 months of age, regardless of their Bacille Calmette–Guérin (BCG) vaccination status. Table 7-8 summarizes interpretation of the TST in internationally adopted children.
• A chest radiograph and complete physical exam to assess for pulmonary and extrapulmonary tuberculosis are indicated for all children with positive TST results.
• Hilar lymphadenopathy is a more sensitive finding for TB in young children than are pulmonary infiltrates or cavitation.
• Some experts recommend a repeat TST 3–6 months after arrival.
• A child who has a positive TST but no evidence of active disease should be treated with isoniazid for 9 months.
• 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, such as Russia, Eastern Europe, and Asia.

Eosinophilia

Children with eosinophil counts >450 cells/mm³ may warrant further evaluation. Evaluation may include testing for parasites that can migrate through tissues and filarial worms such as Strongloides stercoralis, Toxocara canis, Schistosoma species, Ancyclostoma species, and Trichinella spiralis.

Noninfectious Diseases

Screening tests for noninfectious diseases that should be performed in all or selected internationally adopted children are outlined in Table 7-9.

Immunizations

The U.S. Immigration and Nationality Act requires that any person seeking an immigrant visa for permanent residency must show proof of having received the ACIP-recommended vaccines (see Tables 7-2 and 7-3) prior to immigration. This applies to all immigrant infants and children entering the United States, but internationally adopted children <11 years of age have been exempted from the overseas immunization requirements. Adoptive parents are required to sign a waiver indicating their intention to comply with the immunization requirements within 30 days of the infant’s or child’s arrival in the United States.

Most children throughout the developing world receive BCG, DPT, OPV, and measles vaccine per the original immunization schedule of the United Nations’ Expanded Programme of Immunizations (begun in 1974). Upon arrival in the United States, >90% of newly arrived internationally adopted children need catch-up immunizations to meet the ACIP guidelines. Varicella, pneumococcal conjugate, rubella, mumps, and Haemophilus influenzae type b vaccines are not usually available in developing countries.

Reliability of Vaccine Records

• Appears to differ by and even within country.
• Either of two approaches to vaccination can be taken for internationally adopted children: a) reimmunize regardless of immunization record or b) if the child is >6 months of age, test antibody titers (see Table 7-7) to the vaccines potentially administered, and reimmunize only for those to which the child has no protective titers. Serologic testing that can be done in children >6 months and >12 months is outlined in Table 7-10. Antibody titers to pertussis do not correlate with immune status to pertussis.
• If the infant is <6 months old and there is uncertainty regarding immunization status or validity of immunization record, reimmunize according to the ACIP schedule.
• MMR is not given in most of the countries of origin. Measles vaccine is administered as a single antigen. Unless the child has had mumps and rubella, administration of the MMR vaccine is recommended over serologic testing.
• Varicella testing for children coming from tropical countries is not recommended before 12 years of age unless there is a history of disease. In the tropics, varicella is a disease of adolescents and adults.

References

1. United States Department of Homeland Security. Yearbook of Immigration Statistics: 2007. Washington, D.C.: U.S. Department of Homeland Security, Office of Immigration Statistics; 2008. [updated 2008 Apr 2; cited 2008 Nov 30]. Available from: http://www.dhs.gov/xlibrary/assets/statistics/yearbook/2007/ois_2007_yearbook.pdf (PDF)
2. CDC. Advisory Committee on Immunization Practices (ACIP); recommendations and guidelines. [cited 2008 Nov 26]. Available from: http://www.cdc.gov/vaccines/recs/ACIP/default.htm
3. Lee PJ. Vaccines for travel and international adoption. Pediatr Infect Dis J. 2008;27(4):351–4.
4. Hofstetter MK, Iverson S, Dole K, Johnson D. Unsuspected infectious diseases and other medical diagnoses in the evaluation of internationally adopted children. Pediatrics. 1989;83(4):559–64.
5. American Academy of Pediatrics. Medical evaluation of internationally adopted children for infectious diseases. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red book: 2006 Report of the Committee on Infectious Diseases, 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006. p.183.
6. Chen LH, Barnett ED, Wilson ME. Preventing infectious diseases during and after international adoption. Ann Intern Med. 2003;139(5):371–8.
7. Miller LC. International adoption: infectious diseases issues. Clin Infect Dis. 2005;40(2):286–93.
8. Stauffer WM, Kamat D, Walker PF. Screening of international immigrants, refugees, and adoptees. Prim Care. 2002;29(4):879–905.
9. Mazzulli T. Laboratory diagnosis of infection due to viruses, Chlamydia, Chlamydophila, and mycoplasma. In: Long SS, Pickering LK, Prober CG, editors. Principles and practice of pediatric infectious diseases, 3rd ed. Orlando: Churchill Livingstone; 2008.
10. Schulte JM, Maloney S, Aronson J, et al. Evaluating acceptability and completeness of overseas immunization records of internationally adopted children. Pediatrics. 2002;109(2);E22.
11. Fuglestad AJ, Lehmann AE, Kroupina MG, et al. Iron deficiency in international adoptees from Eastern Europe. J Pediatr. 2008;153(2):272–7.
12. Mandalakas AM, Kirchner L, Iverson S, et al. Predictors of Mycobacterium tuberculosis infection in international adoptees. Pediatrics. 2007;120(3):e610–6.