Chapter 7International Travel With Infants & Children
In 2011, 9,504 internationally adopted children arrived in the United States, compared with an average of 21,400 each year from 2003 through 2007 and 13,700 each year from 2008 through 2010. The number of internationally adopted children and their countries of birth are in constant flux. Consequently, the epidemiology of diseases in these children shifts. In 2011, the 12 most common countries of origin for internationally adopted children were, in descending order, China, Ethiopia, Russia, South Korea, Ukraine, India, Philippines, Colombia, Taiwan, Uganda, Haiti, and Nigeria (Map 7-01). In 2011, 15% of internationally adopted children were aged <1 year, 55% were aged 1–4 years, and 30% were aged ≥5 years; 56% were girls.
Families traveling to unite with their adoptive child, siblings who wait at home for the child’s arrival, extended family members, and child care providers all are at risk for acquiring infectious diseases secondary to travel or contact with the newly arrived child. International adoptees are usually underimmunized and are at increased risk for infections such as measles, hepatitis A, and hepatitis B because of crowded living conditions, malnutrition, lack of clean water, lack of immunizations, and exposure to endemic diseases that are not common in the United States. Challenges in providing care to internationally adopted children include the absence of medical history, lack of availability of biological family history, questionable reliability of immunization records, variation in preadoption living standards, varying disease epidemiology in the countries of origin, the presence of previously unidentified medical problems, and the increased risk for developmental delays in these children.
Map 7-01. Countries of origin of adopted children immigrating to the United States, 20111
1 Data from US Department of Homeland Security. Yearbook of Immigration Statistics: 2011. Washington, DC: US Department of Homeland Security, Office of Immigration Statistics; 2012.
TRAVEL PREPARATION FOR ADOPTIVE PARENTS AND THEIR FAMILIES
A pre-travel visit is strongly recommended for prospective adoptive parents. In preparation, the travel health provider must know the disease risks in the adoptive child’s country of origin and the medical and social histories of the adoptee (if available), as well as which family members will be traveling, their immunization and medical histories, the season of travel, and length of stay in the country.
Family members who remain at home, including extended family, should 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 care for the adopted child. Measles immunity or 2 doses of MMR vaccine separated by ≥28 days should be documented for all people born in or after 1957. ACIP recommends that unprotected family members and close contacts of the adopted child be immunized against hepatitis A virus (HAV) before the child’s arrival. Most adult family members will also require immunization with hepatitis B vaccine. Adults who have not received the tetanus-diphtheria-acellular pertussis (Tdap) vaccine, including adults >65 years old, should receive a single dose of Tdap to protect against Bordetella pertussis in addition to tetanus and diphtheria. Family members should ensure they have completed the recommended age-appropriate polio vaccine series; a one-time inactivated polio booster is also recommended for adults who have completed the primary series in the past.
Prospective adoptive parents and any children traveling with them should receive advice on travel safety, food safety, immunization, malaria chemoprophylaxis, 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.
OVERSEAS MEDICAL EXAMINATION OF THE ADOPTED CHILD
All immigrants, including infants and 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 certain serious contagious diseases 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.
The medical examination consists of a brief physical examination and a medical history. A chest radiograph examination for tuberculosis (TB) and a blood test for syphilis are required for immigrants aged ≥15 years. Immigration applicants aged <15 years are tested only if there is reason to suspect any of these diseases. However, children aged 2–14 years who are coming from countries with an estimated TB incidence of ≥20 cases per 100,000 population per year must have a tuberculin skin test or interferon-γ release assay (IGRA) before arrival in the United States. TB incidence exceeds this rate in all the top 12 countries from which children were adopted internationally in 2011.
Additional information about the medical examination and the vaccination exemption form for internationally adopted children is available on the Department of State website at http://adoption.state.gov/adoption_process/how_to_adopt/health.php and http://travel.state.gov/pdf/DS-1981.pdf, respectively.
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. Items to consider during medical examination of an adopted child include the following:
- Temperature (fever requires further investigation)
- General appearance: alert, interactive
- Anthropometric measurements: height/age, weight/age, weight/height, head circumference/age
- Facial features: length of palpebral fissures, philtrum, upper lip (fetal alcohol syndrome: short palpebral fissures, thin upper lip, indistinct philtrum)
- Hair: texture, color
- Eyes: jaundice, pallor, strabismus, visual acuity screen
- Ears: hearing screen
- Mouth: palate, teeth
- Neck: thyroid (enlargement secondary to hypothyroidism, iodine deficiency)
- Heart: murmurs
- Chest: symmetry, Tanner stage breasts
- Abdomen: liver or spleen enlargement
- Skin: Mongolian spots, scars, Bacillus Calmette-Guérin (BCG) scar
- Lymph nodes: enlargement suggestive of TB
- Back: scoliosis and neurocutaneous findings
- Genitalia: Tanner stage, presence of both testicles
In addition, all children should receive a complete neurodevelopmental examination by a clinician with experience in child development. Further evaluation will depend on the country of origin, the age of the child, previous living conditions, nutritional status, developmental status, and the adoptive family’s specific questions. Concerns raised during the preadoption medical review may dictate further investigation.
SCREENING FOR INFECTIOUS DISEASES
The current panel of tests for infectious diseases recommended by the American Academy of Pediatrics (AAP) for screening internationally adopted children is as follows:
- Hepatitis B virus (HBV) serologic testing (repeat at 6 months if negative)
- Syphilis serologic testing
- HIV 1 and 2 serologic testing
- Complete blood cell count with differential and red blood cell indices
- Stool examination for ova and parasites (3 specimens)
- Stool examination for Giardia intestinalis and Cryptosporidium antigen (1 specimen)
- TST or IGRA (repeat at 6 months if negative)
Additional screening tests may be useful, depending on the child’s country of origin or specific risk factors. These screens include HAV, hepatitis C virus (HCV), and Chagas disease serologic tests; malaria smears; and Helicobacter pylori antigen screening of stool if there is persistent abdominal pain or refractory anemia.
Gastrointestinal parasites have been found in up to 74% of internationally adopted children. G. intestinalis is the most common parasite identified. The highest rates of infection have been reported from Ukraine and Ethiopia. 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. Stool samples should be cultured for enteric bacterial pathogens for any child with diarrhea.
HAV serology is useful in identifying the infant or child from a HAV-endemic area who may be asymptomatic but is acutely infected and shedding virus. 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. 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. In addition, identifying children who have natural immunity and do not need the HAV vaccine is cost-effective.
HBV surface antigen (HBsAg) has been reported in 1%–5% of newly arrived adoptees. Because of widespread use of the HBV vaccine, the prevalence of HBV infection has decreased. Children found to be positive for HBsAg should be retested for confirmation. 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. Children with chronic HBV infection should receive additional tests for HBV e antigen, hepatitis D virus antibody, and liver function; 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.
Routine screening for HCV is not recommended. However, AAP suggests that clinicians consider HCV serologic screening for children from Russia, Eastern Europe, Egypt, and China. HCV screening for children from other areas may be indicated depending on presence of symptoms consistent with hepatitis and on histories of prevalence in the country of origin, receipt of blood products, and maternal drug use.
Screening for Treponema pallidum is recommended for all internationally adopted children. Initial screening may be done with either a nontreponemal or treponemal test, but any positive result must be confirmed by using the opposite test. Care must be taken in interpreting either test method. 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 are seen in tropical countries. If syphilis cannot be satisfactorily excluded, a full evaluation for disease must be undertaken and antitreponemal treatment given.
Clinical symptoms of malnutrition, long-term institutionalization, and acquired immunodeficiency may overlap, but positive HIV antibodies in children aged <18 months may reflect maternal antibody and not infection. Assaying for HIV DNA with PCR will confirm the diagnosis of HIV in the infant or child. Standard screening for HIV is with ELISA antibody testing, but some experts recommend PCR for any infant aged <6 months on arrival. If PCR testing is done, 2 negative results from assays administered 1 month apart, ≥1 of which is done after the age of 4 months, are necessary to exclude infection. Some experts recommend repeating the screen for HIV antibodies 6 months after arrival.
Chagas disease is endemic throughout much of Mexico, Central America, and South America. 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 very effective. If a child comes from a country with endemic Chagas disease, testing for Chagas disease should be considered. Serologic testing when the child is aged >1 year will avoid possible false-positive results due to maternal antibody.
Thick and thin malaria smears should be obtained immediately for any febrile child newly arrived from a malaria-endemic area. A child with fever should have 3 sets of malaria smears ≥12 hours apart to exclude the diagnosis.
Internationally adopted children are at 4–6 times the risk for TB than their US-born peers. The TST of purified protein derivative is indicated for all children, regardless of their BCG status. TST results must be interpreted carefully for internationally adopted children; guidelines may be found in the bibliography. For children aged ≥5 years, IGRAs (such as QuantiFERON-TB Gold) are an acceptable screening alternative to the TST. IGRAs have the advantage of not requiring a follow-up visit for testing or requiring individual interpretation of results (although results may be termed “indeterminate” by the laboratory). In addition, they appear to be more specific than the TST for M. tuberculosis infection in children who have had BCG vaccination. However, the TST remains the most widely used screening test for TB in children. A chest radiograph and complete physical examination to assess for pulmonary and extrapulmonary TB 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. A repeat TST 3–6 months after arrival is recommended for children who initially test negative. Children who have a positive TST result but have 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, South Africa, or Asia.
An eosinophil count >450 cells/mm3 in an internationally adopted child may warrant further evaluation. One option for children who appear well is to repeat a complete blood count with differential 4 weeks after the initial test. If eosinophilia persists, further investigations should be based on the child’s country of origin and might include evaluation for Strongyloides stercoralis, Toxocara canis, Schistosoma species, Ancylostoma species, Trichinella spiralis, intestinal parasites that can migrate through tissues, and filarial worms.
SCREENING FOR NONINFECTIOUS DISEASES
Several screening tests for noninfectious diseases should be performed in all or select internationally adopted children. Serum levels of thyroid-stimulating hormone, iron, iron-binding capacity, transferrin, ferritin, C-reactive protein, total vitamin D 25-hydroxy, and lead should be measured in all internationally adopted children. Hemoglobin electrophoresis and testing glucose-6-phosphate dehydrogenase deficiency should be performed on all children from sub-Saharan Africa. In certain circumstances, neurologic and psychological testing may also be considered.
The US 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 (Table 7-01) before immigration. This requirement applies to all immigrant infants and children entering the United States, but internationally adopted children aged <10 years are exempt 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, oral polio, measles, diphtheria, tetanus, and pertussis vaccines per the original immunization schedule of the United Nations Expanded Programme of Immunizations (begun in 1974). In many developing countries, HBV and Haemophilus influenzae type b vaccines have become more widely available. Upon arrival in the United States, >90% of newly arrived internationally adopted children need catch-up immunizations to meet ACIP guidelines. Varicella, pneumococcal conjugate, rubella, mumps, and Haemophilus influenzae type b vaccines are often not available in developing countries.
Reliability of vaccine records appears to differ by, and even within, country of origin. Providers can choose 1 of 2 approaches for vaccination of internationally adopted children. The first is to reimmunize regardless of immunization record. The second, applicable to children aged ≥6 months, is to test antibody titers to the vaccines reportedly administered and reimmunize only for those diseases to which the child has no protective titers. Immunity to B. pertussis is an exception; antibody titers do not correlate with immune status to B. pertussis. However, protective antibody levels to diphtheria and tetanus imply protective antibody levels to B. pertussis.
Most experts recommend serologic testing for infants and children aged ≥6 months. MMR is not given in most 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 age 12 years, unless there is a history of disease. In the tropics, varicella is a disease of adolescents and adults.
Immunizations should be given according to the current ACIP schedule for catch-up vaccination. If the infant is <6 months old and there is uncertainty regarding immunization status or validity of the immunization record, the child should be re-immunized according to the ACIP schedule.
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