Chapter 7 International Travel with Infants & Children
In the past 15 years, >250,000 children have come to the United States to join their families through international adoption. Families traveling to unite with their adopted child, siblings who wait at home for the child’s arrival, extended family members, and childcare providers are all at risk for acquiring infectious diseases secondary to travel or resulting from contact with the newly arrived child. International adoptees may be 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 commonly seen in the United States. Challenges in providing care to internationally adopted children include the absence of a complete medical history, lack of availability of a 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 and psychological issues in these children.
TRAVEL PREPARATION FOR ADOPTIVE PARENTS AND THEIR FAMILIES
A pretravel clinic visit is strongly recommended for prospective adoptive parents. In preparation, the travel health provider must know the disease risks in the adopted 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, the length of stay in the country, and the itinerary while in country. Family members who remain at home, including extended family, should be current on their routine immunizations. Protection against measles, varicella, tetanus, diphtheria, pertussis, hepatitis A, hepatitis B, and polio must be ensured for everyone who will be in the household or in close contact by providing care for the adopted child. Measles immunity or 2 doses of measles-mumps-rubella (MMR) vaccine separated by ≥28 days should be documented for all people born in or after 1957. Varicella vaccine should be given to those without a history of varicella disease or documentation of 2 doses of varicella vaccine
≥3 months apart. 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. Unprotected family members and close contacts of the adopted child should be immunized against hepatitis A virus (HAV) before the child’s arrival. Most adult family members and caretakers will need to be immunized with hepatitis B vaccine, since it has only been routinely given since 1990.
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. Additional polio vaccination requirements for long-term travelers (staying >4 weeks) and residents departing from countries with polio transmission may affect travel (see Chapter 3, Poliomyelitis).
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.
OVERSEAS MEDICAL EXAMINATION OF THE ADOPTED CHILD
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://travel.state.gov/content/adoptionsabroad/en/us-visa-for-your-child/medical-examination.html and travel.state.gov/content/dam/aa/pdfs/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, vomiting, or other medical concerns. Items to consider during medical examination of an adopted child include the following:
- Temperature (fever requires further investigation)
- General appearance: alert, interactive
- Anthropometric measurements: weight/age, height/age, weight/height, head circumference/age, body mass index
- Facial features: length of palpebral fissures, philtrum, upper lip (fetal alcohol syndrome: short palpebral fissures, thin upper lip, indistinct philtrum), other facial features suggestive of a genetic syndrome
- Hair: texture, color, areas of alopecia with dry patches (tinea capitis)
- Eyes: jaundice, pallor, strabismus, visual acuity screen
- Ears: hearing screen, otitis media
- Mouth: palate, thrush, presence of a uvula, teeth (number and condition)
- Neck: thyroid (enlargement secondary to hypothyroidism, iodine deficiency), lymph nodes
- Heart: murmurs
- Chest: symmetry, Tanner stage breasts
- Abdomen: liver or spleen enlargement
- Skin: Mongolian spots, scars, bacillus Calmette-Guérin (BCG) scar, birth marks, molluscum contagiosum, tinea capitis, tinea corporis
- Lymph nodes: enlargement suggestive of TB or other infections
- Back: scoliosis, sacral dimple
- Genitalia: Tanner stage, presence of both testicles, findings of sexual abuse
- Extremities: presence of bowing (rickets) or deformities
- Neurologic: presence and quality of reflexes
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. 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:
- HAV serologic testing (IgG and IgM)
- Hepatitis B virus (HBV) serologic testing (repeat at 6 months if initial testing is negative)
- Hepatitis C antibody (repeat at 6 months if initial testing is negative)
- Syphilis serologic testing (treponemal and nontreponemal testing)
- HIV 1 and 2 serologic testing (antigen/ antibody)
- 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)
- Tuberculin skin test (TST) (all ages) or interferon-γ release assay (IGRA) (for children >5 years of age) (repeat at 6 months if initial test is negative)
Additional screening tests may be useful, depending on the child’s country of origin or specific risk factors. 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 2007 and early 2008, 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. HBV infection 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 over the years. 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. Children with chronic HBV infection should receive additional tests for HBV e antigen, HBV e antibody, hepatitis D virus antibody, viral load, and liver function. 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.
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. Since maternal antibody may be present in children <18 months of age, PCR testing should be done if the EIA is positive. 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. In children with a history of syphilis, the child’s initial evaluation, treatment (antibiotic type and treatment duration), and follow-up testing are rarely available; therefore, a full evaluation for disease must be undertaken and antitreponemal treatment given dependent upon the results.
HIV screening is recommended for all internationally adopted children. 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, 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. Chagas disease is endemic throughout much of Mexico, Central America, and South America (see Chapter 3, Trypanosomiasis, American [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. Testing by PCR can be done in children <9 months of age. 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. The TST 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, IGRA (such as QuantiFERON-TB Gold) is an acceptable screening alternative to the TST. IGRA has 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 Mycobacterium tuberculosis infection in children who have had BCG vaccination. 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 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. Children who have a positive TST or IGRA result but have no evidence of active disease have latent tuberculosis infection (LTBI) and should generally be treated with isoniazid for 9 months. In consultation with TB experts, a shorter-course LTBI treatment regimen may be considered. Additional information is available at www.cdc.gov/tb/topic/treatment/ltbi.htm. 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).
A complete blood count with a differential should be done on all internationally adopted children. An eosinophil count >450 cells/mm3 in an internationally adopted child may warrant further evaluation. Intestinal parasite screening will identify some helminths that may cause eosinophilia. Further investigation of the eosinophilia might include serologic evaluation for Strongyloides stercoralis, Toxocara canis, Ancylostoma spp., and Trichinella spiralis. For children arriving from countries endemic for Schistosoma spp. and filariasis, serologic testing should be done for these diseases as well.
SCREENING FOR NONINFECTIOUS DISEASES
Several screening tests for noninfectious diseases should be performed in all or in select internationally adopted children. All children should have a complete blood count with a differential, hemoglobin electrophoresis, and G6PD deficiency screening. Serum levels of thyroid-stimulating hormone and lead should be measured in all internationally adopted children. Testing for serum levels of iron, iron-binding capacity, transferrin, ferritin, and total vitamin D 25 hydroxy should be considered. All children should have vision and hearing screening and a dental evaluation. 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 Advisory Committee on Immunization Practices (ACIP)-recommended vaccines before immigration (www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-schedule.pdf). 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 child’s arrival in the United States. The vaccination exemption form can be found at www.state.gov/documents/organization/80002.pdf.
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, Haemophilus influenzae type b (Hib), and rotavirus 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. Hepatitis A, Hib, human papillomavirus, mumps, pneumococcal conjugate, rotavirus, rubella, and varicella vaccines are often not available in developing countries. Reliability of vaccine records appears to differ by, and even within, country of origin. Some children may have an immunization record with documentation of the vaccines and dates they were given, and others may have incomplete documentation or no record at all. In addition, some children may be immune to vaccine-preventable diseases such as hepatitis A, measles, mumps, rubella, or varicella. A clinical diagnosis of any of these diseases should not be accepted as evidence of immunity.
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. For children ≥6 months of age, testing can be done for diphtheria (IgG), tetanus (IgG), polio (neutralizing antibody to each serotype), hepatitis B (surface antibody), and Hib. Reimmunization for pneumococcus is recommended given that there are 13 serotypes in the vaccine. Most experts recommend serologic testing for infants and children aged ≥6 months. For children ≥12 months of age, testing can be done for measles, mumps, rubella, hepatitis A, and varicella. MMR is not given in most countries of origin; measles vaccine is often administered as a single antigen.
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 reimmunized according to the ACIP schedule.
- American Academy of Pediatrics. Medical evaluation of internationally adopted children for infectious diseases. In: Pickering LK, editor. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.
- American Academy of Pediatrics Committee on Infectious Diseases. Recommendations for administering hepatitis A vaccine to contacts of international adoptees. Pediatrics. 2011 Oct;128(4):803–4.
- CDC. Measles among adults associated with adoption of children in China—California, Missouri, and Washington, July–August 2006. MMWR Morb Mortal Wkly Rep. 2007 Feb 23;56(7):144–6.
- CDC. CDC immigration requirements: technical instructions for tuberculosis screening and treatment: using cultures and directly observed therapy. 2009 [cited 2016 June 20]. Available from: http://www.cdc.gov/immigrantrefugeehealth/pdf/tuberculosis-ti-2009.pdf.
- CDC. Recommended immunization schedules for persons aged 0 through 18 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2014 Feb. 7, 2014;63(5):108–9.
- CDC, ACIP. Updated recommendations from the Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoption. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006–7.
- Immigrant visas issued to orphans coming into the US. [database on the Internet]. US Department of State. 1999–2015 [cited 2016 Apr. 17]. Available from: http://adoption.state.gov/about_us/statistics.php.
- Mandalakas AM, Kirchner HL, Iverson S, Chesney M, Spencer MJ, Sidler A, et al. Predictors of Mycobacterium tuberculosis infection in international adoptees. Pediatrics. 2007 Sep;120(3):e610–6.
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- Page created: June 12, 2017
- Page last updated: June 12, 2017
- Page last reviewed: June 12, 2017
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