Background

Note: Hepatitis A Risk Associated with Ethiopian Adoptees

International adoptions have become increasingly popular as a means of building and expanding families. Approximately 23,000 infants and children are adopted from abroad each year by citizens of the United States. Overall, internationally adopted children account for 2% of persons legally immigrating to the United States each year (1).

International adoptions bring a host of special considerations, as these adopted children come from diverse cultural backgrounds, living conditions, and medical histories. Adoptive families should be aware of the unique medical, nutritional, environmental and psychological issues they may face. Government and private websites provide information on travel advisories (http://wwwn.cdc.gov/travel), legislation, country-specific adoption requirements and procedures, and many other resources. This summary is not meant to be comprehensive, since resources are constantly changing; it will serve merely as a starting point for information on international adoptions.

Demographic Profile of Internationally Adopted Children Immigrating to the United States

Over the past 10 years, the number of international adoptions has more than doubled, from 11,316 in 1996 to 22,710 in 2005 (1). Although U.S. citizens adopted children from 116 different countries, the majority of infants and children were adopted from Asia, Eastern Europe, Central America and the Caribbean (1). In 2005, the percentage of adoptions by region of birth was 46.5% for Asia, 29.0% for Eastern Europe, and 18.8% for Central America and the Caribbean; Africa, South America and Oceania accounted for 3.6%, 2.0% and 0.1% of adoptions, respectively (See Map 8-1) (1).

Even as there has been a steady increase in the number of adoptions in recent years, numbers and trends in the country of birth of adopted infants and children have shifted. It is important for health-care providers and adoptive families to be aware of these trends, since risk and prevalence of infectious diseases and other medical conditions vary by country and region. Over a 5-year period, from 2001 through 2005, several countries have become more frequent sources for international adoptions. Ethiopia, Guatemala, and China have had marked increases in the number of overall adoptions, while the number of adoptions from Cambodia, Vietnam and Romania decreased substantially (1). Overall, six countries, including China, Russia, Guatemala, South Korea, Kazakhstan, and Ukraine, accounted for 86% of the international adoptions for 2005.

Children less than 1 year of age represented 46% of the adoptions over the last 10 years, with children 1-4 years of age accounting for 42% of adoptions, and children 5-9 years of age and children older than 9 years of age representing approximately 8% and 4% of the international adoptions, respectively (1). These proportions remained relatively constant over time. In addition, on average, from 1996 to 2005, 64% of the adopted children were female and 36% were male, and the proportion of males and females remained relatively constant from year to year (1). There is a marked difference in the number of female versus male children adopted from China, with female children accounting for approximately 95% of all adoptions from China. In 2005, half of all international adoptions of female children by U.S. citizens were from China (1).

Adoptive Parents

Adoptive parents who travel overseas to pick up their child should visit a health-care provider or travel medicine specialist to ensure that their routine vaccinations are up to date and to obtain pre-travel advice tailored to their own medical history and the country they will visit (see Chapter 1). During travel, they need to take precautions regarding proper rest, food, water, and insect exposure (see Chapter 2) to protect their own health, so that they can care for the child. Adoptive parents should be aware that unexpected complications in the adoption process may prolong their stay, and they should plan accordingly, especially if malaria prophylaxis or other important medication is needed. Recently, an outbreak of measles was identified among children being adopted from China and their family members. In 2002 and 2004, adoptions from the affected orphanages were temporarily suspended while Chinese authorities implemented measures to control and prevent further transmission of measles among adopted children (2-4). Prospective parents who are traveling internationally to adopt children, as well as their household contacts, should ensure that they have a history of natural disease or have been vaccinated against measles according to guidelines of the Advisory Committee on Immunization Practices (ACIP). All persons born after 1957 should receive two doses of measles-containing vaccine.

Overseas Medical Examinations for the Child

All immigrants, including infants and children adopted overseas by U.S. citizens, and all refugees coming to the United States must have a medical examination overseas by a physician designated by the Department of State. The medical examination focuses primarily on detecting 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. If an infant or a child is found to have an illness or disability that may make the child ineligible for a visa, a visa may still be issued after the illness has been adequately treated or after a waiver of the visa eligibility has been approved by the Bureau of Citizenship and Immigration Services. If the physician notes that the infant or child has a serious disease or disability, the prospective parent(s) will be notified and asked if they wish to proceed with the infant’s or child’s immigration.

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 15 years of age and older. Applicants younger than 15 years of age are tested only if there is reason to suspect any of these diseases.

A new subsection of 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 vaccines recommended by ACIP (See Tables 8-2 and 8-3) before immigration. While this new subsection now applies to all immigrant infants and children entering the United States, internationally adopted children younger than 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 after the infant’s or child’s arrival in the United States.

Additional information about the medical examination and the vaccination exemption form for internationally adopted children is available on the Department of State website athttp://www.travel.state.gov/family/adoption/notices/notices_473.html and http://www.travel.state.gov/family/adoption/info/info_458.html, respectively.

Follow-up Medical Examinations after Arrival in the United States

The varied geographic origins of internationally adopted infants and children, their unknown backgrounds before adoption (including parental history and living circumstances), and the inadequacy of health care in many developing countries make appropriate medical evaluation of internationally adopted children a complex and important task. This evaluation should be performed within 2 weeks of the child’s arrival in the United States. The content of the medical evaluation should be guided by the unique circumstances and needs of the child, taking into account the child’s region and country of birth, past living conditions, and travel and medical history. In addition to the screening for infectious disease described below, a full medical and developmental assessment should be done, with attention to possible malnutrition, conditions undetected by limited prior care, and ectoparasites such as scabies and lice, in addition to other indicated tests, such as lead (5) or G6PD.

SCREENING FOR INFECTIOUS DISEASES

Infectious diseases, among the most common medical diagnoses, have been found in up to 60% of internationally adopted children, depending on their country of origin; many of these infections can be asymptomatic (6-10). Screening for these diseases is important for the health of the adopted infant or child as well as that of their adoptive family. The American Academy of Pediatrics (AAP) recommends that all internationally adopted children be screened with the following: hepatitis B serology, HIV serology, syphilis serology, Mantoux intradermal skin test for tuberculosis, stool examination for ova and parasites, and complete blood count including a peripheral eosinophil count and red blood cell indices (11). Regardless of eosinophil count, all international adoptees should have three separate stool samples, collected on 3 separate days, analyzed for ova and parasites. HIV antibodies in a child younger than 18 months of age may reflect maternal infection without transmission to the infant, and infection in the infant should be confirmed with an assay for HIV DNA by polymerase chain reaction. Two negative tests obtained 1 month apart are required for the child to be considered uninfected.

Tuberculin skin tests measuring less than 5 mm are negative; reactions larger than 5 mm are interpreted based on risk factors for diseases. For internationally adopted children born in regions of the world with high TB prevalence, a reaction of 10 mm or more of induration is always positive; a reaction from 5 to 9 mm is positive if the child is immunocompromised, has been exposed to tuberculosis, or has signs or symptoms of TB disease. If the TST is positive, a chest radiograph should be performed to evaluate for active TB disease. If evidence of TB disease is found, efforts to isolate an organism for sensitivity testing are very important because of the high proportions of drug resistance in many other countries, including countries in Eastern Europe, the former Soviet Union, and Asia. Some experts also recommend that health-care providers consider repeating the TST (if negative) 2-3 months after arrival when nutritional status has been improved, particularly if the child had evidence of under- or malnutrition at the initial screening (10). Receipt of BCG vaccine is not a contraindication for TST. Because BCG does not prevent infection with TB and because of the high risk for exposure in most countries where BCG is given, the AAP recommends that children with a positive TST be given 9 months of isoniazid therapy (11).

Up to 35% of internationally adopted children have ova or parasites identified on stool examinations (6-10). For Giardia intestinalis and Cryptosporium parvum infection, stool examination for antigen by enzyme immunoassay may be more sensitive than microscopic exam. Giardiasis is particularly prevalent in internationally adopted children from Eastern Europe. Strongyloides stercoralis serologic testing, available at CDC on request through the state public health laboratory, should be considered for children who have a high eosinophil count. If enteric symptoms develop in the future, tests should be repeated, even if it has been several years after arrival in the United States.

Other screening tests may be recommended based on country of origin, risk factors, symptoms, or clinical findings. For example, children from schistosomiasis-endemic areas (see Map 4-11) should have serologic tests for schistosomiasis performed at CDC, which may be requested through the state public health laboratory (http://www.dpd.cdc.gov/dpdx/HTML/DiagnosticProcedures.htm). Screening for hepatitis C should be considered for all infants and children adopted from Asia, Eastern Europe, or Africa. Hepatitis C testing for children adopted from other areas should be considered if the records indicate potential risk factors, such as receipt of blood products or maternal drug use. Testing for hepatitis D, which is available at CDC, should be considered for children from the Mediterranean area, Africa, Eastern Europe, and Latin America who have chronic infection with hepatitis B virus.

Laboratory reports from the country of origin should not necessarily be considered reliable.

VACCINATION

Internationally adopted infants and children frequently are underimmunized and should receive necessary immunizations according to the ACIP-recommended schedules in the United States (see Tables 8-2—8-4) (12,13). In a retrospective review of records of 504 children, the majority (65%) had no written records of overseas vaccination. Among the 178 children with documented overseas vaccination, 167 (94%) had valid records and some vaccine doses that were acceptable and up to date under the U.S. schedule (14).

In assessing the immunization status of an internationally adopted child, only written documentation should be accepted as proof of receipt of immunization. In general, written records are deemed valid if the vaccine type, date of administration, number of doses, intervals between doses, and age of the patient at the time of administration are comparable with the current U.S. schedule. Although some vaccines with inadequate potency have been produced in other countries, most vaccines used worldwide are produced with adequate quality control standards and are reliable (11,13). However, immunization records for some internationally adopted children, particularly those from orphanages, may not reflect protection because of inaccurate or unreliable records, lack of vaccine potency, poor nutritional status, or other problems (2-4, 14). For any child, if there is any question as to whether the immunizations were administered or were immunogenic, the best course is to repeat them. Vaccination is generally safe and avoids the need to obtain and interpret serologic tests.

In an older infant or child who is thought to have been vaccinated appropriately, judicious use of serologic testing can be helpful in determining which immunizations may be needed and can decrease the number of injections required (10,11). Children who do not have serologic evidence of previous hepatitis B infection should receive the full vaccine series. Many adopted children acquire hepatitis A virus infection early in life and are immune thereafter. Thus, in the United States it may be cost effective to screen these children for previous immunity before initiating the vaccination series. Verification of protection from MMR vaccine requires testing for antibodies to each virus. Serology is of limited availability or difficult to interpret for Haemophilus influenzae type b (Hib) and poliovirus. Vaccination for these, as well as varicella and pneumococcal disease, which are not administered in most countries, should be administered to internationally adopted children based on age and medical history.

Data indicate increased risk of local adverse reactions after the fourth and fifth doses of DTP or DTaP. In some circumstances, judicious use of serologic testing of antibody levels to assess immunity may be helpful in decreasing the possibility of vaccine side effects. For children whose records indicate that they have received more than 3 doses, options include initial serologic testing or administration of a single booster dose of DTaP, followed by serologic testing after 1 month. If a severe local reaction occurs after revaccination, serologic testing for specific IgG antibody to tetanus and diphtheria toxins can be measured before additional doses are administered. No established serologic correlates exist for protection against pertussis, but protective concentrations of antibody to both diphtheria and tetanus toxin can serve to validate the vaccination record.

References

 

1. Department of Homeland Security, Office of Immigration Statistics. 2005 Yearbook of Immigration Statistics. Available from: http://www.uscis.gov/graphics/shared/statistics/yearbook/ Updated 2006 Jun 2; accessed 2006 Jun 5.
2. Hostetter MK, Johnson DE. Immunization status of adoptees from China, Russia, and Eastern Europe [Abstract 851]. Presented at the 1998 Pediatric Academic Societies Annual Meeting, New Orleans, May 5, 1998.
3. Miller LC, Comfort K, Kelly N. Immunization status of internationally adopted children. Pediatrics. 2001;108:1050-1.
4. Schulpen TWJ, Van Seventer AHJ, Rumke HC, van Loon AM. Immunization status of children adopted from China. Lancet. 2001;358:2131-2.
5. CDC. Elevated blood lead levels among internationally adopted children–United States, 1998. MMWR Morbid Mortal Wkly Rep. 2000;49:97-100.
6. Saiman L, Aronson J, Zhou J, Gomez-Duarte C, Gabriel PS, Alonso M, et al. Prevalence of infectious diseases among internationally adopted children. Pediatrics. 2001;108:608-12.
7. Staat MA. Infectious disease issues in internationally adopted children. Pediatr Infec Dis J. 2002;21:257-8.
8. Chen LH, Barnett ED, Wilson ME. Preventing infectious diseases during and after international adoption. Ann Intern Med. 2003;139:371-8.
9. Miller LC. International adoption: infectious disease issues. Clin Infect Dis. 2005;40:286-93.
10. Barnett ED. Immunizations and infectious disease screening for internationally adopted children. Pediatr Clin North Am. 2005;52:1287-1309.
11. American Academy of Pediatrics. Medical evaluation of internationally adopted children for infectious diseases. In: Pickering LK, editor. Red book: 2006 report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006. p. 182-191.
12. CDC. Childhood and adolescent immunization schedule. 2007. Available from: http://www.cdc.gov/nip/recs/child-schedule.htm. [accessed 26 March 2007]
13. Atkinson WL, Pickering LK, Schwartz B, et al. General recommendation on immunizations: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 2006;55(RR15):1-48.
14. Schulte JM, Maloney S, Aronson J, San Gabriel P, Zhou J, Saiman L, et al. Evaluating acceptability and completeness of overseas immunization records of internationally adopted children. Pediatrics. 2002;109:e22.

ASHLEY MAUSER, SUSAN MALONEY

 

MAP 8-01. Internationally adopted children immigrating to the United States, 2005.

Data source: Department of Homeland Security, Office of Immigration Statistics, 2005 Yearbook of Immigration Statistics.