International Adoption in 2005

Abstract & Commentary

Synopsis: A number of infectious diseases are of special concern to internationally adopted children and their adoptive families. These include infection with HIV, hepatitis B, tuberculosis, syphilis, intestinal parasites, or other pathogens, completion of childhood immunizations, and preparing for international travel.

Source: Miller LC. International Adoption: Infectious Diseases Issues. Clin Infect Dis. 2005;40:186-193.

Dr. Laurie Miller, from New England Medical Center in Boston, Massachusetts, reviewed many aspects of international adoption that specialists in infectious diseases and international adoption medicine may encounter. The pediatric infectious disease consultant may be asked to interpret pre-adoption medical and vaccination records, screen the adopted children after arrival, and care for the children when infectious diseases are suspected or diagnosed. Infectious disease consultants may also be asked to prepare families for their travel to meet the child.

Dr. Miller identified some common issues in reviewing pre-adoption medical records, pre-travel evaluations, post-arrival infectious disease screening, and management of immunizations, and highlighted some infectious diseases diagnosed after arrival in the United States (see Table 1).

Comment by Lin H. Chen, MD

Several studies have analyzed results of screening for infectious diseases in internationally adopted children. Dr. Miller’s review sums up the data from these studies, and formulates clinically relevant approaches to these diseases. Dr. Miller’s experience, from evaluating international adoptees, has led to some helpful reflections. For example, she noted that medical records from South Korea have been excellent, and immunization records are probably reliable; immunization records from Guatemala and India may also be acceptable. Similarly, adoptees from South Korea were rarely infected with intestinal parasites.

Dr. Miller recommends screening for hepatitis A to assess the need for immunization in children with hepatitis B or C. Medical providers should keep in mind that children may be asymptomatic shedders of hepatitis A virus, and most internationally adopted children come from intermediate to high endemicity regions for hepatitis A. One case report documented a probable transmission of hepatitis A from a child adopted from Russia to the adoptive father,1 although screening for hepatitis A in newly arrived international adoptees is usually not necessary. Adoptive family members should be cautioned about hepatitis A, and preventive strategies including good hand hygiene and immunization.

Dr. Miller also summarized immunization issues in international adoptees. A number of studies have found low antibody levels against vaccine-preventable diseases, sometimes in spite of documented immunizations.2-5 Many children have incomplete immunization records, especially adoptees from China as reported by Dr. Miller. On the other hand, some international adoptees have demonstrated adequate antibody levels to diphtheria and tetanus.6 The decision to repeat immunizations versus testing for antibodies to vaccine-preventable diseases in international adoptees has been debated. The American Academy of Pediatrics has recommended using a combination of antibody testing and repeat immunizations.7 Dr. Miller recommends testing for antibodies to diphtheria, tetanus, and poliovirus serotypes 1-3 to verify immunity. These strategies continue to be evaluated, and cost-effectiveness data should help to define the best approach to fulfill the recommended childhood immunizations in internationally adopted children.

References

1. Wilson ME, et al. Post-Travel Hepatitis A: Probable Acquisition From an Asymptomatic Adopted Child. Clin Infect Dis. 2001;33:1083-1085.

2. Hostetter MK, et al. Immunization Status of Adoptees From China, Russia, and Eastern Europe. Pediatric Research 1998;43:147a. Abstract #851.

3. Schulpen TWJ, et al. Immunisation Status of Children Adopted From China. Lancet. 2001;358:2131-2132.

4. Miller LC, et al. Immunization Status of Internationally Adopted Children. Pediatrics. 2001;108:1050-1051.

5. Miller LC. Internationally Adopted Children—Immunization Status [letter]. Pediatrics. 1999;103:1078.

6. Staat MA, et al. Immunization Verification in Internationally Adopted Children. Pediatric Research. 2001;49:468A. Abstract #2680.

7. American Academy of Pediatrics—2000 Red Book. Report of the Committee on Infectious Diseases. Pickering LK, et al. Elk Grove Village, IL; American Academy of Pediatrics. 2000.