Infectious Disease and the Internationally Adopted Child
International adoption is a politically sensitive phenomenon. Every year, thousands of children arrive in the USA from over 100 countries for adoption. Infectious disease screening of children from these diverse political, social, and geographic backgrounds is best accomplished using a standardized protocol, including a review of immunizations, a complete blood count and urinalysis, and screening tests for hepatitis B, HIV, intestinal parasite, tuberculosis and syphilis.
Current Opinion in Infectious Diseases 1993, 6:576-584
Adoption of children from developing countries has become common in industrialized nations. As the United States experience demonstrates, the face of international adoption is rapidly changing. The movement to adopt children born in other countries began in the aftermath of the Korean War with the desire to care for war orphans. through the 1960s and 1970s, most children adopted by unrelated US citizens originated in Korea and, later, Vietnam. Of the more than 82,000 children adopted from 1979 to 1989, more than 70% were born in Korea, India, or the Philippines, with another 25% born in various Central and South American nations.
With the self-affirmation of Korea as an industrialized nation during the 1988 Olympic Games and the break-up of many communist block nations, the availability of children for adoption has changed dramatically. In 1991, for the first time since 'orphan' statistics have been tabulated, Korea fell from the number one position. In that year, 35% of children came from Asia, 30% from Romania and 28% from Latin America. In 1992, only 43% of children came from Korea, India, or the Philippines, with China, Russia, and other countries of the former Soviet Union listed in the top 10 sources of US adoptees.
Before the mid-1980s only a few anecdotal reports existed on the medical evaluation of foreign-born adopted children. The available studies of long-term outcome concentrated on physical growth and intellectual achievement. Knowledge has advanced rapidly in the past decade but remains in a constantly evolving state as the demographics of adoptees change. The first and major concern for a newly adopting family is usually, the potential for 'exotic' infections. Thus, the infectious disease consultant often serves as a first stop in the comprehensive evaluation that these children require.
Unlike refugee or immigrant children, adoptees most commonly arrive in the USA without any care giver who is familiar with their past medical or social environment. Records are frequently, scanty, unavailable or, occasionally, even fraudulent. Evaluation before adoption is highly variable, with excellent documentation from government-sanctioned adoption agencies in Korea to virtually none from poorer nations. Terminology and medical practices vary tremendously; diagnoses made, such is 'vegetative dystonia' in survivors of the Chernobyl accident, may not be recognized in the USA. Treatments used in other countries, such as quinghaosu or artemether for malaria, may also be unavailable.
Immunization records Immunizations are frequently not given or are poorly documented . Occasionally, records that are 'too perfect'-- for example, with exactly, 1 or 2 month intervals between doses -- merely reflect slavish attention to the vaccine schedule recommendations. Even when vaccines have been given reliably, the immune response may have been inadequate in the severely malnourished or chronically ill child]. When in doubt, it is always best to repeat the series of vaccinations, as there is no harm in re-immunization, provided the HIV status is known.
Visa medical examination
There are no international standards for medical evaluation before adoption. A US orphan visa application does not require any specific tests of a child under 16 years of age other than physical examination. Conditions excludable under current immigration law are several sexually-transmitted diseases, including HIV but not hepatitis B, active tuberculosis, infectious leprosy, psychiatric impairment, and some severe physical deformities. Examining physicians may require any evaluation that they feel necessary on the basis of the physical examination or history. Thus, abandoned infants from any country are often screened for syphilis, whereas children originating in Romania, Haiti, or Uganda will invariably be tested for HIV.
There have been reports of superficial evaluation and inappropriate diagnosis from physicians, who adoptive parents, have observed the medical visa examination process. Unless the child has an 'excludable condition' diagnosed, the results of the visa examination are almost never made available to the adopting parent or to the pediatrician providing subsequent care. When testing has been accomplished in the other country, the results may be unreliable, especially in long-incubation conditions such as hepatitis B or HIV. Thus, any medical evaluation before immigration to the USA does not preclude a thorough re-evaluation in this country.
About one-half of internationally adopted children will have an acute illness within the first month after arrival . Although the tendency of the anxious new adoptive parent is to rush the child to the physician for a full check-up, a symptom-oriented approach is usually the most appropriate initial step. Most early illnesses are simple pediatric conditions such as upper respiratory tract infection, gastroenteritis, or skin infections. Hospitalization is unusual except in children with chronic medical or physical conditions, such as unrepaired cleft palate.
It is advisable to follow all acute illnesses closely and to resolution. Failure to improve as expected or to resolve completely may be the first indication of an underlying condition. Common scenarios are impetigo complicating scabies or pneumonia masking pulmonary tuberculosis .
Few exotic conditions require immediate attention. Among those providing a significant health hazard to the child or the community are some vaccine-preventable diseases and malaria. Measles in a severely malnourished child presents a high risk of morbidity and mortality. Outcome may be improved by giving a dose transmission risk in the health care setting. One report documents widespread dissemination of the measles virus to unimmunized children attending a pediatrician's office for well child care. The index case was a Korean child seen during the lunch hour on l Summer day: the ventilation system re-circulated the virus throughout the office for the afternoon.
Although not yet reported in adopted children after arrival in the USA, poliomyelitis has been recognized in Hmong refugees from Vietnam. Malaria has been noted in Montagnard refugees from Cambodia, where multiple-drug resistance is common, requiring treatment with unusual agents such as halofantrine. Adoption from these countries is not infrequent, with 50-80 children arriving annually, in the 1990s.
Other short incubation conditions seen in travelers from developing countries include hepatitis A, hepatitis E, cholera, and bacterial gastroenteritis or dysentery. Children from developing countries are similar to travelers: they are not as immunologically experienced with these agents as adults in the same country. None, except Salmonella., have been studied in adopted children. Nevertheless, these conditions should be sought in unusual illness in the newly arrived child. Studies of Salmonella spp. excretion in adoptees indicated low rates of transmission to family members; however, parents should be advised to practice careful hand-washing with all new arrivals.
Routine infectious disease evaluation
Accumulated experience from the USA verified by series of studies from other , indicates that a simple standardized protocol will identify most of the serious or long-term infectious disease issues of the internationally adopted child. In addition to a urinalysis and a complete blood count, all children, regardless of age or country of origin, should receive screening tests for syphilis, tuberculosis, intestinal parasites, HIV, and hepatitis B.
Hepatitis B is endemic in both the geographic areas and the social environments from which adoptees originate. Although vaccination programs are public-health policy in some countries and child care institutions, the circumstances that leave a child available for adoption are the same as those that afford the child the least access to medical care. Even when vaccine programs are subsidized by international aid or adoptive parent organizations, there are reports of vaccine failure. Hepatitis B screening in the country of origin may not be reliable. Some experts advise against screening children before adoption since the testing process itself, using contaminated needles, may be yet another source of infection. Others report inaccurate, misinterpreted or ignored positive results, especially, from Romania.
Early protocols for hepatitis B screening recommended hepatitis B surface antigen testing and emphasized the risks for children from Asian countries, especially Korea. However, numerous reports indicate high rates of infection from most areas of the world and particularly, from medically, impoverished orphanages, as in Romania and India. In a series reporting a full screening panel (surface antigen, anti-core antigen ,And anti-surface antigen), up to 50% of children from some institutions showed evidence of past or current infection. One study, reported that, over a decade, children living in Romanian child-care institutions had an incidence of hepatitis B infection of 767 in 100,000, compared with 40 in 100,000 in the surrounding non-institutionalized child population. Screening repeated after arrival, that is, after the maximum incubation period, reveals additional infections unrecognized on arrival.
With the new recommendation for universal hepatitis B immunization of US newborns, it is important to determine the past hepatitis B experience of any adopted child. Children who are immune will need documentation to fulfill eventual school-entry immunization requirements. Also, many families subsequently adopt other children who are infected, and thus it is useful to know the immune status of everyone in the household.
The risk of transmission of hepatitis B to other family members was examined in Washington State and Sweden in the pre-vaccine era. Rates of infection in other family members ranged from 5 to 37%, increasing with younger children and within the first year of arrival. Early screening allowed immunization of susceptible household contacts. The social and day care issues of hepatitis B chronic infection remain important to families but are somewhat lessened by the impact of the newborn vaccination recommendations.
The general experience of over 40,000 Korean adoptees, approximately 5% of whom are chronically infected, is generally good. However, most Korean children acquired their infections perinatally, while children from other countries, such as Romania, are more likely to have horizontally transmitted disease.
Recent experience with the Romanian adoptees seems to indicated a higher risk of abnormal liver function associated with chronic infection. Biopsies have shown chronic active hepatitis in a number of these children. A multicenter trial of alpha-interferon is in progress in Romanian adoptees, postulating that the immunologic circumstances of infection and thus response to treatment may be different from those in Asian-born childhood carriers who appear not to respond well to interferon.
A final new issue in hepatitis B in adoption is the recognition of a number of children from Romania with delta hepatitis virus infection. Delta virus screening has not been routine in the past but should now be included in the evaluation of any child with chronic hepatitis B infection. Case reports indicate that there may he some benefit from interferon therapy, in this special group of adoptees who have a high risk of poor hepatic outcome.
Tuberculosis (TB) remains a significant problem in diagnosis. Practitioners are reluctant to test healthy-appearing children, those who have lived in foster homes, or those who may have received bacille Calmette-Guerin (BCG) vaccine. Series of results from Maryland and Minnesota indicate that the rate of TB in adopted children is 50-150 times the rate in the general US population and that serious sequelae, including TB meningitis and death, occur in adoptees.
A Mantoux skin test is the only appropriate test for this population. All children should be screened at arrival and at any time they develop symptoms compatible with TB. Skin test reactions of greater than 20 mm are due to infection with TB, and require a thorough evaluation for infection and the start of a course of treatment. Reactions of less than 5 mm are likely to be BCG-induced in the otherwise healthy child. Reactions of greater than 5 mm in the HIV-infected child or greater than 10 mm in the HIV negative child should be evaluated and the child began in the appropriate prophylactic or therapeutic course. Newborns with very recent BCG administration (usually from Latin-America or some Eastern European countries) should be screened with a chest radiograph on arrival in the adoptive home and 1 year with a Mantoux test unless other symptoms intervene.
Multiply-resistant TB has not yet been reported in an adoptee but, with the increasing numbers of adoptions from Southeast Asia, it is only a matter of time. The clinician should choose the anti-TB regimen on the basis of the epidemiology of disease as known in the country of origin, or should use at least two, and preferably three drugs.
HIV infection had not been a major issue in international adoption until recent years because the incidence of infection had been low in areas from which most adopted children came. Unusual epidemics, such as the one in Romanian orphanages, have increased the impetus to test all children. Errors in diagnosis before arrival have occurred. Both British and US reports discuss Romanian children unknowingly adopted with positive serology,. A Panamanian child, infected and adopted before 1985, now has AIDS. Others report positive serology of infants from Haiti, Paraguay, and Honduras secondary to maternal antibody or false-positive tests (Adoptive Families of America, personal communications, 1989-1993).
Adoptive parents and their physicians are in a dilemma about pre-adoptive screening. Are the tests and techniques used reliable? Will blood-drawing expose the child to new infection? How under-reported is infection in the country or region of origin? Delaying the child's arrival for retesting at intervals is an option not acceptable to most families. Foreign agencies and lawyers vary widely in their willingness to screen children. Parents who travel to complete the adoption have the option to provide sterile equipment and to observe the blood-drawing. Otherwise, parents must depend on the judgment and policies of the agencies involved.
Changes in the US immigration laws in 1990 permit waivers of excludability for HIV infected children. Thus, there are now adoptive parents who actively, seek and adopt children with known HIV infection. Five such waivers were granted in 1992 and early
1993 (Office of Quarantine, Center for Disease Control and Prevention, personal communication, March, 1993).
Screening for syphilis does not present many serious problems. Infants with positive serology and documented treatment must be followed until the serology reverts to negative, as it is usually impossible to determine whether the child received adequate evaluation or therapy for central nervous system syphilis. Older children and children from certain tropic regions are more likely to have positive serology secondary to sexual abuse or to endemic or non-venereal syphilis, yaws or pinta. Such children should receive a full course of documented therapy.
After hepatitis B, parasites cause the most long-term problems for children. A few organisms, such as Giardia lamblia, are easily transmitted to other family members and may cause considerable distress. Scabies and lice are extremely common and may be difficult to diagnose because of partial treatment or secondary skin infection. Intestinal parasites are prevalent in most child-care institutions. The older the child the more impoverished the previous living circumstances, the higher is the risk of multiple infestations. Except in Korean children from middle class foster homes, a single stool examination is almost never adequate. Children should provide at least three specimens, transported in preservative agents, and collected at intervals of no less than one week. Stool examination must be repeated after any course of therapy, as it is not unusual to find five or six different organisms sequentially diagnosed in a child. Symptoms are not reliable indicator of infection. Symptoms of chronic starvation or lactose intolerance may also mimic parasitosis.
At times, various experts have recommended screening for diseases such as cytomegalovirus, salmonellosis, hepatitis A, hepatitis C, and malaria. Most of these have no implications for the health of the child, are not treatable, are not recognized as high incidence in this population, or screening tests are of low yield in asymptomatic children. Except in the symptomatic child, in whom a diagnosis may be helpful in management, there is no particular value to routine screening for these conditions. All parents should be advised to practice good hand washing techniques, as the children may transmit a variety of agents in their environment, especially measles, polio, hepatitis A, and hepatitis E. Adoptive mothers considering pregnancy subsequent to adoption may want to determine their own cytomegalovirus status
Although the countries of origin of internationally adopted children are changing, the circumstances leading to availability for adoption remain the same: poverty, abandonment, abuse or neglect and political upheaval. A standardized screening protocol has served well in the past to screen children from diverse backgrounds. The same protocol should continue to be used for all adoptees, regardless of age or origin, to ensure optimal care for both the children and their families. Early experience with Romanian adoptees indicates more high-risk medical conditions than detected in children from 'traditional' Asian and Latin American sources.
Jerri Ann Jenista, MD is a pediatrician and well known author of articles on adoption medical issues. She provides health evaluations for pre and post adoption and publishes Adoption/Medical News, a newsletter on adoption health issues.
From the Children Youth and Family Consortium Electronic Clearinghouse.
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