Thousands of international adoptees join families in the United States every year. Many have been in institutional care and are from countries or areas with a high risk of several infectious diseases. Focused infectious disease testing is important to ensure the health of the adoptee, as well as their new family and the larger community in which they now live. Newly arrived internationally adopted children should be screened for specific infections, including viral, bacterial, and parasitic infections. They should ideally be seen shortly after arrival by a multidisciplinary team at a center specializing in international adoption.
Key points
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The infectious and noninfectious health issues of international adoptees (IAs) are complex. Where possible, IAs should be evaluated at a clinic or a center specializing in international adoption, as specialized expertise and a multidisciplinary approach are often required for optimal evaluation and care of these children.
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IA children often have noninfectious health concerns, notably developmental delays and exposure to alcohol in utero, which require screening and evaluation by experts in these areas.
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Screening for specific infections for which IAs are at higher risk is important to prevent short- and long-term morbidity from these infections.
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Infections for which IAs are at higher risk and therefore require screening include viral (hepatitis A, B, and C and human immunodeficiency virus [HIV]), bacterial (syphilis and tuberculosis), and parasitic (stool helminths and Giardia ) infections.
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All persons who will be in close contact with IAs should be vaccinated with hepatitis A vaccine or documented as immune to hepatitis A before the adoption of the IA child.
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Latent tuberculosis infection (LTBI) occurs in 21% to 28% of IAs. All IAs should be tested for tuberculosis on arrival and again 6 months after arrival (tuberculin skin test [TST] in children <5 years of age, TST or interferon-gamma release assay (IGRA) in children ≥5 years of age).
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It is critical to follow up on the results of tuberculosis screening and to treat children with LTBI with appropriate therapy, as children younger than 4 years with LTBI have the greatest risk of developing tuberculosis (TB) disease.
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Other infectious disease testing depends on specific risk factors.
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If history or physical findings are suggestive of sexual abuse, test for gonorrhea and chlamydia.
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If the child lived in a malaria endemic area, perform a blood smear for malaria.
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If the child has eosinophilia that persists after successful treatment of helminth infection, test for Toxocara canis and Strongyloides and, if from a schistosomiasis endemic area, for schistosomiasis.
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Introduction
The number of international adoptions in the United States approached 16,000 in 1998, peaked at almost 23,000 in 2005, and was 9319 in 2011. For more than 30 years, until 1995, South Korea had been the leading country for international adoption in the United States. As of 2011, the 5 main countries of origin for adoptions to the United States are China, Ethiopia, Russia, South Korea, and Ukraine.
In the 1980s, physicians began to research and understand the increased risks infectious diseases present in the internationally adopted population. Poor or absent prenatal care and low socioeconomic resources are common among IAs. Prenatal risk factors such as maternal illness, malnutrition, and exposures to maternal infectious diseases or drug or alcohol exposures, as well as orphanage and institutional care, all contribute to the increased potential for medical and infectious diseases in IAs. The first American Academy of Pediatrics (AAP) recommendations regarding universal screening for infectious and noninfectious diseases were issued in 1991 given low rates of complete IA screening after arrival to the United States at that time.
IAs often have complex medical and psychosocial health problems that go beyond infectious disease issues. These health problems are beyond the scope of this article but have been summarized in other recent reviews. IAs should ideally be evaluated at a clinic specializing in international adoption, because of the medical complexity of many of the health problems in these children and the need for a multidisciplinary team with expertise and experience in these health problems. Health screening of IAs should be done within the first 2 to 3 weeks postadoption to allow the children to first settle in with their adoptive family and then be seen for a comprehensive examination by an adoption provider or general pediatrician.
Evaluation of the IA child should start with a detailed history and physical examination, followed by routine screening for specific infectious diseases, micronutrient deficiencies, developmental delays, and tailored additional screening based on risk factors elicited from the history and physical examination.
Introduction
The number of international adoptions in the United States approached 16,000 in 1998, peaked at almost 23,000 in 2005, and was 9319 in 2011. For more than 30 years, until 1995, South Korea had been the leading country for international adoption in the United States. As of 2011, the 5 main countries of origin for adoptions to the United States are China, Ethiopia, Russia, South Korea, and Ukraine.
In the 1980s, physicians began to research and understand the increased risks infectious diseases present in the internationally adopted population. Poor or absent prenatal care and low socioeconomic resources are common among IAs. Prenatal risk factors such as maternal illness, malnutrition, and exposures to maternal infectious diseases or drug or alcohol exposures, as well as orphanage and institutional care, all contribute to the increased potential for medical and infectious diseases in IAs. The first American Academy of Pediatrics (AAP) recommendations regarding universal screening for infectious and noninfectious diseases were issued in 1991 given low rates of complete IA screening after arrival to the United States at that time.
IAs often have complex medical and psychosocial health problems that go beyond infectious disease issues. These health problems are beyond the scope of this article but have been summarized in other recent reviews. IAs should ideally be evaluated at a clinic specializing in international adoption, because of the medical complexity of many of the health problems in these children and the need for a multidisciplinary team with expertise and experience in these health problems. Health screening of IAs should be done within the first 2 to 3 weeks postadoption to allow the children to first settle in with their adoptive family and then be seen for a comprehensive examination by an adoption provider or general pediatrician.
Evaluation of the IA child should start with a detailed history and physical examination, followed by routine screening for specific infectious diseases, micronutrient deficiencies, developmental delays, and tailored additional screening based on risk factors elicited from the history and physical examination.
Medical history and physical examination
All IAs require a thorough history and physical examination, as many have medical, social, or behavioral issues that require investigation in addition to infectious issues. With regards to infectious disease, key findings to be assessed in IAs by medical history and physical examination are summarized in Tables 1 and 2 .
| History | Comments |
|---|---|
| Care before adoption | Evaluate for risk of abuse, sexually transmitted diseases |
| Time spent in institution | Prolonged time in institution is related to increased risk of diarrhea, tuberculosis, and other infectious diseases |
| Growth chart, if available | May see stunting with infectious diseases such as repeated episodes of diarrhea or recurrent malaria |
| Maternal infection history, including syphilis and HIV testing | Often not known |
| Immunization records, including BCG | See section on immunization; records often unreliable |
| Country of origin | Institutional care and poor country resources can increase risk of infectious diseases |
| Examination Area | Specific Signs |
|---|---|
| Height, weight | — |
| Skin | Look for birthmarks, signs of abuse (eg, bruises), signs of infection (eg, scabies and tinea) |
| Face | Signs of fetal alcohol spectrum disorder or other syndromes |
| Abdomen | Hepatosplenomegaly (could indicate several infectious and noninfectious diseases, including malaria, schistosomiasis, sickle cell disease) |
| Genitalia | Signs of abuse, sexually transmitted diseases, ritual or other circumcision, precocious puberty |
| Head circumference (OFC) | Microcephaly or macrocephaly are clues to cognitive issues, prenatal infections, and other medical issues (eg, hydrocephalus and rickets) |
Infectious disease screening
Recent guidelines for IA health screening tests were published in the Yellow Book in 2010 and in the Red Book in 2012. Fig. 1 summarizes the routine infectious disease and other screening tests performed on all IA children seen at the University of Minnesota International Adoption Clinic (IAC), and Table 3 summarizes the screening done if prompted by specific findings on history taking or physical examination.
| Indication | Test |
|---|---|
| Infectious Disease Screening | |
| Suspected sexual abuse | Neisseria gonorrhea and Chlamydia trachomatis PCR |
| Resided in malaria endemic area | Thick and thin blood smear for malaria |
| Diarrhea with fever, especially if bloody diarrhea is present | Stool cultures |
| Eosinophilia | Depending on area and risk factors, consider testing for antibodies to Schistosoma species, Strongyloides stercoralis , and T. canis a |
| Other Screening | |
| Clinical findings consistent with disorders assessed in newborn screen | Newborn screen for congenital metabolic and other disorders |
a Recommend sending to the Centers for Disease Control and Prevention laboratories.
Vaccine Preventable Infections
Immunization practices for IAs vary widely in the countries of origin, as well as in what is done for adoptees once they join their families in the United States. Vaccines vary by country, and availability of vaccines is variable depending on the country of birth. Rarely do vaccine schedules meet US standards, due to cost and other factors ( Table 4 ).
| Ukraine | Ethiopia | South Korea | Russia | China | |
|---|---|---|---|---|---|
| MMR | M12, Y6 | (Measles only, W6) | M12–15, Y4–6 | Y1, Y6 | M18 |
| DTaP | M3, M4, M5 | W6, W10, W14 | M2, M4, M6, M15–18, Y6 | M3, M4.5, M6, M18, Y6 | M3, M4, M5, M18 |
| DT | Y6 | Y11–12 | Y6–7, Y14 | Y6 | |
| Hib | M3, M4, M18 | W6, W10, W14 | M6, M7 | M6, M7 | |
| HepB | B, M1, M6 | W6, W10, W14 | B, M1, M6 | B, M1, M6 | B, M1, M6 |
| BCG | D3, Y7 | B | B-W4, variable | D3, Y7, Y14 | B |
| IPV/OPV | IPV: M5, M18, Y6, Y14, | OPV: W6, W10, W14 | IPV: M2, M4, M6, Y4–6 | IPV: M3, M4.5, then OPV M6, M18, M20, Y14 | OPV: M2, M3, M4, Y4 |
| PCV | W6, W10, W14 | ||||
| VZV | M12–15 | ||||
| HepA | M12–15 | M18 |
Studies of IAs have shown wide variation in the response rate to vaccinations, with as low as a 56% response rate to the mumps vaccine in children from China. Inaccurate documentation, poorly stored vaccines, stressed immune systems, and timing issues can all contribute to the lack of response. For this reason, 2 options exist for IAs as recommended by the AAP. First, in any age but especially in children younger than 6 months, it is acceptable to choose to start over and fully reimmunize. Alternatively, titers can be sent to demonstrate immunity to given/documented vaccinations or illnesses reported (eg, hepatitis A and varicella).
Measles/mumps/rubella (MMR), hepatitis A and B, polio, diphtheria/tetanus, Haemophilus influenzae type b, and varicella are all vaccination titers that can be verified by serology. Although pertussis titers do not correlate well with immunity, if immunity is demonstrated to diphtheria and tetanus, pertussis immunity is assumed. If protective titers are documented for a vaccine, the IA child does not need to be revaccinated, and families can proceed with vaccinations that were not available/given at the typical schedule for age. However, if protective titers are not found for a specific vaccine, then the primary care physician should restart vaccinations on the catch-up schedule available online at http://www.cdc.gov/vaccines/schedules/downloads/child/catchup-schedule-pr.pdf .
Vaccinations such as the pneumococcal conjugate, hepatitis A, MMR, and varicella vaccines are frequently not available before adoption and should be tested for with titer or restarted.
Bacterial Infections
Tuberculosis
TB is caused by Mycobacterium tuberculosis complex organisms. One-third of the world is estimated to have infection with M. tuberculosis , and every year, 9 million people develop clinical disease caused by the infection. Approximately 1 million cases of TB (11%) occur in children younger than 15 years Twenty-two high-prevalence countries have been identified as having 80% of the TB cases worldwide. All 10 countries with the highest numbers of adoptees to the United States, including Russia, Ethiopia, Vietnam, China, and India, are on this list. LTBI is defined as a positive result on IGRA, for example, the QuantiFERON-GOLD blood test, or a positive result on TST, with no clinical evidence of active pulmonary disease by radiographic imaging. LTBI was present in 21% to 28% of all IAs in 2 recent surveys.
The bacille Calmette-Guérin (BCG) vaccine is given to newborns in 157 countries. A comprehensive database of countries that administer BCG vaccination is available at http://www.bcgatlas.org/ . Although BCG vaccination within 6 months of a TST may result in a false-positive TST result, the AAP and Centers for Disease Control (CDC) recommend that TST results be interpreted according to standard guidelines, regardless of BCG vaccination history. The vast majority of IAs are older than 6 months, and therefore, it has been more than 6 months since their BCG vaccination, which is typically done at birth. For the small percentage of IAs who have a still-healing BCG scar or known BCG immunization within the past 6 months, some clinicians would defer a TST in children until greater than 6 months after the immunization, but care should be taken that testing is done on follow-up and not missed. BCG administration does not affect IGRA testing.
The AAP recommends screening for TB (TST in children <5 years of age; TST or IGRA in children ≥5 years of age) in all internationally adopted children. Children in the international adoption system are seen and examined by panel physicians in their country of origin. Panel physicians are doctors who have been selected and trained for standardization by their respective governmental Department of State. They perform examinations for children who are applying for visas, before travel. Panel examinations are generally limited to major or serious communicable disease and/or mental health defects. However, panel examinations do include evaluation for LTBI or TB in children 2 to 14 years of age by TST, with chest radiograph testing in those with a positive TST result, and screening for TB in children 15 years or older. Children younger than 2 years do not have any screening for LTBI or TB unless they have symptoms of TB.
Because many IAs are younger than 2 years and the quality of TST administration can vary among sites, the authors recommend that all IAs be screened for TB when seen in the United States, regardless of prior testing. IA children should be screened by TST if younger than 5 years and may be screened by TST or IGRA if 5 years or older. In IA children, without other major risk factors for TB, a positive TST result is 10 mm of induration. Children should be retested by TST or IGRA 6 months after adoption, as up to 20% may be negative on initial testing but positive on testing 6 months later. All children with a positive TST or IGRA result must have a chest radiograph and repeat physical examination to assess for evidence of tuberculous disease. An algorithm for evaluation and treatment of TB and LTBI is outlined in Fig. 2 .
