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Health Concerns and International Adoption

Reprinted with permission from Passport Health

Foreign adoptions are on the rise. From 1989 to2002, U.S. families adopted more than 167,000 children internationally. In 2002, U.S. citizens adopted 20,099 children from 20 countries. During the past decade, the countries from which most children have been adopted have changed. In 1989, children were adopted most frequently from Korea, Colombia, India, the Philippines, and Chile. By 2002, only Korea remained in the list of top five countries; China, Russia, Guatemala, and the Ukraine replaced the other four countries. This shift can be associated with a change in disease epidemiology in adopted children. The outbreaks of severe acute respiratory syndrome (SARS) illustrate the dynamic relationship of infectious disease and travelers and the need to have up-to-date information. In April 2004, the Centers for Disease Control and Prevention temporarily suspended adoption processing from an orphanage in China’s Hunan Province after nine cases of measles in recently adopted children were determined. This is the second time since 1997 that the agency suspended foreign adoptions. The previous suspension occurred in February 2001, and was also related to measles outbreak that originated in a Chinese orphanage. These events demonstrate how adoptive parents must be tuned in to a range of healthy issues that can arise with foreign-born children. Parents should select a pediatrician who knows how to recognize childhood diseases that are becoming less familiar to doctors in the U.S. Measles is one of the most infectious diseases in the world, but the U.S. sees fewer than 100 measles cases a year on an average, mostly imported from other countries.

The families of internationally adopted children face health risks associated with travel when picking up their adopted children overseas. Unlike other travelers, they may be at increased risk because the child’s immunization status is often unclear and these children may harbor infections. Tuberculosis, hepatitis A, hepatitis B, and measles have been transmitted from adoptive children to family and community members. Intestinal parasites and other infectious diseases can also be transmitted. Some of these infections may not manifest in adopted children until many years after the adoption. Practitioners providing health care to families planning international adoption should know about standard pre-travel advice, as well as possible infections that may affect adopted children. By doing so, they can protect the health of the travelers, family members and close friends who will welcome the new child into the home.

Adoptee's often arrive in the U.S. without in-depth information on the past medical history or social environment. Records are frequently unavailable, offer little information, or sometimes, even falsely recorded. Records that seem “too perfect” are often times, just that. Even when vaccines have been given reliably, the immune response may have been inadequate in severely malnourished or chronically ill children. When in doubt, it’s always best to repeat the series of vaccinations, as there is no harm in re-immunize internationally adopted children against the vaccine-preventable diseases specified by immigration law, and to screen them for HIV, tuberculosis, parasites, and hepatitis C. U.S. law passed in 1996 requires all immigrants applying for a permanent visa to show proof of immunity of several vaccine-preventable diseases, such as measles, mumps, polio, and hepatitis B. The law has been amended and now exempts adopted children under 11 years of age. Proponents of this amendment argued that the requirements placed an unnecessary burden on children and lengthened what is already a heavily bureaucratic and emotionally exhausting experience for the adoptive parents.

In addition to following through on screening and vaccinations, parents of newly adopted children should cocoon for a few weeks after their arrival at home. Even though this is a time when it is customary to show off the newest member of the family, it is especially important in those initial weeks to minimize contact between the child and family members of friends who have compromised immune systems. About one-half of internationally adopted children will have an acute illness within the first month after arrival. The first response of the new adoptive parent is to rush the child to the physician for a full check-up. Most early illnesses are simple pediatric conditions, such as URI (upper respiratory infections), gastroenteritis or skin infections. It is advisable to follow all acute illnesses closely to resolution. Failure to improve as expected, or to resolve completely may be the first indication of an underlying condition. Among those conditions that would warrant immediate attention are some vaccine-preventable diseases and malaria, depending on the origin of the adoptee.

Although hepatitis B vaccine programs are public health policy in some countries, the circumstances that leave a child available for adoptions are the same as those that afford the child the least access to medical care. Some experts advise against screening children before adoptions as the testing process itself may be yet another source of infection. The screening results may also be inaccurate or misinterpreted.

Tuberculosis (TB) remains a significant problem among adoptee's. It is prevalent in many host countries and is a silent infection in children. All children should be screened at arrival and at any time they develop systems compatible with TB. Routine ppds (purified protein derivative) are often mandated.

Until recent years, HIV infections had not been a major issue in international adoption. Now, adoptive parents are presented with a new dilemma about pre-adoption screening.

In order to protect the adoptive families, immunization records of travelers should be reviewed to update routine vaccinations such as measles, tetanus/diphtheria and polio. Travelers to most parts of the world will benefit from protection against hepatitis A and B. In areas where safety of food and water cannot be guaranteed, protection against typhoid is also desirable. Travelers to parts of Africa and South America where yellow fever is epidemic should receive yellow fever vaccine and information about preventing mosquito bites. Individuals traveling to parts of Asia and the Indian subcontinent in the rainy season may be candidates for Japanese Encephalitis, especially if travel includes rural areas during transmission season. Rabies is a serious problem in parts of Asia, Africa, and Latin America and is present in Eastern Europeans well. Adoptive families planning extended travel to remote areas should be advised to avoid befriending animals and should consider pre-exposure rabies.

Families traveling to areas where malaria is present should be protected against malaria. Using insect repellant's with 20% to 30% DEET and permetherin spray for bedding and clothing can significantly reduce exposure to mosquitoes. Choice of an anti-malarial agent depends on the destination country, medical history, length of stay, and to some degree, personal preference.

As the number of international adoptions continues to increase, so does the need to protect adoptive families, not just for those who are traveling, but also in the entire household. Pre-travel evaluation of adoptive families should include updating routine immunizations including the hepatitis B series for all family members. Pre-travel advice should include country specific health and security information for the family members traveling, instructions and supplies for the adoptee and preparation of household members who will assist with the care of the child upon arrival.