Infectious Diseases Among Internationally Adopted Children
Abstract & Commentary
Synopsis: Children adopted from abroad have a high prevalence of latent tuberculosis, giardiasis, and chronic HBV infection.
Source: Saiman L, et al. Pediatrics. 2001;108:608-612.
This is a retrospective study of a cohort of 504 children adopted from abroad from January 1997 through December 1998 evaluated at an outpatient international adoption practice in New York. These children were from 16 countries, although most were born in China (48%) and Russia (31%). The mean age was 1.4 years (range, 1 month to 11.2 years). They showed high rates of positive tuberculin skin tests and Giardia lamblia infection. Overall, 75 (19%) of 404 children had tuberculin skin tests > 10 mm, which was associated with bacille Calmette-Guérin (BCG) vaccination (odds ratio [OR] 7.37; 95% CI, 2.19-17.16) and birth in Russia (OR 2.90; 95% CI, 1.68-5.00). However, all children had normal radiographs. G lamblia antigen was detected in 87 of 461 (19%) children, and hepatitis B surface antigen was detected in 14 of 485 (2.9%) children. There were no cases of syphilis among 478 children tested, no cases of hepatitis C infection among 496 children tested, and no cases of HIV infection among 490 children tested.
Comment by Hal B. Jenson, MD, FAAP
United States citizens adopt more than 15,000 foreign-born children each year. Between 1960 and 1990, most internationally adopted children came from Korea, Latin America, and various Asian nations. Since 1990, greatly increased numbers of adopted children have come from Eastern European countries, especially Romania and Bulgaria, the former Soviet Union (particularly Russia), Kazakhstan, and Ukraine; and also from China, Cambodia, and Vietnam. Many of these children resided in orphanages before adoption. This report indicates changing patterns of infections seen among international adoptees as the countries of origin have changed.
In this cohort, 75 of 404 (19%) had positive tuberculin skin tests > 10 mm. Of the 404 children, 242 (60%) had evidence of BCG immunization, including 220 (54%) by scar, 83 (21%) by vaccination record, and 61 (15%) by both. All children had normal chest radiographs. The rates of positive skin tests and of previous BCG vaccination are substantially higher than reported among earlier cohorts, where BCG use was uncommon. Some of the positive skin tests could have been due to recent BCG vaccination, although no reliable criteria exist to distinguish infection from BCG vaccination as the cause of the positive skin test. The origin of many children from Russia, where multidrug-resistant tuberculosis is more frequent, is a concern. Consistent with current recommendations by the American Academy of Pediatrics, all skin test- positive children were recommended to receive isoniazid therapy for treatment of latent tuberculosis infection.
The highest prevalence of hepatitis B infection among international adoptees is among Romanian children, with reported rates of 20%. These children can be the source of intrafamily spread, although routine hepatitis B vaccination for all children and household contacts should reduce this possibility. There is not a consensus for reimmunizing adopted children with hepatitis B vaccine, although there is concern about use of outdated or poorly stored vaccine, and suboptimal responses in malnourished children. In this study, only 29 of 42 (69%) children who had received 3 doses of hepatitis B vaccine had detectable HBsAb, which corroborates such concerns.
Reported rates of G lamblia infections among adoptees have ranged from 0-18%. The use of G lamblia antigen rather than diagnosis by microscopy may have facilitated identification of infection, which was diagnosed in 87 of 461 (19%) children tested. Extremely high rates were found among adoptees from Eastern Europe, particularly Bulgarian (67%), Romania (50%), and Moldovan children (36%). Adoptees from China had a 15% G lamblia infection rate.
No infections were identified with syphilis, hepatitis C, or HIV. Infections with enteric bacteria were rare, and included Campylobacter (5 children), Shigella (3 children), and Salmonella (2 children).
Dr. Jensen, Chief, Pediatric Infectious Diseases, University of Texas Health Science Center, San Antonio, TX, is Associate Editor of Infectious Disease Alert.
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