International Adoptions

General Information

Approximately 20,000 infants and children are adopted from abroad each year by citizens of the United States. Infants and children from Asia, Central and South America, and Eastern Europe account for >90% of international adoptions. To complete an international adoption and bring an infant or a child to the United States, prospective parents must fulfill the requirements set by the Bureau of Citizenship and Immigration Services (BCIS) http://uscis.gov/graphics/index.htm (formerly the Immigration and Naturalization Service [INS]), the foreign country where the infant or child resides, and sometimes the state of residence of the adoptive parent(s). The adoption of a foreign-born orphan does not automatically guarantee the child's eligibility to immigrate to the United States. The adoptive parent needs to be aware of U.S. immigration law and legal regulatory procedures. An orphan cannot legally immigrate to the United States without BCIS processing.

An infant or child cannot be brought to the United States without an immigrant visa, issuance of which is based on a BCIS-approved petition (BCIS Form I-600A: Application for Advance Processing of Orphan Petition, which can be found at: http://uscis.gov/graphics/formsfee/forms/i-600a.htm). Detailed information about the procedures and requirements for international adoptions is available on the BCIS website at http://www.bcis.gov/graphics/services/index2.htm. When the Orphan Petition has been approved by the BCIS, the adoptive parent(s) can apply for an immigrant visa (IR-3) at the appropriate U.S. consular office abroad. In addition to the approved Orphan Petition, the consular officer will also require specific documentation, including a medical examination of the adoptee.

Adoptive parents who travel overseas to pick up their child should obtain pre-travel advice. They should be aware that unexpected complications in the adoption process may prolong their stay and should plan accordingly, especially if malaria prophylaxis or other important medication is needed. In addition, they need to take precautions regarding proper rest, food, water, and insect exposure to protect their own health, so that they can care for the child. Recently, an outbreak of measles was identified among children being adopted from China and their family members. Therefore, all travelling family members should be sure that they are up to date on recommended vaccinations, including MMR, prior to travel.

Overseas Medical Examinations

All immigrants, including infants and children adopted overseas by U.S. citizens, and refugees coming to the United States must have a medical examination overseas by a designated physician. The medical examination focuses primarily on detecting certain serious contagious diseases that may be the basis for visa ineligibility; prospective adoptive parents should be advised not to rely on this medical examination to detect all possible disabilities and illnesses. If an infant or a child is found to have an illness or disability that may make the child ineligible for a visa, a visa may still be issued after the illness has been adequately treated or after a waiver of the visa eligibility has been approved by the BCIS. If the physician notes that the infant or child has a serious disease or disability, the prospective parent(s) will be notified and asked if they wish to proceed with the infant's or child's immigration.

The medical examination consists of a brief physical examination and a medical history. A chest radiograph examination for tuberculosis and blood tests for syphilis and HIV are required for immigrants greater than or equal to15 years of age. Applicants <15 years of age are tested only if there is reason to suspect any of these diseases.

A new subsection of the U.S. Immigration and Nationality Act requires that any person seeking an immigrant visa for permanent residency must show proof of having received the vaccines recommended by the Advisory Committee on Immunisation Practices (ACIP) before immigration. While this new subsection now applies to all immigrant infants and children entering the United States, internationally adopted children <11 years of age have been exempted from the overseas immunisation requirements. Adoptive parents are required to sign a waiver indicating their intention to comply with the immunisation requirements within 30 days after the infant's or child's arrival in the United States.

Additional information about the medical examination and the vaccination exemption form for internationally adopted children are available on the Department of State website at http://www.travel.state.gov/adopt.html.

Follow-Up Medical Examination after Arrival in the United States

The varied geographic origins of internationally adopted infants and children, their unknown backgrounds before adoption (including parental history and living circumstances), and the inadequacy of health care in many developing countries make appropriate medical evaluation of internationally adopted children a complex and important task. An internationally adopted infant or child should be examined within 2 weeks of his or her arrival in the United States, but an adoptee who has an acute illness or a chronic condition needs immediate attention. All adopted infants and children should have a complete physical examination, a review of any available medical records, and age-appropriate screening tests, including evaluation for possible anaemia, vision and hearing impairments, and assessment of growth and development. Children >18 months of age should also have a dental evaluation.

Screening for Infectious Diseases

Infectious diseases, among the most common medical diagnoses, have been found in up to 60% of internationally adopted children, depending on their country of origin; many of these infections can be asymptomatic. Screening for these diseases is important for the health of the adopted infant or child as well as that of their adoptive family. The American Academy of Paediatrics recommends that all internationally adopted children be screened with the following: hepatitis B serology; HIV serology, syphilis serology, Mantoux intradermal skin test for tuberculosis, stool examination for ova and parasites, and complete blood count with red blood cell indices. Other screening tests may be recommended based on country of origin, risk factors, symptoms, or clinical findings. Laboratory reports from the country of origin should not be considered reliable.

Viral Hepatitis

Routine serologic screening for hepatitis A infection is not indicated. Many adopted children acquire hepatitis A virus infection early in life and are immune thereafter. However, for adopted children who will be residing in an area of the United States where routine hepatitis A vaccination is recommended, it may be cost effective to screen these children for previous immunity before initiating the vaccination series.

All internationally adopted children should be screened for hepatitis B infection, including hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs) and hepatitis B core antibody (anti-HBc). If a child is hepatitis B surface antigen (HBsAg) positive, all unvaccinated household contacts should receive the full vaccine series. Children who test positive for HBsAg should receive a medical evaluation for chronic hepatitis B infection. Children who do not have serologic evidence of previous infection should receive the full vaccine series.

Screening for hepatitis C should be considered for all infants and children adopted from Asia, Eastern Europe, or Africa. Hepatitis C testing for children adopted from other areas should be considered if the records indicate potential risk factors such as receipt of blood products or maternal drug use. Testing for hepatitis D, which is available at CDC, should be considered for children from the Mediterranean area, Africa, Eastern Europe, and Latin America who have chronic infection with hepatitis B virus.

HIV

Risk of HIV depends on country of origin and individual risk factors. However, because of the rapidly changing global epidemiology of HIV and often unknown backgrounds, screening for antibodies to HIV should be considered for all internationally adopted children. If test results are available from the adopted child's country of origin, repeat testing should be performed to confirm the overseas results. Antibodies in a child <18 months of age may reflect maternal infection without transmission to the infant, and infection in the infant should be confirmed with an assay for HIV DNA by polymerase chain reaction. Two negative tests obtained 1 month apart are required for the child to be considered uninfected.

Syphilis

Regardless of overseas testing results and/or history of treatment, internationally adopted children should be tested for syphilis by nontreponemal and treponemal serologic tests upon arrival. Children who have positive tests should receive further evaluation for treatment.

Tuberculosis

Mantoux tuberculin skin testing (TST) is recommended for international adoptees because their rates of TB infection are several times higher than those of U.S.-born children. The definition of a positive TST for children born in regions of the world with high TB prevalence is greater than or equal to10 mm of induration. If the TST is positive, a chest radiograph must be performed to evaluate for active TB disease. If evidence of TB disease is found, efforts to isolate an organism for sensitivity testing are very important because of the high proportions of drug resistance in many other countries, including countries in Eastern Europe, the former Soviet Union, and Asia.

Receipt of BCG vaccine is not a contraindication for TST. After BCG immunisation, however, distinguishing between a positive TST result caused by M. tuberculosis infection and that caused by BCG can be difficult. However, infection with M. tuberculosis should be strongly suspected in any asymptomatic child with a positive TST result, regardless of history of BCG immunisation. Circumstances that increase the likelihood that a positive TST is due to TB infection include contact with a person with active TB, immigration from a country with high TB prevalence, or a long interval since the last BCG immunisation. Because BCG does not prevent infection with TB and because of the high risk for exposure in most countries where BCG is given, the AAP recommends that children with a positive TST be given 9 months of isoniazid therapy.

Parasites and Intestinal Pathogens

Up to 35% of internationally adopted children have ova or parasites identified on stool examinations. Internationally adopted children should have a complete blood count with a peripheral eosinophil count, which may be an indicator of parasitic disease infection. Regardless of the eosinophil count, all internationally adopted children should be screened initially with three separate stool samples, collected on 3 separate days, analyzed for ova and parasites. If enteric symptoms develop in the future, these tests should be repeated, even if it has been several years after arrival in the United States. For Giardia intestinalis and Cryptosporium parvum infection, stool examination for antigen by enzyme immunoassay may be more sensitive than microscopic exam. Giardiasis is particularly prevalent in internationally adopted children from Eastern Europe. Strongyloides stercoralis serologic testing, available at CDC on request through the state public health laboratory, should be considered for children who have a high eosinophil count.

Children from schistosomiasis-endemic areas should have serologic tests for schistosomiasis performed at CDC. These tests may be requested through the state public health laboratory,

Children with diarrhoea should also be evaluated for bacterial organisms, including Escherichia coli species, Salmonella species, Shigella species, and Campylobacter species.

Ectoparasites

Internationally adopted children should be carefully examined for scabies and lice, so that they can be appropriately treated and to prevent infestation of family members and contacts.

Evaluation for Other Medical Problems

Lead

Potentially dangerous levels of lead have been reported in internationally adopted children, particularly those from China, Cambodia, Russia, and other countries in Eastern Europe. Lead exposure in other countries can result from a variety of sources, including leaded gasoline exhaust, ceramic ware, and traditional medicines. All children from these areas of the world and any others in whom lead toxicity is suspected should be screened, with follow-up and treatment based on standard guidelines. Information about lead poisoning is available at www.cdc.gov/nceh/lead/lead.htm or by calling 1-800-232-6789.

G6PD Deficiency

This enzyme deficiency is relatively common in persons from Asia, the Mediterranean area, and Africa. Screening for this deficiency in children from these areas should be considered before drugs are prescribed that can cause haemolysis in persons who have G6PD deficiency.

Vaccination

Internationally adopted children <11 years of age are not required to have vaccinations before arrival in the United States as long as the adoptive family signs a waiver stating that they will have the child vaccinated within 30 days of arrival in the United States.

Internationally adopted infants and children frequently are underimmunised and should receive necessary immunisations according to recommended schedules in the United States (see Table 8-2). In a retrospective review of records of 504 children, 65% had no written records of overseas vaccination. Among the 178 children with documented overseas vaccination, 167 (94%) had valid records and some vaccine doses that were acceptable and up to date under the U.S. schedule.

In assessing the immunisation status of an internationally adopted child, only written documentation should be accepted as proof of receipt of immunisation. In general, written records are deemed valid if the vaccine type, date of administration, number of doses, intervals between doses, and age of the patient at the time of administration are comparable with the current U.S. schedule. Although some vaccines with inadequate potency have been produced in other countries, most vaccines used worldwide are produced with adequate quality control standards and are reliable. However, immunisation records for some internationally adopted children, particularly those from orphanages, may not reflect protection because of inaccurate or unreliable records, lack of vaccine potency, poor nutritional status, or other problems. For any child, if there is any question as to whether the immunisations were administered or were immunogenic, the best course is to repeat them. Vaccination is generally safe and avoids the need to obtain and interpret serologic tests.

In an older infant or child who is thought to have been vaccinated appropriately, judicious use of serologic testing can be helpful in determining which immunisations may be needed and can decrease the number of injections required. Verification of protection from MMR vaccine requires testing for antibodies to each virus. Serology is of limited availability or difficult to interpret for Haemophilus influenzae type b (Hib) and poliovirus. Vaccination for these as well as varicella and pneumococcal disease, which are not administered in most countries, should be administered to internationally adopted children based on age and medical history.

Data indicate increased risk of local adverse reactions after the fourth and fifth doses of DTP or DtaP. In some circumstances, judicious use of serologic testing of antibody levels to assess immunity may be helpful in decreasing the possibility of vaccine side effects. For children whose records indicate that they have received >3 doses, options include initial serologic testing or administration of a single booster dose of DTaP, followed by serologic testing after 1 month. If a severe local reaction occurs after revaccination, serologic testing for specific IgG antibody to tetanus and diphtheria toxins can be measured before additional doses are administered. No established serologic correlates exist for protection against pertussis, but protective concentrations of antibody to both diphtheria and tetanus toxin can serve to validate the vaccination record.

In the United States, multiple outbreaks of measles have been reported in children who were recently adopted from China and in their U.S. contacts. Measles outbreaks among children in Chinese orphanages were also reported. In 2002 and 2004, adoptions from the affected orphanages were temporarily suspended while Chinese authorities implemented measures to control and prevent further transmission of measles among adopted children. Prospective parents who are travelling internationally to adopt children, as well as their household contacts, should ensure that they have a history of natural disease or have been vaccinated against measles according to guidelines of the Advisory Committee on Immunisation Practices. All persons born after 1957 should receive two doses of measles-containing vaccine.

Bibliography
  • American Academy of Paediatrics. Medical evaluation of internationally adopted children for infectious diseases. In: Pickering LK, editor. Red book: 2003 report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Paediatrics; 2003. p. 173-180.
  • Atkinson WL, Pickering LK, Schwartz B, et al. General recommendation on immunisations. Recommendations of the Advisory Committee on Immunisation Practices (ACIP) and the American Academy of Family Physicians (AAFP). Morbid Mortal Wkly Rep MMWR. 2002;51(RR-2):1-35.
  • CDC. Measles outbreak among internationally adopted children arriving in the United States, February - March 2001. Morbid Mortal Wkly Rep MMWR. 2002 51:1115-6.
  • CDC. Multistate investigation of measles among adoptees from China — April 9, 2004. Morbid Mortal Wkly Rep MMWR. 2004;53:309-10.
  • CDC. Update: measles among children adopted from China. Morbid Mortal Wkly Rep MMWR. 2004;53:459.
  • Schulte JM, Maloney S, Aronson J, et al. Evaluating acceptability and completeness of overseas immunisation records of internationally adopted children. Paediatrics. 2002; 109:e22.

- Michelle Weinberg and Susan Maloney

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