International Adoptions

General Information

Approximately 15,000 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, a prospective parent or parents must fulfill the requirements set by the Bureau of Citizenship and Immigration Services (formerly the Immigration and Naturalization Service [INS]), the foreign country in which 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 an BCIS-approved petition (BCIS Form I-600A: Application for Advance Processing of Orphan Petition). 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 go 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 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 traveling family members should be sure that they are up to date on recommended vaccinations, including MMR, prior to travel.

Overseas Medical Examination for Internationally Adopted Children

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 any 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 or child's immigration.

The medical examination procedure consists of a brief physical examination and medical history. A chest radiograph examination for tuberculosis and blood tests for syphilis and HIV are required for immigrants >15 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 Naturalization Act requires that any person seeking an immigrant visa for permanent residency must show proof of having received the recommended vaccines (as established by the Advisory Committee on Immunization Practices [ACIP]; see Chapter 1, Vaccination Information) 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 immunization requirements. Adoptive parents are required to sign a waiver indicating their intention to comply with the immunization requirements within 30 days after the infant or child's arrival in the United States.

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

Follow-Up Medical Examination after Arrival in 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 resource-poor 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, review of any available medical records, and age-appropriate screening tests, including evaluation for possible anemia, 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 are among the most common medical diagnoses and 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 Pediatrics recommends that all internationally adopted children be screened with the following: hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody; HIV serology, syphilis serology, Mantoux (Purified Protein Derivative, PPD) intradermal skin test, 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, as many of these adopted children acquire HAV infection early in life, and are therefore immune, and chronic HAV infection does not occur. Internationally adopted children should be screened for hepatitis B infection. Presence of surface antigen indicates ongoing infection with the hepatitis B virus and potential for liver injury and spread to family members. If a child is HBsAg positive, all unvaccinated household contacts should receive the full vaccine series. Infants and children from Asia or Eastern Europe should be screened for hepatitis C, as should children from other areas if the records indicate potential risk factors such as receipt of blood products or maternal drug use. Testing for hepatitis D should be considered in children from the Mediterranean area, Africa, Eastern Europe, and Latin America who are infected with hepatitis B.

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.

Tuberculosis

Mantoux (PPD) skin testing is recommended for international adoptees because their rates of TB infection are several times higher than in U.S.-born children. The definition of a positive tuberculin skin test for children born in regions of the world with high TB prevalence is 10mm of induration. If the skin test 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 PPD testing. After BCG immunization, 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 immunization. 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 immunization. Because BCG is not fully protective and because of the high risk for exposure in most countries where BCG is given, the AAP recommends that children with a positive PPD skin test be given 9 months of isoniazid therapy.

Intestinal Parasites

Up to 35% of internationally adopted children have ova or parasites identified on stool examinations. Internationally adopted children should be screened initially and then at any time if enteric symptoms develop, even years after arrival in the United States. For Giardia lamblia infection, stool examination for antigen by enzyme immunoassay may be more sensitive than microscopic exam. This infection is particularly prevalent in internationally adopted children from Eastern Europe.

Ectoparasites

Internationally adopted children should be carefully examined for scabies and pediculosis, so that they can be appropriately treated and so that family members and contacts do not become infested.

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 URL: 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 prescribing drugs that can cause hemolysis in persons who have G6PD deficiency.

Vaccination

Internationally adopted infants and children frequently are underimmunized and should receive necessary immunizations according to recommended schedules in the United States (see Table 7–1). When assessing the immunization status of an internationally adopted child, only written documentation should be accepted as proof of receipt of immunization. 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 to 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, immunization 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 immunizations were administered or were immunogenic, the best course is to repeat them. Doing so is generally safe and avoids the need to obtain and interpret serologic tests. Detailed recommendations from ACIP are available in MMWR, February 8, 2002 (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5102a1.htm).

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 immunizations 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 polio virus. 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, and 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.

Other sources of recommendations for the medical evaluation of adopted infants and children is the American Academy of Pediatrics, including the publication 2000 Red Book: Report of the Committee on Infectious Diseases, 25th edition, and the AAP policy statement, “Initial Medical Evaluation of an Adopted Child,” published in Pediatrics, Volume 88, Number 3, September 1991.

— Tamara Fisk, Susan Maloney