International adoption: infectious diseases issues

Early-life influenza A (H1N1) infection independently programs brain connectivity, HPA AXIS and tissue-specific gene expression profiles

Early-life adversity covers a range of physical, social and environmental stressors. Acute viral infections in early life are a major source of such adversity and have been associated with a broad spectrum of later-life effects outside the immune system or "off-target". These include an altered hypothalamus-pituitary-adrenal (HPA) axis and metabolic reactions. Here, we used a murine post-natal day 14 (PND 14) Influenza A (H1N1) infection model and applied a semi-holistic approach including phenotypic measurements, gene expression arrays and diffusion neuroimaging techniques to investigate HPA axis dysregulation, energy metabolism and brain connectivity. By PND 56 the H1N1 infection had been resolved, and there was no residual gene expression signature of immune cell infiltration into the liver, adrenal gland or brain tissues examined nor of immune-related signalling. A resolved early-life H1N1 infection had sex-specific effects. We observed retarded growth of males and altered pre-stress (baseline) blood glucose and corticosterone levels at PND42 after the infection was resolved. Cerebral MRI scans identified reduced connectivity in the cortex, midbrain and cerebellum that were accompanied by tissue-specific gene expression signatures. Gene set enrichment analysis confirmed that these were tissue-specific changes with few common pathways. Early-life infection independently affected each of the systems and this was independent of HPA axis or immune perturbations.

Suboptimal Serologic Immunity Against Poliomyelitis Among New Migrant Children in Greece Calls for Organized Action

BACKGROUND

Migration-flows pose the risk of poliovirus reintroduction from endemic countries to Greece. This study aims to evaluate serologic-immunity/vaccination against poliomyelitis in newly-arriving migrant children.

METHODS

Demographic-immunisation data and blood-serum were obtained from migrants 1-14years-old, referred to a hospital-clinic in Athens-Greece within three months from arrival. Immunity to polioviruses-1-3 was determined by serum-neutralizing-antibodies(WHO guidelines). Titers ≥ 1:8 were considered positive.

RESULTS

From 9/2010 to 9/2013, 274 children(150 refugees/124 immigrants), mean age 7.1years-old, were enrolled. Only 57(20.8%) of them presented with vaccination-records. Children originated mainly from Asia(n = 198), Eastern Europe(n = 28), Middle East(n = 24) and Africa(n = 24) with 160(58.4%) from polio-endemic-countries(Afghanistan-112(40.8%), Pakistan-24(8.8%) and India-24(8.8%)). Seropositivity against polio-1-2&3 was 84.3%, 86.1% and 74.5%, respectively. Immigrants, had higher seroprotective rates against polioviruses-1-2&3 than refugees(polio-1:p = 0.002;polio-2:p = 0.004,polio-3:p < 0.001). Seronegativity to 1PVs-2PVs and all three polio serotypes was found in 37(13.5%),12 (4.4%), and 30 children(10.9%) respectively. Increasing number of vaccine-doses, and younger-age, were positively-associated with seropositivity.

DISCUSSION

A remarkable fraction of newly-arrived migrant-children were seronegative to one or more polioviruses.

Screening for parasites in migrant children

BACKGROUND

Globalization has pushed population movements in the last decades, turning imported diseases into the focus. Due to behavioral habits, children are at higher risk of acquiring iparasitosis. This study aims to investigate the prevalence of parasites in migrant children and factors associated with parasitic diseases.

METHOD

Retrospective cross-sectional study (2014-2018) including children diagnosed with parasitosis. The diagnosis was based on serology and/or microscopic stool-sample evaluation. Epidemiological and clinical data were recorded.

RESULTS

Out of 813 migrant children screened, 241 (29.6%) presented at least one parasite, and 89 (10.9%) more than one. The median age was 6.6 years (IQR: 3.1-11.9) and 58.9% were males. Most cases were referred for a health exam; only 52.3% of children were symptomatic, but 43.6% had eosinophilia. The most common diagnosis were giardiasis (35.3%), schistosomiasis (19.1%), toxocariasis (15.4%), and strongyloidiasis (9.1%). After the multivariate analysis, African origin and presenting with eosinophilia were the main risk factors for parasitism.

CONCLUSIONS

parasitosis are frequent among migrant children. Children are often asymptomatic, and thus active screening for parasitosis should be considered among high-risk populations. Eosinophilia can be useful to guide complimentary tests, as well as geographical origin, but normal eosinophil count does not exclude parasitosis.

Seroprevalence of Hepatitis C in Children Without Identifiable Risk-Factors: A Systematic Review and Meta-Analysis

OBJECTIVES

Hepatitis C virus (HCV) remains a major public health burden for >30 years since its discovery. It is estimated that >80 million people have been already infected. Direct-acting antiviral (DAA) treatment is now approved for young children over the age of 3 years. Treating children before the development of high-risk behaviors is optimal. Thus, assessing the current epidemiology of HCV in children becomes important and may promote awareness.

METHODS

Articles describing the prevalence of hepatitis C in children, were systematically reviewed. To assess HCV infection prevalence in the general population, studies discussing high-risk groups alone were excluded.

RESULTS

Data from 58 studies were analyzed. National data was scarce. An overall prevalence of HCV in children of 0.87% was found, ranging from 0.34% in Europe to 3.02% in Africa. Prevalence of viremic infection is important and data synthesis from available data indicated that HCV viremia was detected in 56.8% of children. The prevalence of HCV according to sex was described in 25 studies but no difference between sexes was detected. HCV prevalence was significantly higher in children older than 10 years (0.97%) when compared to those ages under 10 years old (0.75%, P < 0.001).

CONCLUSIONS

Considering probable underdiagnosis of HCV infection in children, this information reveals that prevalence is substantial. One may argue that future strategies aiming towards HCV elimination, may need to include antiviral treatment of pre-adolescent children as well.

Infections and nutritional status of internationally adopted children in France

AIM

In the context of global changes in the epidemiology of internationally adopted children (IACs), the prevalence of infectious diseases and nutritional impairment has not been recently reviewed. Moreover, in France, these characteristics of the children according to their continents of origin and preadoption special needs (SN) status have been incompletely explored.

METHODS

Demographic, infectious data and anthropometric of all the newly arrived IACs seen in a specialised clinic for international adoptees in Paris, France, between 2013 and 2016 were retrospectively reviewed.

RESULTS

Three hundred and fifty IACs [mean age: 3.4 years (±2.7), 204 male] from 39 countries were included; 55% had SN. Ninety-nine patients had at least one infection, 42% being classified as 'serious' (chronic viral infection, tuberculosis or malaria). Chronic viral infection was diagnosed in 26 (7%) patients (HIV: 16 cases, HBV: 5, HCV: 4) and affected especially Asian children (P < .001). The prevalence of stunting, underweight, wasting and microcephaly was, respectively, 25%, 22%, 15% and 8%. Stunting was more frequent in children from Eastern Europe (P = .02), while SN children were more often microcephalic or underweight (respectively P = .03 and .02).

CONCLUSION

The prevalence of serious infections and nutritional impairment remains high in IACs and requires early detection and careful follow-up.

Intestinal parasites may be associated with later behavioral problems in internationally adopted children

Aim

At arrival in new home country, internationally adopted children often have intestinal parasites. International adoptees also exhibit more behavioral problems than their biological peers. We examined whether intestinal parasite infections in international adoptees on arrival in Finland are associated with their later behavioral and emotional problems.

Methods

Data for this study were sourced from the Finnish Adoption Study (FinAdo) based on parental questionnaires for all internationally adopted children under 18 years (n = 1450) who arrived in Finland from 1985 to 2007. A total of 1293 families provided sufficient information on the adoptee’s background, parasitic status on arrival, and behavioral symptoms at the median time of 5 years after arrival (mean age = 7.8 years). Behavioral and emotional disorders were evaluated with the Child Behavior Checklist (CBCL). Statistical analyses were conducted using linear regression.

Results

Of the 1293 families, parents of 206 adoptive children reported intestinal parasites in their adopted children on arrival. Parasite-infected children had subsequently higher CBCL problem scores than the children without parasites (p < 0.001). The association between intestinal parasites and later behavioral problems was stronger than that between intestinal parasites and any other factors measured in this study, except disability.

Limitations

The control group was naturally provided by the adopted children without parasite infections, but we could not compare the adopted children to non-adopted children without a defined parasite infection. We were unable to specify the effects associated with a specific parasite type. It was not possible either to include multiple environmental factors that could have been associated with behavioral problems in the models, which indicated only modest explanatory values.

Conclusions

In this study, intestinal parasite infections in early childhood may be associated with children’s later psychological wellbeing, even in children who move to a country with a low prevalence of parasites. Our findings may support further developments pertaining to the gut-brain theory.

Prepared but unprepared: a qualitative study of provider perspectives on the preparation and adjustment of U.S. families who internationally adopt children with HIV

An increasing number of U.S. families are adopting children with HIV born outside the country. This exploratory qualitative study seeks to understand providers' perspectives on international adoptee and family preparation and adjustment to life in the U.S. Eleven psychosocial and five medical care providers participated in hour-long, semi-structured, recorded interviews focused on their experiences caring for internationally adopted children with HIV (IACH) and their adoptive parents. Transcribed interviews were analyzed to identify emergent themes. Providers described considerable variation among families who adopted children. Some had grown biological children and several adopted multiple children with special needs. Most were connected to communities of faith which served as an inspiration to adopt and offered support. Serious medical and HIV-related issues were minimal. Psychosocial concerns were more common and included attachment, adjustment, and behavioral issues. Participants noted that adoptive parents were well informed about HIV, but less prepared for cognitive delays and emotional challenges. Some providers experienced or expected to have challenges offering sexual and reproductive health education to adolescents due to their adoptive parents' religious beliefs on sexuality. Additional support managing behavioral and emotional challenges, as well as sexual education, may be needed especially as IACH transition into adolescence and young adulthood.

Cleft Care of Internationally Adopted Children From China

Objective:

To quantify a population of international adoptees from China with cleft lip and/or palate to assess presentations and team management practices.

Design:

Single institution retrospective.

Patients:

One hundred one patients with cleft lip and/or palate and history of international adoption from China.

Results:

Forty-nine males and 52 females were adopted from 2001 to 2014. Median age at arrival was 26 months. A total of 88.1% had a combined cleft lip and palate: 59 unilateral, 30 bilateral. Only 4 patients had isolated cleft palate. A total of 85.6% had cleft lip repair before adoption; 41.6% had both cleft lip and palate repairs in China. A total of 14.9% of adoptees had no prior surgery. In China, median age at lip repair was 10 months, and palate repair was 19 months. Once in the United States, lip repair was at 24 months and palate repair at 24 months. Eighty-three revision surgeries were performed. A total of 79.2% of children demonstrated moderate to severe articulation disorders. A total of 36.6% had velopharyngeal insufficiency with hypernasal speech. Forty percent required palatal revision surgery to achieve normal resonance. Fifty seven percent of patients presented with concomitant medical issues but less than 10% with global delays or autism.

Conclusions:

Chinese adoptees have more complex presentations and delayed surgical care compared to their domestic counterparts. Engaging prospective families starting before adoption helps to manage expectations. Long-range planning, timely surgery, aggressive therapy, and close careful follow-up can mitigate some of these differences. Speech and language problems including articulation disorders, expressive delays, and hypernasality are frequent and can persist despite interventions.

International adoption from Ethiopia: An overview of the health status at arrival in Belgium

BACKGROUND

Ethiopia is a densely populated country with a fast growing economy. Still socioeconomic and health issues render many children parentless. One thousand and twenty eight Ethiopian children have been adopted in Belgium from September 2005 to September 2015. Little has been published about their health status at arrival.

METHODS

Three hundred and fifteen children adopted from Ethiopia were clinically evaluated at the Institute of Tropical Medicine in Antwerp from 1 January 2008 until 31 December 2014. Epidemiological and medical data were collected and analysed retrospectively.

RESULTS

Data about 164 boys and 151 girls with a mean age of three years were analysed. Twenty per cent was adequately vaccinated, for 66.7% of children these data were absent. About 8.6% of the children were wasted/thin, 28.9% stunted. Skin abnormalities were seen in 40.3%, especially Tinea capitis. No children tested positive for HIV, syphilis or hepatitis C. Four children had an acute or chronic hepatitis B (HBV) infection, eight children had a cured HBV infection. Two children tested positive for malaria. Active pulmonary tuberculosis was found in six children. Sixty-two per cent had one or more intestinal parasite. Giardia lamblia (41.9%) and Blastocystis hominis (27.0%) were most frequently isolated. There is a statistically relevant association between the number of intestinal parasites and age at presentation. In this group eosinophilia had a sensitivity of 30.2%, a specificity of 79.1% for intestinal parasites and a positive likelihood ratio of 1.44 with a negative likelihood ratio of 0.88.

CONCLUSION

Apart from the high prevalence of stunting and intestinal parasites important medical problems were infrequent. A systematic clinical examination and screening for infectious diseases remain important to ensure a healthy start of a new life in Belgium.

Infectious diseases prevalence, vaccination coverage, and diagnostic challenges in a population of internationally adopted children referred to a Tertiary Care Children's Hospital from 2009 to 2015

Infectious diseases are common in internationally adopted children (IAC).With the objective to evaluate infectious diseases prevalence in a large cohort of IAC and to explore possible risk factors for tuberculosis (TB) and parasitic infections, clinical and laboratory data at first screening visit of all IAC (<18 years) consecutively referred to our Center in 2009 to 2015 were collected and analyzed.In total, 1612 children (median age: 5.40 years; interquartile range: 3.00-7.90) were enrolled, 123/1612 (7.60%) having medical conditions included in the special needs definition. The most frequent cutaneous infections were Molluscum contagiosum (42/1612; 2.60%) and Tinea capitis (37/1612; 2.30%). Viral hepatitis prevalence was <1% (hepatitis B virus [HBV]: 13 children, 0.80%; hepatitis C virus: 1 child, 0.10%; hepatitis A virus: 6 children, 0.40%). A parasitic infection was diagnosed in 372/1612 (23.10%) children. No risk factors for parasitosis were evidenced. Active TB was diagnosed in 4/1355 (0.3%) children, latent TB in 222/1355 (16.40%). Only 3.7% (51/1355) children had concordant positive tuberculin skin test (TST) and QuantiFERON-TB-Gold In-Tube (QFT-G-IT) results. Risk factors for TST+/QFT-G-IT- results were previous Bacille de Calmette-Guérin vaccination (adjusted odds ratio [aOR]: 2.18; 96% confidence interval [CI]: 1.26-3.79; P = 0.006), and age ≥5 years (aOR: 1.49; 95% CI: 1.06-2.11; P = 0.02). The proportion of children with nonprotective titers for vaccine-preventable diseases (VPD) ranged from 15.70% (208/1323) for tetanus to 35.10% (469/1337) for HBV.Infectious diseases were commonly observed in our cohort. The high rate of discordant TST/QFT-G results brings up questions regarding the optimal management of these children, and suggests that, at least in children older than 5 years, only QFT-G-IT results may be reliable. The low proportion of children protected for VPD, confirms importance of a timely screening.

Infectious Diseases and Immunizations in International Adoption

Children who are adopted internationally have an increased risk of infectious diseases due to endemic conditions and variable access to preventive health care, such as vaccines, in their country of origin. Pediatricians and other providers who care for children should be familiar with the recommended screening for newly arrived international adoptees. Testing for gastrointestinal pathogens, tuberculosis, hepatitis, syphilis, and HIV should be routinely performed. Other endemic diseases and common skin infections may need to be assessed. Evaluation of the child's immunization record is also important, as nearly all international adoptees will require catch-up vaccines. The provider may also be asked to review medical records prior to adoption, provide travel advice, and ensure that parents and other close contacts are up-to-date on immunizations prior to the arrival of the newest family member. The pediatrician serves a unique role in facilitating the evaluation, treatment, and prevention of infectious diseases in international adoptees. [Pediatr Ann. 2017;46(2):e56-e60.].

Clinical Practice and Knowledge in Caring: Breastfeeding Ties and the Impact on the Health of Latin-American Minor Migrants

In the context of the project "Clinical and social evaluation of medical practices in the treatment of infectious diseases in pediatrics for children of vulnerable population" carried out in 2013 by a multidisciplinary team at the National Institute for Health, Migration and Poverty (NIHMP) in Rome, a study in medical anthropology on the incorporation of illnesses that mothers feel they transmit to their children through breastfeeding was conducted. The results of the anthropological study, that targeted 34 children and adolescents from the age of 3 to the age of 17, all immigrants from Latin America residing in Italy, show that some forms of suffering in minors are described by women as being connected to factors such as susto ("fright"), coraje, muina, enojo ("anger") and mal de ojo ("evil eye"), and are in relation to a specific cultural frame. It is clear that barriers that prevent the access to the healthcare system must be removed, barriers that are accentuated by linguistic and cultural incomprehension, through adequate multidisciplinary healthcare settings such as the one we are presenting, composed of a medical doctor, an anthropologist and a cultural mediator.

Screening for parasite infections in immigrant children from low-income countries

INTRODUCTION

In Spain, minors represent approximately 20% of the immigration flow. Many of these immigrants come from countries in the tropics and sub-tropics where intestinal parasitic infections caused by helminths and protozoa are one of the major causes of human disease. The main objective of the present work was to describe parasite infections in a group of immigrant children.

METHODS

A prospective evaluation was performed in 373 minors from Sub-Saharan Africa, North Africa, and Latin America. Details were collected from the medical records and physical examination. Urine, stool and peripheral blood samples were obtained for serological and routine laboratory tests. Direct and indirect parasitological tests were also performed.

RESULTS

At least 1 parasitic disease was diagnosed in 176 (47.1%) immigrant children, while 77 (20.6%) minors were infected with two or more parasites. The number of parasites was highest in children from Sub-Saharan Africa compared with the rest of the areas of origin (p<.001), and in children from urban areas compared with those from rural areas (OR 1.27 [1.059-1.552], p=.011). The most frequent causes of multiple parasite infection were filariasis plus strongyloidiasis and filariasis plus schistosomiasis. Intestinal parasite infection was diagnosed in 38 cases (13.8%). Logistic regression analysis revealed that for each month of stay, the probability of a positive finding in the stool sample decreased by 0.02% [β=-0.020, (p=.07)].

CONCLUSIONS

The high infection rates of parasite diseases in immigrant children point to the need for screening protocols for certain infectious diseases in these children according to their country of origin and their length of residence in Spain.

Discordances Between Serology and Culture for Strongyloides in an Ethiopian Adopted Child With Multiple Parasitic Infections: A Case Report

RATIONALE

infectious diseases screening of international adoptees is complex because of the concurrence of different pathogens in a child at same time. We describe an international adopted child born at Ethiopia infected by 5 different pathogens (Hymenolepis nana, Giardia intestinalis, Entamoeba histolytica, Strongyloides stercoralis, and Trichuris trichiura), 2 of them S. stercoralis and E. histolytica with a capacity to develop severe clinical complications if not detected promptly with appropriate diagnosis tests.Concerns of the patient: according to the screening protocol a stool sample is always processed for culture addressed to find out protozoan and helminthic pathogens but not specifically for S. stercoralis. Only, when eosinophilia is detected 3 serial stool samples are collected to rule out intestinal parasitic infection including S. stercoralis.

INTERVENTIONS

in our case, S. stercoralis would not have been detected if we had followed the protocol because eosinophilia was absent and its specific serology was negative. Fortunately, the initial inclusion of the feces charcoal culture for S. stercoralis allowed us to detect this infection.

OUTCOMES

discordances between direct methods such as culture and indirect as serology or antigen test forces us to be very cautious before ruling out S. stercoralis or E. histolytica infection, respectively. Also, if a child from tropical areas has persistent symptoms (such as diarrhea or fever) that have not been treated we have to rule out other infections that have not been detected yet.Main lessons: The introduction of different sequencing tests and the insistence to find out pathogens such as S. stercoralis or E. histolytica was determinant to be able to cure this symptomatic child and to prevent potential severe clinical forms in case of immunosuppression.

Importation and Transmission of Parasitic and Other Infectious Diseases Associated with International Adoptees and Refugees Immigrating into the United States of America

Each year, hundreds of millions of people travel across international borders or even oceans, and up to 230 million may remain for long periods. Among these, 3–5 million settle permanently in their new homes, with about 1 million migrating permanently to the United States of America. This may result in transport of parasites and other pathogens, which might become established, infecting individuals in the new location. Beyond concern of disease spread, the health of migrants is of concern since the rigors, circumstances, and living conditions surrounding migrations may increase the vulnerability of migrants to infections. International adoptees and refugees are a small subset of these migrants but are of special significance inasmuch as adoptees may be more vulnerable to infection due to their immature immune status, and refugees may be more vulnerable due to substandard living conditions. Both originate from diverse regions, but often from environments of low hygiene and health care standards. This review examines recent examples of infections reported from adoptees and refugees entering the USA through 2010, highlighting the most common origin countries and the diseases most frequently involved, including Chagas disease, Balamuthia amebic meningoencephalitis, giardiasis, microsporidiosis, hepatitis, measles, pertussis, tuberculosis, malaria, intestinal helminths, and syphilis.

Frequency and characteristics of infectious diseases in internationally adopted children: a retrospective study in Nantes from 2010 to 2012

BACKGROUND AND AIMS

Internationally adopted children are more susceptible to developing and carrying acute or chronic infectious diseases. Specialized consultations exist in the main French cities; however, specialized consultation with a pediatrician is not mandatory. The main objective of this study was to determine the frequency and characteristics of infections (bacterial, viral, and parasitic) among a group of international adoptees in Nantes over a 3-year period.

METHODS

A retrospective chart review was conducted of internationally adopted children who went through the Medical Guidance for Adopted Children Consultation between 2010 and 2012.

RESULTS

A total of 133 children were included in the study. Of these, 55% had an infectious disease; 8% were severe infections. We found a frequency of 38% [confidence interval (CI) 95% 30-46] for parasitic intestinal and 35% (CI 95% 27-43) for dermatologic infections. African children were more likely to have infections that required hospitalization [odds ratio (OR) = 12, p = 0.004, CI 95% 1.3-113.7] and more likely to carry extended-spectrum β-lactamase-producing bacteria.

CONCLUSION

The frequency of infectious diseases, and sometimes severe diseases, found among our cohort of internationally adopted children highlights the need for systematic, specialized medical care.

Dermatologic conditions in internationally adopted children

Over 200,000 children have been adopted into United States (US) families from abroad since the year 2000. Health care providers who care for children adopted internationally should be aware of the spectrum of illnesses seen in this population, and should be prepared to encounter potentially unusual situations. An appreciation for the unique pre-adoption exposures and vulnerabilities inherent in international adoption is critical for proper diagnosis and treatment of this heterogeneous group of children. It is important to consider the impact of potential early childhood stressors such as nutritional, sensory, and emotional deprivation, trauma and abuse, as well as prenatal exposures to drugs, alcohol, and infectious diseases. Providers must also take into account international variation in health care practices, including immunization, treatment, surgical, and hygiene standards. The differential diagnosis for cutaneous eruptions in children adopted internationally is broad and must encompass endemic systemic illnesses with skin manifestations, such as measles, tuberculosis, leprosy, and congenital syphilis, and primary dermatologic diseases such as scabies and bacterial and fungal infections. The importance of maintaining a broad differential and open mind when addressing the dermatologic needs of these children cannot be overemphasized.

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Dermatologists caring for children adopted internationally should be prepared for unusual situations.

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It is important to consider potential iatrogenic and infectious exposures, early physical and psychosocial stressors, and international variation in health care practices.

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The importance of maintaining a broad differential and open mind in these cases cannot be overemphasized.

Hepatitis B and hepatitis C virus infections among antiretroviral-naive and -experienced HIV co-infected adults

Most HIV positive people have not been tested for viral hepatitis and their treatments have not been optimized for possible co-infections. The aim of this study was to investigate the serological pattern of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among antiretroviral (ARV)-naive and -experienced HIV co-infected adults in Addis Ababa, Ethiopia. A total of 500 frozen HIV positive serum and plasma samples collected from ARV-naive (n = 250) and -experienced (n = 250) adults were randomly selected and screened for HBsAg, anti-HBs, HBeAg and anti-HCV using rapid two-site sandwich immunochromatographic assay. The test was performed at Aklilu Lemma Institute of Pathobiology, Addis Ababa University. Positive specimens for HBsAg and anti-HCV markers were further confirmed using third generation ELISA. Of the 500 specimens tested, 15 (3 %), 58 (11.6 %), 3 (0.6 %), 18 (3.6 %), 3 (0.6 %) and 1 (0.2 %) were positive for HBsAg, anti-HBs, HBeAg, anti-HCV, HBsAg and HBeAg, and HBsAg and anti-HBs markers, respectively. No specimen tested positive for both HBeAg and anti-HBs, and 442 (88.4 %) individuals were non-immune to HBV. Of the 250 ARV-naive individuals, 8 (3.2 %), 33 (13.2 %), 2 (0.8 %), 10 (4 %), 2 (0.8 %), and 1 (0.4 %) were positive for HBsAg, anti-HBs, HBeAg, anti-HCV, HBsAg and HBeAg, and HBsAg and anti-HBs markers, respectively. Of the 250 ARV-experienced individuals, 7 (2.8 %), 25 (10 %), 1 (0.4 %), 8 (3.2 %), 1 (0.4 %), and 0 (0 %) were positive for HBsAg, Anti-HBs, HBeAg, anti-HCV, HBsAg and HBeAg, and HBsAg and anti-HBs markers, respectively. In summary, seroprevalence of HIV/HBV and HIV/HCV co-infections was lower in Addis Ababa, Ethiopia, than in Sub-Saharan Africa and globally. HBV and HCV infections were not significantly different between HIV positive subjects who were or who were not on ARV. This suggests that the two groups have equal chance of being infected with these two viruses; despite this, disease progression could be different.

Infections in internationally adopted children

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.

Infectious disease issues in adoption of young children

PURPOSE OF REVIEW

To provide an update and overview of infectious disease issues in children of international adoption.

RECENT FINDINGS

International adoption by US families has decreased since 2004. Countries from where children are adopted have changed by 2011, with Ethiopia the second largest contributor of international adoptees after China. Since 2003, international adoptees are older, as fewer young children (<1 year of age) have been available for adoption. Although children are declared healthy in their home countries, medical disorders are often missed or become apparent after adoption. Comprehensive evaluations by providers in the USA after adoption frequently identify unsuspected medical disorders, infections, as well as delayed or incomplete vaccination in these recently adopted children. Early identification of infections allows treatment of potential communicable diseases and updating of immunizations.

SUMMARY

All international adoptees on arrival in the USA should be evaluated by a health practitioner knowledgeable in adoption medicine to identify medical problems, especially infections.

Hepatitis A infection in recent international adoptees and their contacts in Minnesota, 2007-2009

OBJECTIVE

The goal of this study was to describe hepatitis A-infected adoptees and the risk of transmission to their contacts.

METHODS

This was a retrospective review of adoptee-associated cases of hepatitis A and hepatitis A-infected adoptees identified in Minnesota from 2007 through 2009.

RESULTS

From 2007 through 2009 in Minnesota, 10 cases of hepatitis A, including 1 fulminant case, were associated with international adoptees. Eight cases were direct contacts of a hepatitis A-infected adoptee, and 2 other cases secondary contacts of an adoptee. During the same period, hepatitis A infection was identified in 21 recently arrived foreign-born adoptees; all were younger than 60 months of age, and only 6 were symptomatic.

CONCLUSIONS

Clinicians should be aware that transmission of hepatitis A may occur among both direct and secondary contacts of young children recently adopted from hepatitis A-endemic areas and that infected young children may be asymptomatic. Household members and other close contacts of international adoptees should be counseled about hepatitis A prevention, including vaccination. In addition, screening for hepatitis A should be considered for recently arrived adoptees from endemic areas.

Transmission of multiple resistant Salmonella Concord from internationally adopted children to their adoptive families and social environment: proposition of guidelines

Since 2004, an increasing number of multidrug-resistant Salmonella serovar Concord infections have been isolated in Belgium among children adopted from Ethiopia. The patients or their family were interviewed and the isolates were subtyped. Between 2004 and 2009, a total of 39 Salmonella Concord infections were isolated from patients. Thirty-four isolates presented a multidrug resistance including resistance to extended-spectrum cephalosporins. Thirty-six cases involved children and 30 of these were adopted from Ethiopia. One case was due to contact with an adopted child and for the other 5 cases no direct epidemiological link with Ethiopia could be found, although four isolates displayed the same patterns observed on the adoptees’ isolates, strongly suggesting a phylogenetic relationship with the Ethiopian isolates. Our study confirmed the emergence in Europe of S. Concord isolates resistant to third-generation cephalosporin among Ethiopian adoptees. We have demonstrated that transmission (intra- and extra familial) can happen even if the frequency seems to be low. The presence and the transmission of such a multidrug-resistant Salmonella infection constitute a major concern, since such strains could jeopardize classical antibiotic therapy in patients at risk. This study provides useful information for parents adopting children and for their family practitioner.

The role of chest radiographs and tuberculin skin tests in tuberculosis screening of internationally adopted children

BACKGROUND

Internationally adopted children (IAC) are a growing group of US immigrants who often come from countries with high tuberculosis (TB) burdens. There is limited evidence to support current TB screening guidelines in these high-risk children. Therefore, we have prospectively examined the clinical utility of tuberculin skin testing (TST) and subsequent chest radiograph screening for TB disease in recently immigrated, asymptomatic IAC.

METHODS

Within 6 months of immigration to the United States, we collected demographic information and assessed the nutritional status of 566 IAC who presented for routine postadoptive care. Children completed standardized clinical examination and TSTs. Chest radiographs were recommended for children with TST induration ≥ 5 mm. The association between TST induration and clinical outcome was assessed. The clinical utility of chest radiographs was evaluated.

RESULTS

There was no difference in age, birth country, or nutritional status between IAC with TST induration of 0 to < 5 mm and those with 5 to < 10 mm; IAC with TST ≥ 10 mm were older, more chronically malnourished, and more likely to emigrate from Guatemala. Among children with TST ≥ 5 mm (35%), 4 IAC had chest radiographs which were initially interpreted to be abnormal and consistent with TB; ultimately none were diagnosed with TB.

CONCLUSIONS

The 5-mm TST cut point did not capture IAC with risk factors for latent TB infection or progression to TB disease, suggesting that this is not a useful screening threshold. In contrast, a 10-mm cut point identified IAC at risk for TB infection and therefore should be a more useful screening threshold. We question the clinical utility of radiographic screening for pulmonary TB in asymptomatic children.

Screening for depression in patients with hepatitis C using the Beck Depression Inventory-II: do somatic symptoms compromise validity?

OBJECTIVE

The objective of the study was to evaluate the validity of the Beck Depression Inventory-II (BDI-II) when used to measure depression in patients with hepatitis C virus (HCV).

METHOD

Factor analysis was utilized to validate the BDI-II in a sample of 671 patients with HCV recruited from a large Veterans Affairs medical center. The data were split randomly: the first half was subjected to exploratory factor analysis, and confirmatory factor analysis was used with the second half to confirm the model. Diagnostic data were retrieved from the electronic medical records.

RESULTS

Subjects were 97.0% male, average age was 52.8 years, 16.1% had a cirrhosis diagnosis, 62.9% had a current major depressive disorder diagnosis, and 42.3% endorsed significant depressive symptoms on the BDI-II. A two-factor model was an excellent fit for the data; the factors were labeled Cognitive-Affective and Somatic. Patients scored significantly higher on the Somatic factor than on the Cognitive-Affective factor (P<.001), and this discrepancy increased when comparing patients based on whether they had a diagnosis of cirrhosis.

CONCLUSIONS

When screening for depression in HCV patients, questions targeting cognitive and affective symptoms of depression may provide a more valid measurement of depression than questions targeting somatic symptoms of depression, particularly for patients with more advanced liver disease.

Internationally adopted children: what vaccines should they receive?

It is of paramount importance to know the vaccination status in internationally adopted children, so that they can be correctly immunized. This study ascertains the seroprotection rate for vaccine-preventable diseases and the validity of the immunization cards in 637 adopted children. The absence of the immunization card (13% of children) correlated with a poor global vaccine protection. Children with immunization records (87%) had a better global seroprotection but the information obtained from the card did not accurately predict seroprotection for each particular antigen. The best variable to predict the status of seroprotection was the country of origin. The highest rate of protection was found in children from Eastern Europe and, in descending order, India, Latin America, China and Africa. General recommendations for immunization of internationally adopted children are difficult to establish. Actions for vaccination have to be mainly implemented on the basis of the existence of the immunization card and of the country of origin.

[Hepatitis B serological markers in children adopted from Russia and Ukraine]

OBJECTIVE

To determine the prevalence of the hepatitis B virus (HBV) infection and to verify the immunization status against HBV of children adopted from Russia and Ukraine.

PATIENTS AND METHODS

Cohort study of 102 children (58.8% boys) adopted from Russia (90) and Ukraine (12) between 2002 and 2007. All children had medical records that certified they had received 3 doses of HBV vaccine from the birth country. They were evaluated within 2 weeks of their arrival (mean age of 28.3 months; range, 12 to 88 months) according to a standard protocol that includes the hepatitis B serological markers, surface antigen (HBsAg), core antibody (HBcAb), and surface antibody (HBsAb).

RESULTS

All children were negative for HBsAg and HBcAb (prevalence of active or previous HBV infection, 0%), and 78 (76.5%) showed a protective antibody response (HBsAb>or=10 mIU/ml) due to HBV vaccination. The results are contrasted with those observed by other researchers.

CONCLUSIONS

We show that children adopted from Russia and Ukraine have a relatively high prevalence of protective immunity due to effective HBV vaccination. Therefore, we recommended determining the 3 serological markers for HBV (HBsAg, HBcAb, and HBsAb). Using this, we may detect an active infection or other infection risks, and we know the immunization status. Thus we can assess the need for retest, and provide criteria for individualized vaccinations, which could avoid generalized HBV vaccination in this specific population of internationally adopted children.

World Wide Web hepatitis B virus resources

BACKGROUND

Hepatitis B virus infection is a global public health issue, often under-discussed due to social prejudices related to its mode of transmission. The World Wide Web, an increasingly popular means of dissemination of health-related information, can serve continuing medical practitioner awareness and enhance public health literacy.

OBJECTIVE

The authors sought to investigate the existence of, and evaluate the content of websites offering information on hepatitis B.

STUDY DESIGN

Sites were selected by certain criteria (sponsor, language options, free access, validation of content by independent medical and non-medical personnel), which unavoidably rendered the lists subjective.

RESULTS

At least three medical personnel-oriented websites (American Association for the Study of Liver Diseases, Clinical Care Options and The Hepatitis B Foundation sites) offer significant, up to date information on hepatitis B for clinicians. Sites offering information for the public used simple patterns as fact sheets and question-answer sets. The majority of the sites were based in the US.

CONCLUSIONS

Hepatitis B virus infection is adequately represented in the web, regarding the needs of medical practitioners. Dissemination of information for the public appears in various modes, and at least at present, can only safely be achieved through simplified reports on the disease.

Medical problems of internationally adopted children presenting to a travel medicine clinic in Nepal

Dermatologic, respiratory, and gastrointestinal infections were the most commonly diagnosed conditions among adopted Nepali children presenting to a travel medicine clinic in Kathmandu. Surveillance and early treatment of infections in international adoptees in their birth country may help prevent the importation of infectious diseases.