Infectious Conditions

1. Transmission

Spread primarily through direct contact with human blood and secretions
The main ways of contracting this disease:

– Perinatal (from mother to baby at the birth)
– Unsafe injections and blood transfusions
– Sexual contact
– rarely child-to-child (biting)
Infectious Conditions in Adoptee – HEPATITIS

2.Hepatitis

– generally there is spontaneous recovery and no routine testing is necessary.
Hepatitis B (HBV)
– Is very common in the following countries: Romania, Asia, Central/South America,US & Western Europe

3.Vertical (Mother-child) Transmission most common route

children can develop chronic disease
– children with chronic Hepatitis B can later on in life develop complications such cirrhosis, hepatocellular carcinoma

4.Percutaneous exposure - rare, but still may occur

Horizontal transmission rare but can still occur- weeping skin rashes, oral secretions
Children should all be screened regardless of vaccine history
Screening blood test performed.
– HBsAg (HBV surface antigen)
– anti-HBc
– HBcAb (HBV core antibody)
– anti-HBs or HBsAb (HBV surface antibody)

5.Transmission

– vertical rate (mother to child)
– percutaneous blood product exposure

Can be a co-pathogen (with other viruses) develop persistent infection
– chronic hepatitis, cirrhosis, hepatocellular carcinoma

6.Infectious Conditions in International Adoptees –

- HIV transmission

7.Vertical transmission (mother to child)

– Rare but increasing in Russia, Vietnam, China, Cambodia, Korea

8. Percutaneous transmission – very unusual because of single use needles

 – “mini-transfusions” in Romania PAST practice
– reuse of unsterile needles
– some injections undocumented

9. All children should be screened for HIV

- HIV – Diagnosis is made with the following tests.

10. Enzyme-linked immunoassay (EIA/ELISA)

– confirm with Western blot

Antibody test is NOT diagnostic because it may may be the maternal antibody response
– young infants or recently infected may have delayed sero conversion if acutely infected
– positive testing indicates only exposure
– confirm with HIV DNA PCR or HIV RNA PCR

11. SYPHILIS

Is seen more commonly in Eastern Europe & Russia.Treatment is injectable penicillin for a couple of weeks. Unfortunately many reports have inadequate therapy performed, such as: pregnant women/infants may be treated incorrectly with

– erythromycin in a single dose or with Penicillin by mouth.
– sometimes there is inadequate follow-up lab studies performed to prove the irradiation of the disease process.

12. DIAGNOSIS is generally made with the following test

– RPR or VDRL – screening shows EXPOSURE
– FTA-Ab – confirms infection
– Even with negative tests, routine testing should be performed and repeated upon arrival to the USA.

13. TUBERCULOSIS

Declared GLOBAL EMERGENCY by WHO in 1993
1/3 of the WORLD’s population currently infected
3% adoptees have ACTIVE disease

– Southeast Asia, India, malnourished
Many more are infected (PPD+) without active disease – rates 50-150x more than US children

IGNORE BCG vaccine history when interpreting PPD
-+PPD => evaluate for active disease
Bacille Calmette-Guérin (BCG Vaccine)

Live vaccine from attenuated Mycobacterium bovis

Administered at birth in >100 countries
Does NOT protect from TB infection

ATTEMPTS to prevent disseminated or life-threatening disease
Protects from PULMONARY TB
– (only about 50% effective)
PPD Skin test will always be positive
– (Only if BCG recently given & active)
does not have dangerous reaction to PPD test
Changes the PPD interpretation
– (actually should be ignored in interpreting PPD)
Tuberculosis: Types & Treatment

14. Latent TB: PPD+, CXR-

– No symptoms, but infected!
– Isoniazid alone provides almost 100% protection if compliant
– (Treat for 9 months)
   Pulmonary TB: PPD+, CXR +
– Often abnormal exam, symptoms (cough, fever, wt. Loss)
     Disseminated TB (extrapulmonary)
– Meningitis, hepatitis, bones, joints
– 4 drugs, 9-12 months, morbidity/mortality

15. INTESTINAL PATHOGENS – parasites

Russia, Eastern Europe,Vietnam, India, Central/South America, Haiti

Risk Factors:
– >1 year of age
– ambulatory – abandoned
– malnourished

16. TESTING

– single stool diagnostic
– document clearance after treatment?
– non-pathogenic parasites or persistent symptoms suggest contact and further testing
bacterial pathogens (Salmonella, Shigella, Yersenia, Campylobacter) seen from some orphanages in Russia/Eastern Europe

Consider stool cultures for enteric bacterial pathogens in children with persistent diarrhea, blood in stools, and from these locations Non-infectious Conditions in International Adoptees

16. TESTING

Many immigrant children have dental disease
more likely to have caries in elementary school than US born
HEMATOLOGIC
– congenital hemoglobinopathies
– iron deficiency anemia VERY COMMON
Screen with CBC & RBC indices
– Lead poisoning common (>10mg/dL)
– Sources: leaded fuels, industry, traditional medicines, cosmetics, ceramics, foods

17.NUTRITION

– growth delay common, esp. from orphanage adoptees
– catch-up growth common in first year
– consider underlying feeding disorders, vitamins

IMMUNIZATIONS

Problems:

– may be falsified or poorly documented from institutionalized settings
– vaccines may not be properly stored or produced by standardized methods
– poor nutrition/chronic illness may prevent adequate or protective response

AAP 2000 Red Book suggests “Only written documentation should be accepted as evidence of prior immunization.” written immunization records may be considered valid if the vaccines, date of administration, number of doses, intervals between doses, and age of the patient at the time of immunization are comparable to that of the current US schedule.”

MMR, HiB, VZV vaccines rarely given
– measles generally given without rubella
For most adoptees 2 alternatives:
– Draw titers to verify immunity
Use Hep B results also if pertinent
OR
– Readminister full series

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