By Dr. Jane Aronson

Vaccination for hepatitis B virus (HBV) infection should be considered essential for families contemplating intercountry adoption. While the risk of an adopted child from abroad being chronically infected with HBV varies from country to country, concerns over the possibility of transmission to others can be alleviated if family members seek the readily available hepatitis B vaccination series before the child arrives.

Recently, I was the consulting pediatrician for two families whose adopted children from abroad had been diagnosed with chronic HBV infection after arrival in the U.S. Their stories were typical of families contacting adoption medicine specialists across the country. One child was a 14-month-old boy from China, and the other was a one-year-old girl from Russia. The boy had actually been in the U.S. for seven months before he was tested for HBV infection. His mother told me that the pediatrician felt that the child did not need to be tested because he looked healthy. The mother and father had not been vaccinated against hepatitis B.

The mother of the little girl from Russia contacted me because she had just been told by the pediatrician that the child was chronically infected with HBV. She was anxious about her child's health, but she was also quite disturbed about her risk and her family's risk for contracting HBV infection. No one in the family had been vaccinated.

I discussed the issue of in-household transmission and reassured both families. They have all begun the process of completing the hepatitis B vaccine series.

Visual diagnosis is impossible
The story of the Chinese boy illustrates a myth about hepatitis B. The facts are that most children who are chronically infected with HBV are healthy in their appearance and no one can tell if a person is a carrier by just looking at him. All children adopted from abroad should be tested for hepatitis B soon after arrival in the U.S. The standard list of laboratory studies that should be performed on all internationally adopted children within a few weeks of their arrival in the U.S. is found on many adoption websites including my own (www.orphandoctor.com).

Among my patients, the vast majority of parents had either not completed or even begun the hepatitis B vaccine series by the time their adoption was completed. Most of the families who contact me from around the U.S. whose children are chronically infected with HBV have not completed their hepatitis B vaccine series when they find out the diagnosis for their children.

In-household transmission
When a family calls me to discuss chronic HBV infection, I find my time on email or the phone to be divided equally between the prognosis or treatment of chronic HBV infection and the in-household transmission risks. People are very anxious about the possible infection of family members, friends, and schoolmates. I would rather see the family in a position of comfort and control knowing that with a completed hepatitis B vaccine series, they are essentially safe

In addition to vaccination, it is, of course, essential that everyone understand the concept of "standard precautions" for prevention of infection at home or at work. Usually people do not know the infection status of children or adults in any environment since this is confidential information.

When someone is bleeding, gloves should be available so that a family member, teacher, or friend can safely assist the bleeding patient. Blood on surfaces should be cleaned up with a simple bleach solution. Most schools have requirements for gloves and bleach for handling blood exposure. People with chronic HBV infection should not share toothbrushes or razor blades.

A chance for control
What concerns me is that the majority of families do not complete their hepatitis B vaccine series before the adoption is complete. We have so little control during the adoption process and here is an opportunity for control. For other children at home, there is usually no issue, because hepatitis B vaccine has been a universal vaccine in the U.S. since 1991. Pediatricians are actively working to catch up kids who missed the series in the first year of life. In New York State and many other locales, all children entering kindergarten must be vaccinated.

The time needed for an international adoption allows for easy completion of the three-dose series over a six-month period. It can be administered by a family physician, internist, nurse practitioner, physician assistant, or even the prospective pediatrician for the adoptee.

The pain and guilt that families feel could be completely replaced with a feeling of control if they knew they were protected against in-household transmission with effective vaccination. We simply need to make hepatitis B vaccine universal for families considering an international adoption.

Dr. Jane Aronson, Director
International Pediatric Health Services, PLLC
151 East 62nd Street, Suite 1A
New York, NY 10021
Ph: (212) 207-6666; Fax: (212) 207-6665
www.orphandoctor.com
orphandoctor@aol.com

Adapted with permission from the The Bulletin of the Joint Council on International Children's Services, Summer 1998.

The Joint Council on International Children's Services, Ph: (703) 535-8045 Website: www.jcics.org

Immunization Action Coalition's international adoption hepatitis B web section:
www.immunize.org/adoption

Item #P4153 (11/04)
www.immunize.org/catg.d/4153adop.pdf