ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

International adoption: Infectious disease aspects

International adoption: Infectious disease aspects
Literature review current through: Jan 2024.
This topic last updated: Jun 19, 2023.

INTRODUCTION — Each year thousands of children immigrate to the United States through international adoption. Internationally adopted children are at increased risk for common infectious diseases such as tuberculosis, intestinal parasites, skin infections, and infestations because they come from resource-poor countries where these conditions are common.

The infectious disease aspects of international adoption will be discussed here. Immunization of international adoptees and their close contacts and general issues related to adoption are discussed separately. (See "International adoption: Immunization considerations" and "Adoption".)

EPIDEMIOLOGY — Since 1999, more than 278,000 children have immigrated to the United States through international adoption [1]. The number of international adoptions peaked at nearly 23,000 in 2004 and has declined since then (figure 1).

In 2019, 2971 children were adopted internationally from 80 countries, with fewer than 10 children adopted from 48 of these countries [2]. The majority of children came from China (819). More than 100 children were adopted from each of seven other countries, including Ukraine (298), Colombia (244), India (241), South Korea (166), Bulgaria (134), Haiti (130), and Nigeria (116). The full list is available from the Bureau of Consular Affairs at the United States Department of State [1].

In 2019, most international adoptees (54 percent) were ≥5 years of age at the time of adoption, 46 percent were <5 years, and <1 percent were <1 year of age [1], compared with 2003 when 87 percent of children were <5 years of age and 56 percent were <1 year of age. Since 2003, there has been a steady decline in children ≤1 years of age available for adoption [3], and nearly all of the children available and adopted from China and other countries (eg, India, Ukraine, South Korea, Bulgaria, and the Philippines) have special medical or developmental needs.

Most internationally adopted children have resided all or most of their lives in orphanages or other institutional settings. However, children adopted from South Korea typically are cared for in state-subsidized foster care homes, and some children adopted in other countries such as China and Colombia may have spent some time in foster care [4].

EVALUATION IN BIRTH COUNTRY — The United States State Department requires that internationally adopted children undergo a medical examination in their birth country (a "panel evaluation") by a United States-designated clinician before admission into the United States [5,6]. The evaluation is required to complete the visa application and is limited to screening for serious physical and mental disorders and certain communicable diseases (eg, tuberculosis, syphilis). Re-evaluation for these conditions and evaluation for other illnesses and infections should be performed after arrival to the adoptive country. (See 'Post-arrival evaluation' below.)

Medical records should be available for review at the time of the preadoption medical evaluation. However, information about family and perinatal history is often unavailable or limited for most countries [3].

Laboratory tests such as serologic testing for syphilis, hepatitis B, and HIV are routinely available for all countries of adoption and generally are reliable. Additional laboratory testing may include a complete blood count in China. Nearly all children >2 years of age have documentation of tuberculosis testing either from a tuberculin skin test or blood test. Laboratory results must be interpreted with caution because they may have been performed months before the preadoption evaluation (typically at time of entry to the institution or at birth) and the child may have become infected after testing. For this reason, it is recommended that laboratory tests be repeated upon arrival to the adoptive country.

POST-ARRIVAL EVALUATION — All internationally adopted children, regardless of their country of origin, should be evaluated by a health care professional within two weeks after arrival to assure that their initial health care needs are addressed, initial screening is performed, and a plan for receiving preventive services (eg, immunizations) is initiated.

Recommendations for the initial evaluation are largely focused on infectious diseases. However, the initial assessment should be comprehensive and include [7-11]:

Assessment of growth parameters and nutritional status – Short stature may reflect overall poor nutrition, chronic illness, or recurrent episodes of diarrhea; microcephaly may occur in children with in-utero exposure to alcohol or chronic malnutrition. (See "Persistent diarrhea in children in resource-limited settings", section on 'Prevalence and morbidity' and "Malaria: Clinical manifestations and diagnosis in nonpregnant adults and children" and "Overview of TORCH infections".)

Examination for congenital anomalies (including fetal alcohol syndrome). (See "Fetal alcohol spectrum disorder: Clinical features and diagnosis", section on 'Clinical features' and "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Management and outcomes", section on 'Other substances'.)

Evaluation of the skin for evidence of Bacille Calmette-Guérin vaccination (picture 1), skin infection or infestation, and signs of abuse (eg, bruises, burns). (See 'Dermatologic infections and infestations' below and "Physical child abuse: Recognition", section on 'Red flag physical findings'.)

Evaluation for hepatosplenomegaly (may occur in schistosomiasis, sickle cell disease, chronic malaria).

Evaluation of the genitalia for signs of sexual abuse (the absence of which does not exclude sexual abuse), in which case testing for gonorrhea and chlamydia should be performed (in addition to testing for HIV and syphilis, which is recommended for all international adoptees). (See "Evaluation of sexual abuse in children and adolescents", section on 'Physical examination'.)

Evaluation of vision and hearing. (See "Hearing loss in children: Screening and evaluation" and "Vision screening and assessment in infants and children", section on 'Overview of vision assessment'.)

Assessment of oral health. (See "Preventive dental care and counseling for infants and young children".)

Evaluation of developmental status. (See "Developmental-behavioral surveillance and screening in primary care".)

Blood lead concentration [12]. (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Complete blood cell count with red blood cell indices and differential of white blood cells – Hemoglobin and red blood cell indices may identify children with anemia, iron deficiency, hemoglobinopathies, or malaria; the differential may identify children with decreased white blood cell counts and lymphopenia (which may indicate HIV infection or malnutrition) or eosinophilia (which may indicate parasitic disease). (See "Approach to the child with anemia" and "Approach to the child with lymphocytosis or lymphocytopenia", section on 'Lymphocytopenia' and "Approach to the patient with unexplained eosinophilia".)

Screening for glucose-6-phosphate dehydrogenase [13]. (See "Diagnosis and management of glucose-6-phosphate dehydrogenase (G6PD) deficiency".)

Hemoglobin electrophoresis. (See "Diagnosis of sickle cell disorders" and "Diagnosis of thalassemia (adults and children)".)

Measurement of thyroid-stimulating hormone concentration. (See "Clinical features and detection of congenital hypothyroidism", section on 'Diagnosis'.)

Screening for infectious diseases (table 1), described in detail in the sections below.

PREVALENCE OF INFECTIOUS DISEASES — The prevalence of infectious diseases varies by country of origin (table 2) [14-22]. In general, the prevalence of infectious diseases is highest in children from Africa and lowest in children from South Korea. Direct comparison of prevalence from one country to another is limited by significant variation in the age of adoptees at the time of arrival. In addition, some children were adopted with known hepatitis B infection in adoptions of children with special health care needs. (See 'Hepatitis B virus' below.)

Tuberculosis infection and intestinal parasites are the most common infectious diseases in internationally adopted children [15-17,23-32]. The prevalence for both conditions increases with increasing age.

EVALUATION FOR INFECTIOUS DISEASES — Our recommendations for evaluation for infectious diseases in internationally adopted children generally are consistent with those of the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) [7,11,33].

Hepatitis

Hepatitis A virus — We test internationally adopted children for acute hepatitis A virus (HAV) infection (with anti-hepatitis immunoglobulin M [IgM] antibody) and children ≥1 year of age for past HAV infection (with total or immunoglobulin G [IgG] anti-HAV antibody) [33]. Identification of acute HAV infection facilitates prevention. (See "Overview of hepatitis A virus infection in children", section on 'Diagnosis'.)

The prevalence of past HAV infection varies by country and age. In several observational studies published between 2006 and 2014, the prevalence of acute hepatitis A infection (positive HAV IgM) upon arrival to the host country ranged from 1 to 4 percent [14,19,20,34]. Between 29 and 39 percent had evidence of chronic infection (positive total HAV antibody) [14,19,34]. In one study, the highest region-specific prevalence was in Africa (72 percent) and the lowest was in the Asia/Pacific Rim Region (17 percent); past infection increased with age (13 percent in children <2 years versus 80 percent in those 12 to 17 years) [14]. Virtually all people residing in resource-poor countries have HAV IgG antibodies, indicative of past infection (figure 2), by early adulthood [35].

Despite the low prevalence of acute infection, internationally adopted children may be incubating HAV infection at the time of adoption and may transmit it to their adoptive families or other contacts while in their birth country or after arrival to the United States [14,19,36-39]. Children with acute HAV infection may shed the virus for months [35]. Thus, adoptive parents and accompanying family members should be immunized against HAV or have documented immunity to HAV before international travel to receive their child [19,33,35,39]. HAV vaccine is also recommended for susceptible nontraveling individuals who plan to have close contact with an internationally adopted child from a country with high or intermediate hepatitis A endemicity (high endemicity: parts of Africa and Asia; intermediate endemicity: Central and South America, Eastern Europe, parts of Asia); the first dose of the vaccine should be administered at least two weeks before the child's arrival [35,39,40]. (See "International adoption: Immunization considerations", section on 'Hepatitis A vaccine' and "Overview of hepatitis A virus infection in children", section on 'Epidemiology'.)

Although most children with acute HAV infection are asymptomatic, HAV infection should be considered in children with vomiting, anorexia, fever, and an enlarged tender liver, with or without jaundice [7,35]. If the child has acute HAV infection (positive anti-HAV IgM antibody), secondary cases can be prevented by providing HAV vaccine to unvaccinated family members and close contacts of the case [39,40]. (See "Hepatitis A virus infection: Treatment and prevention", section on 'Protection following exposure'.)

Serologic testing for past HAV infection is suggested to determine the need for HAV vaccine, which is not routinely administered in resource-poor countries but is recommended in the United States for all children ≥12 months of age [39]. Children who have evidence of past infection (ie, positive total [IgM and IgG] or IgG HAV antibody (figure 2)) do not require immunization.

Hepatitis B virus — We routinely screen internationally adopted children for hepatitis B virus (HBV) infection upon arrival, regardless of results provided in the country of origin [7,11].

Screening is necessary to identify asymptomatic carriers, who may nonetheless transmit HBV to household contacts and caregivers. Early identification permits appropriate management of the adopted child and preventive measures for contacts (eg, HBV vaccination and/or HBV immune globulin). (See "Clinical manifestations and diagnosis of hepatitis B virus infection in children and adolescents" and "Epidemiology, transmission, and prevention of hepatitis B virus infection", section on 'Prevention'.)

Screening consists of assays for HBV surface antigen (HBsAg), HBV surface antibody (anti-HBs), and HBV core antibody (anti-HBc) (table 3). Some centers, including the author's, repeat testing approximately six months after arrival for children who initially test negative for HBsAg, anti-HBs, and anti-HBc, in case the child was infected with HBV just before arrival. In infants and young children, passively acquired maternal anti-HBs may be detected until eight months of age; passively acquired maternal anti-HBc may be detected until 24 months of age [41]. Thus, in children with initial testing done at <12 months of age, repeat testing is done after 12 months of age to determine if the anti-HBs is still present. (See "Hepatitis B virus: Screening and diagnosis in adults".)

Children who are positive for HBsAg can transmit HBV to others. They require additional testing to determine whether they have acute or chronic infection (table 3). In addition, serology for hepatitis e antigen (HBeAg), HBV e antibody (anti-HBe), a quantitative HBV polymerase chain reaction (PCR; viral load), and liver function tests (alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, albumin) should be done. These children should also have serologic testing for HAV (to determine the need for vaccine) and hepatitis C virus (because concomitant hepatitis C virus infection may affect management). Those who are adopted from North Africa, parts of South America, and the Mediterranean Basin should also be tested for hepatitis D virus (delta virus) infection, if such testing is available. Children with HBV should be followed by a hepatologist. (See "Clinical manifestations and diagnosis of hepatitis B virus infection in children and adolescents" and "Epidemiology, clinical manifestations and diagnosis of hepatitis D virus infection".)

The rates of HBV infection in internationally adopted children generally are similar to the reported rates of HBV in the country of origin [17,18,23-31]. In a systematic review, the 2005 prevalence of HBV infection generally ranged between 2 and 7 percent [42]. Adoptees typically acquire HBV perinatally, although bloodborne infection and horizontal transmission also are possible. Universal HBV immunization for infants is provided in many countries of origin. However, the first dose may not be administered at birth (the birth dose is necessary to prevent perinatal transmission), and the full series may not be completed [11].

Nearly all birth countries routinely screen for HBV and report results in the adoption referral information. Chronic HBV infection is considered to be a "special health care need" because children with chronic HBV infection are at risk for long-term liver disease and will need to be followed by a hepatologist throughout their lifetime. (See "Clinical manifestations and diagnosis of hepatitis B virus infection in children and adolescents".)

Hepatitis C virus — We routinely screen internationally adopted children for hepatitis C virus infection upon arrival. The prevalence of hepatitis C is increased in the countries of origin of international adoptees, and it is difficult to obtain information about risk factors [11]. In some countries (eg, Eastern Europe, Taiwan, and Ethiopia) hepatitis C testing may have been performed before the adoption, but repeat testing should be performed regardless of these results. (See "Epidemiology and transmission of hepatitis C virus infection".)

Antibody testing with an enzyme immunoassay is recommended as the initial screen. If the hepatitis C antibody is positive, PCR should be done to confirm infection. Maternal antibody may be present until a child is 18 months of age. (See "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Antibody testing' and "Screening and diagnosis of chronic hepatitis C virus infection".)

Children with hepatitis C virus infection should be immunized against hepatitis A and B and referred to a hepatologist for further management. (See "Hepatitis C virus infection in children".)

Data on the prevalence of hepatitis C in internationally adopted children are limited. The prevalence varies with country of origin and over time. In a cohort of 350 children internationally adopted between 2013 and 2016, the overall prevalence of hepatitis C was 1.1 percent; among children adopted from Eastern European countries, the prevalence was 4 percent [22]. In another cohort of 504 children adopted from various regions in 1997 to 1998, the prevalence was <1 percent [28]. Despite this low prevalence, screening is suggested because of the long-term implications for development of advanced liver disease. Although treatment is not yet recommended for young children with hepatitis C infection, it is important to identify them so that curative therapy can be provided once available. We refer such patients to a pediatric hepatitis specialist who facilitates treatment when available or indicated by age or severity. (See "Hepatitis C virus infection in children", section on 'Natural history'.)

Syphilis — We recommend that internationally adopted children be screened for congenital syphilis upon arrival. We screen with both a nontreponemal test (eg, rapid plasma reagin, Venereal Disease Research Laboratory) and a treponemal test (eg, fluorescent treponemal antibody absorption or Treponema pallidum particle agglutination) [11]. (See "Syphilis: Screening and diagnostic testing".)

Most internationally adopted children have documentation of syphilis screening performed in their birth country before adoption, but repeating these tests is recommended [8]. For children with a history of syphilis or syphilis exposure, it is often difficult to determine when the birth mother contracted syphilis and if she was treated and followed appropriately. In addition, in children with suspected syphilis exposure, details of the evaluation and prescribed treatment regimens are often incomplete or uninterpretable. Although syphilis has rarely been reported in international adoptees (table 2) [17,23-31], untreated syphilis has long-term sequelae. (See "Congenital syphilis: Clinical manifestations, evaluation, and diagnosis", section on 'Late congenital syphilis'.)

Internationally adopted children who have a positive treponemal test for syphilis require additional evaluation, including evaluation of the cerebrospinal fluid, to document the extent of the disease and to insure adequate treatment regardless of a report of prior treatment. (See "Congenital syphilis: Clinical manifestations, evaluation, and diagnosis", section on 'Older than one month' and "Congenital syphilis: Management and outcome", section on '>1 month of age'.)

Positive treponemal tests may also occur in pinta and yaws [43]. Consultation with a specialist who has expertise in the management of these infections is recommended if the child is adopted from a country were pinta and yaws are endemic. (See "Yaws, bejel, and pinta", section on 'Geographic distribution'.)

HIV — We recommend routine screening for HIV-1 for internationally adopted children upon arrival [11]. Testing is recommended regardless of test results from the child's birth country.

The initial screening test is a combined antigen/antibody HIV test. Positive or indeterminate results should be confirmed with PCR (to determine viral load). PCR testing should also be performed if HIV is suspected clinically but antigen/antibody testing is negative. For children whose results are initially negative, we suggest retesting three to six months later because of the possibility of a falsely negative test (eg, early in acute infection) [10]. (See "Diagnostic testing for HIV infection in infants and children younger than 18 months" and "Screening and diagnostic testing for HIV infection", section on 'Tests'.)

In a cohort of 350 children internationally adopted between 2013 and 2016 and tested for HIV after arrival, the prevalence of HIV infection was 4.6 percent [22].

Most internationally adopted children are tested for antibody and/or antigen to HIV-1 in their birth country before adoption [8]. Those who test positive to HIV and were born to mothers with HIV generally also are tested with HIV PCR. Children known to be exposed to HIV generally are treated with antiretroviral drugs. Before 2010, families were not permitted to adopt children infected with HIV because the Immigration and Nationality Act classified HIV as a "communicable disease of public health significance" [44]. However, HIV was removed from this classification in 2010 and HIV-positive children may now be adopted into the United States.

In a 2016 retrospective review, 79 HIV-infected children adopted between 2004 and 2013 were followed for a median of three years [45]. At the time of adoption, only 1 percent were severely immunosuppressed (CD4 percentage <15 percent), 75 percent were receiving antiretroviral therapy, and 76 percent of these had suppressed viral load. Most of the children with detectable viral load had nonnucleoside reverse transcriptase inhibitor resistance.

Pre-adoptive testing for HIV-2 infection is not performed routinely. HIV-2 infection is prevalent in some African nations and is now recognized on several other continents. Perinatal transmission appears to be limited. Symptoms suggestive of HIV infection (eg, lymphadenopathy, hepatosplenomegaly, poor weight gain, oral candidiasis, etc) with negative antigen/antibody results for HIV-1 should prompt testing for HIV-2. (See "Epidemiology, transmission, natural history, and pathogenesis of HIV-2 infection" and "Clinical manifestations and diagnosis of HIV-2 infection", section on 'Testing for HIV-2 infection' and "Pediatric HIV infection: Classification, clinical manifestations, and outcome", section on 'Clinical manifestations'.)

Consultation with an expert in pediatric infectious diseases is recommended for management of HIV-positive international adoptees [3,8].

Tuberculosis

Tuberculosis infection — We recommend routine screening of international adoptees for tuberculosis infection (also called latent tuberculosis infection (table 4)) upon arrival, regardless of results from the child's birth country [7,46]. Screening for tuberculosis infection can be performed with tuberculin skin testing (TST) or interferon-gamma release assays (IGRA) for children ≥2 years [46]. In a 2015 study comparing TST and T-SPOT.TB (an IGRA) in 109 internationally adopted children 4 months to 16 years of age, 23 percent had a positive TST and 5 percent had a positive T-SPOT.TB, with an overall agreement of 71 percent [32]. A positive TST was not associated with Bacille Calmette-Guérin (BCG) vaccination or scar.

Given the high rate of false negative TST tests shortly after arrival [15,47], we suggest that repeat TST testing ≥3 months after the initial test for children whose initial TST test is negative [8,10]. We also suggest repeat IGRA if the initial test is negative given the possibility of a false negative result if the child was exposed just before arrival. Screening tests, interpretation of screening tests, and management of children with positive screening tests for tuberculosis infection in children are discussed separately. (See "Tuberculosis infection (latent tuberculosis) in children".)

Tuberculosis is highly prevalent in the birth countries of internationally adopted children. Data for individual countries are available from the World Health Organization. (See "Epidemiology of tuberculosis", section on 'Global burden'.)

Most internationally adopted children who screen positive for tuberculosis have tuberculosis infection [15,22-31,47,48]. Although tuberculosis disease has rarely been reported, it may result in community outbreaks [49,50].

Children older than two years are evaluated for tuberculosis during the medical evaluation in their birth country, but the quality of TST administration varies from site to site. Children younger than two years are not screened for tuberculosis unless they have symptoms [8,51]. (See 'Evaluation in birth country' above.)

In two large studies in which all TSTs were evaluated by a health care professional, 14 to 21 percent of international adoptees had tuberculosis infection [15,47]. In these studies, tuberculosis infection was most common among adoptees from Russia and Eastern Europe (29 percent) and least common among those from China (10 percent); very few children adopted from Africa were included. Children with initially negative TSTs had repeat testing at least three months later, and 13 to 20 percent of the repeat tests were positive. This suggests that a high proportion of children initially had false negative tests. The authors postulated that this could be due to anergy, testing too soon after infection, or boosting from tuberculosis infection or BCG.

The treatment of tuberculosis infection in children is discussed separately. (See "Tuberculosis infection (latent tuberculosis) in children", section on 'Treatment approach'.)

Tuberculosis disease — Tuberculosis disease (also called active tuberculosis (table 4)) should be considered in internationally adopted children with pneumonia or nonspecific symptoms such as fever, malaise, growth delay, weight loss, cough, night sweats, and chills. (See "Tuberculosis disease in children: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

Every effort should be made to recover the organism in children with suspected tuberculosis disease so that antimycobacterial susceptibilities can be determined. Many children arrive from countries in which drug-resistant Mycobacterium tuberculosis is common. Gastric aspirates, bronchoscopy, or both can be useful adjuncts in a child too young or too ill to expectorate sputum. In children with lymph node disease, the affected lymph node can also be biopsied. (See "Tuberculosis disease in children: Epidemiology, clinical manifestations, and diagnosis", section on 'Diagnosis'.)

Initial management of tuberculosis disease in internationally adopted children should include isoniazid, rifampin, pyrazinamide, and at least one other agent to ensure bactericidal coverage while culture results and susceptibility testing are pending [46]. The resistance patterns from the child's country of origin should be considered along with any other epidemiologic information that can be obtained when making treatment decisions, especially if the cultures are negative. (See "Tuberculosis disease in children: Epidemiology, clinical manifestations, and diagnosis".)

Bacille Calmette-Guérin complications — Vaccination with BCG is common in resource-poor countries from which children are adopted. Information about current and past BCG vaccination policies is available through The BCG World Atlas. Evidence of BCG vaccination can be seen as a 2- to 4-mm scarification (picture 1), often on the left deltoid.

Children occasionally develop complications from BCG vaccination, including granulomatous lesions, enlargement of regional lymph nodes, or nodules or ulcers at the vaccination site that may be accompanied by draining sinus tracts or fistulae. Culture of the lesion will yield Mycobacterium bovis. Management of local of BCG complications is discussed separately. (See "Prevention of tuberculosis: BCG immunization and nutritional supplementation", section on 'Safety and adverse effects'.)

Intestinal parasites — We suggest routine screening of internationally adopted children for intestinal parasites upon arrival [7,11]. Although some clinicians prefer to provide presumptive treatment with albendazole, we prefer to screen children for intestinal parasites because albendazole is expensive and not the drug of choice for all parasites.

Screening involves obtaining three stool specimens to be examined for ova and parasites; antigen testing for Giardia duodenalis and Cryptosporidium spp should be performed on one of the specimens [11]. The three specimens should be collected in the morning, 48 to 72 hours apart, and preserved in formalin and polyvinyl alcohol or sodium-acetate formalin [33]. Testing multiple stool specimens increases the sensitivity of microscopic examination for ova and parasites [16,52,53]. In a case series of 1042 internationally adopted children, the yield was 79 percent with one specimen, 92 percent with two specimens, and 100 percent with three specimens [16]. (See "Giardiasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Diagnosis' and "Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis", section on 'Diagnosis'.)

In observational studies, intestinal parasites are commonly identified through screening of internationally adopted children [16,19-22,27-31,54]. Older children and children adopted from countries other than South Korea were at the highest risk for intestinal parasites. The rates of recovery of intestinal parasites range from 9 to 51 percent, depending upon the age of the child and country of origin. In the largest study, at least one intestinal parasite was detected in 27 percent of 1042 international adoptees [16]. The prevalence was similar in children with and without gastrointestinal symptoms and with and without malnutrition, suggesting that the decision to screen for intestinal parasites should not be based upon symptoms or nutritional status.

G. intestinalis is the most commonly identified intestinal parasite, with as many as 19 percent of children infected [16,17,22,24-31]. Helminthic infections are less common (<3 percent), with Hymenolepis species, Ascaris lumbricoides, and Trichuris trichiura most often reported. (See "Giardiasis: Epidemiology, clinical manifestations, and diagnosis" and "Tapeworm infections", section on 'Hymenolepiasis' and "Ascariasis" and "Enterobiasis (pinworm) and trichuriasis (whipworm)", section on 'Trichuriasis (whipworm)'.)

Specific treatment should be provided for intestinal parasites identified through screening:

Giardiasis (see "Giardiasis: Treatment and prevention", section on 'Initial treatment')

Hymenolepis (see "Tapeworm infections", section on 'Treatment')

A. lumbricoides

T. trichiura

Dientamoeba fragilis

Blastocystis

We suggest treatment if stool studies in international adoptees are positive for these intestinal parasites even if the adoptee lacks symptoms.

Stool studies (three specimens) should be repeated after treatment to assess the effectiveness of treatment for the identified parasite(s) and identify additional pathogens.

For children who remain symptomatic after treatment (eg, diarrhea, growth delay, anemia), repeat examinations of the stool for ova and parasites should be done and testing for other parasites such as Cyclospora and Strongyloides stercoralis, which are not identified through routine testing, may be warranted. (See "Cyclospora infection", section on 'Diagnosis' and "Strongyloidiasis".)

Enteric bacterial infections — Enteric bacterial infections include Salmonella, Shigella, Yersinia, and Campylobacter. The prevalence of enteric bacterial pathogens in internationally adopted children has not been systematically studied. However, they appear to be less common than intestinal parasites.

We do not recommend routine screening of asymptomatic internationally adopted children for enteric bacterial infections. However, for internationally adopted children who have bloody diarrhea or diarrhea associated with fever, we suggest obtaining stool culture for Salmonella spp, Shigella spp, Yersinia spp, and Campylobacter spp [8]. Other experts recommend obtaining stool cultures in newly arrived adoptees who have diarrhea (whether or not it is bloody or associated with high fever) [8,10,11].

Tissue parasites — Tissue parasites are parasites that have a tissue phase during their life cycle (eg, Strongyloides, schistosomiasis). The approach to screening for tissue parasites varies from center to center.

The author's center performs serologic testing for tissue parasites on international adoptees regardless of eosinophil count. The serologic tests vary depending upon the country of origin:

S. stercoralis – Children from Africa, India, and Haiti. (See "Strongyloidiasis", section on 'Epidemiology' and "Strongyloidiasis", section on 'Serology'.)

Schistosomiasis – Children from Sub-Saharan Africa, Southeast Asia, or areas of Latin America where schistosomiasis is endemic. (See "Schistosomiasis: Diagnosis", section on 'Serology' and "Schistosomiasis: Epidemiology and clinical manifestations", section on 'Epidemiology'.)

Filariasis – Children >2 years from areas where filariasis is endemic (eg, sub-Saharan Africa, Egypt, southern Asia, the western Pacific Islands, the northeastern coast of Brazil, Guyana, Haiti, and the Dominican Republic); if testing is positive, consultation with an infectious disease specialist with expertise in filariasis is recommended to ensure appropriate therapy. (See "Lymphatic filariasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Epidemiology' and "Lymphatic filariasis: Treatment and prevention".)

The author's approach is compatible with those of the CDC and AAP. The CDC suggests that serologic testing for strongyloides, Toxocara canis, Ancylostoma spp, and Trichinella spiralis may be warranted for children with eosinophilia (absolute eosinophil count exceeding 450 cells/microL) and negative stool ova and parasite examinations [33]. For children with eosinophilia and negative stool ova and parasite examinations, the AAP suggests testing for S. stercoralis and T. canis in children from any country of origin, testing for filariasis in children >2 years of age from endemic areas, and testing for schistosomiasis in children from schistosomiasis endemic areas [11].

The CDC provides additional information about the diagnosis of parasites.

Chagas disease — Chagas disease, also known as American trypanosomiasis, is caused by infection with the protozoan parasite Trypanosoma cruzi. Children may be infected by vertical transmission or from vectors. (See "Chagas disease: Epidemiology, screening, and prevention".)

We suggest that children who are adopted from regions where Chagas disease is endemic be screened for Chagas disease [11]. Chagas disease is endemic throughout much of Mexico, Central America (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama), and South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Peru, Suriname, Uruguay, and Venezuela) [11]. Within endemic countries, the risk of Chagas disease varies by region. (See "Chagas disease: Epidemiology, screening, and prevention", section on 'Epidemiology and vectorial transmission'.)

Children older than 9 to 12 months can be screened with serologic testing for T. cruzi [55,56]. Antibodies detected by serologic testing of children younger than 9 to 12 months can represent maternal antibodies, so a positive test should be repeated at nine months of age. Children <9 to 12 months can also be screened with microscopy or PCR [56-60]. Consultation with a specialist in infectious diseases and the CDC may be warranted for help with diagnosis and treatment. (See "Chagas disease: Chronic Trypanosoma cruzi infection", section on 'Diagnosis' and "Chagas disease: Acute and congenital Trypanosoma cruzi infection", section on 'Congenital Chagas disease'.)

The prevalence of Chagas disease in internationally adopted children is unknown. Screening is necessary to identify children with asymptomatic congenital or chronic infection. Without treatment, such children have a 20 to 30 percent risk of eventually developing clinical manifestations (eg, cardiomyopathy, cardiac arrhythmias, gastrointestinal disease) [55,61-63]. (See "Chronic Chagas cardiomyopathy: Clinical manifestations and diagnosis" and "Chagas gastrointestinal disease".)

Treatment is most effective when it is initiated early in life [7,55,63]. The antitrypanosomal drugs used to treat Chagas disease are benznidazole and nifurtimox. Both of these agents are approved by the US Food and Drug Administration. Benznidazole is approved for use in children 2 to 12 years of age and is available from the manufacturer. Use of benznidazole to treat a patient outside of the approved age range is based on clinical diagnosis and decision by a treating clinician [64]. Nifurtimox is approved for use in children who are <18 years and weigh ≥2.5 kg. It is available for purchase from several drug wholesalers. Questions regarding treatment of Chagas disease can be directed to the CDC's Parasitic Diseases Inquiries (404-718-4745; [email protected]). (See "Chagas disease: Antitrypanosomal drug therapy".)

Malaria — Routine screening for malaria is not recommended for internationally adopted children [11,65]. However, internationally adopted children from malaria-endemic regions who have symptoms or signs of malaria (eg, fever, chills, rigors, sweats, headache, splenomegaly, anemia, malaise, fatigue, etc) should be evaluated for malaria with microscopy of thick and thin blood smears and/or rapid diagnostic tests [33]. Three sets of malaria smears, separated by at least 12 hours, should be obtained to exclude the diagnosis of malaria. Information about the endemicity of malaria by region and by country is available through the CDC. (See "Malaria: Epidemiology, prevention, and control", section on 'Epidemiology' and "Malaria: Clinical manifestations and diagnosis in nonpregnant adults and children" and "Laboratory tools for diagnosis of malaria".)

Screening of asymptomatic children from endemic areas may be warranted, particularly if they have a history of splenomegaly. In a study conducted from 2006 to 2011, children adopted from Ethiopia were screened for malaria if they previously lived in a malaria-endemic area or had past or current hepatomegaly or splenomegaly [66]. Among the 52 children who met these criteria, seven (14 percent) had asymptomatic parasitemia by microscopy or PCR; the authors of the study suggest that children from endemic regions be screened for malaria with PCR. In another study, among 40 children who were adopted from African countries between 2013 and 2016 and tested for malaria, eight were positive, but only one had symptoms [22].

Dermatologic infections and infestations — Dermatologic infections and infestations are common in internationally adopted children, but the prevalence of specific conditions has not been well documented. The physical examination of internationally adopted children should include evaluation for [19]:

Fungal infections, including tinea corporis (picture 2) and tinea capitis (picture 3) (see "Dermatophyte (tinea) infections")

Molluscum contagiosum (picture 4A-C) (see "Molluscum contagiosum")

Head lice (picture 5A-C), body lice, and eyelash lice (see "Pediculosis capitis" and "Pediculosis corporis" and "Pediculosis pubis and pediculosis ciliaris")

Scabies (picture 6 and picture 7A-D) (see "Scabies: Epidemiology, clinical features, and diagnosis")

Multidrug-resistant organisms — We do not routinely screen internationally adopted children for carriage of multidrug-resistant organisms. Several studies have demonstrated high-rates of carriage and transmission of drug-resistant bacteria, including extended spectrum beta-lactamase (ESBL)-producing organisms, in internationally adopted children [20,21,40,67-71]. In a prospective study, 24 of 25 children adopted from Mali carried at least one ESBL-producing organism upon arrival to France [69]. In another prospective study of adoptees from Mali, ESBL was produced by 26 of 41 Salmonella species isolated in 30 families [70]. The rates of carriage among children adopted from other countries are not well known. Additional information is necessary to refine recommendations for screening. In the meantime, health care providers should be aware of the possibility of carriage of multidrug-resistant organisms, particularly in children with medically complex conditions.

RESOURCES — A number of resources that may be helpful for health care providers or parents of international adoptees are available (table 5).

SUMMARY AND RECOMMENDATIONS

The majority of children internationally adopted to the United States come from China, and most of these children have medical and developmental needs. While the overall number of internationally adopted children has decreased, children come from a broader range of countries and are older than children adopted previously. (See 'Epidemiology' above.)

International adoptees must undergo a medical evaluation in their birth country before adoption. However, the scope of the infectious disease evaluation is limited to "communicable diseases of public health significance" (eg, tuberculosis, syphilis). Laboratory tests performed in the home country may have been performed months before the adoption and should be repeated. (See 'Evaluation in birth country' above.)

Internationally adopted children should be evaluated by a health care professional within two weeks after arrival. Although infectious diseases are a central component of the evaluation, the initial evaluation also should assess other medical issues (eg, growth and nutrition, lead poisoning), development, oral health, and vision and hearing. (See 'Post-arrival evaluation' above.)

We routinely screen international adoptees for hepatitis A, B, and C viruses, syphilis, HIV, and tuberculosis (table 1). (See 'Hepatitis' above and 'Syphilis' above and 'HIV' above and 'Tuberculosis' above and 'Intestinal parasites' above.)

We suggest screening international adoptees for intestinal parasites (eg, Giardia intestinalis, Cryptosporidium parvum). (See 'Intestinal parasites' above.)

We suggest screening international adoptees for enteric bacterial infections (Salmonella, Shigella, Yersinia, and Campylobacter) if they have bloody diarrhea or diarrhea with fever. (See 'Enteric bacterial infections' above.)

We suggest screening international adoptees for tissue parasites regardless of eosinophil count. The serologic tests vary depending upon the country of origin. (See 'Tissue parasites' above.)

We recommend that children who are adopted from regions where Chagas disease is endemic be screened for Chagas disease. (See 'Chagas disease' above and "Chagas disease: Epidemiology, screening, and prevention", section on 'Epidemiology and vectorial transmission'.)

Children who are adopted from malaria endemic regions who have symptoms or signs of malaria (eg, fever, chills, rigors, sweats, headache, splenomegaly, anemia, malaise, fatigue, etc) should be evaluated for malaria with microscopy of thick and thin blood smears and/or rapid diagnostic tests. (See 'Malaria' above and "Malaria: Epidemiology, prevention, and control", section on 'Epidemiology' and "Laboratory tools for diagnosis of malaria", section on 'General principles' and "Malaria: Clinical manifestations and diagnosis in nonpregnant adults and children".)

  1. US Department of State: Adoption statistics. Available at: https://travel.state.gov/content/adoptionsabroad/en/about-us/statistics.html (Accessed on June 14, 2021).
  2. Bureau of Consular Affairs. US Department of State. FY 2019 Annual report on intercountry adoption. https://travel.state.gov/content/travel/en/Intercountry-Adoption/adopt_ref/AnnualReports.html (Accessed on June 14, 2021).
  3. Ampofo K. Infectious disease issues in adoption of young children. Curr Opin Pediatr 2013; 25:78.
  4. Staat MA. Infectious disease considerations in international adoptees and refugees. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 8th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier, Philadelphia 2018. p.2308.
  5. Centers for Disease Control and Prevention. International Adoption: Health Guidance and the Immigration Process. www.cdc.gov/immigrantrefugeehealth/adoption/overseas-exam.html (Accessed on March 22, 2018).
  6. Centers for Disease Control and Prevention. Immigrant and Refugee Health. Laws and Regulations www.cdc.gov/immigrantrefugeehealth/laws-regulations.html (Accessed on March 22, 2018).
  7. Centers for Disease Control and Prevention. Medical Examination of Immigrants and Refugees. www.cdc.gov/immigrantrefugeehealth/exams/medical-examination.html (Accessed on March 22, 2018).
  8. Eckerle JK, Howard CR, John CC. Infections in internationally adopted children. Pediatr Clin North Am 2013; 60:487.
  9. Council on Community Pediatrics. Providing care for immigrant, migrant, and border children. Pediatrics 2013; 131:e2028.
  10. Jones VF, Schulte EE, COUNCIL ON FOSTER CARE, ADOPTION, AND KINSHIP CARE. Comprehensive Health Evaluation of the Newly Adopted Child. Pediatrics 2019; 143.
  11. American Academy of Pediatrics. Medical evaluation for infectious diseases for internationally adopted, refugee, and immigrant children. Consideration for testing for infectious agents. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.159.
  12. Centers for Disease Control and Prevention (CDC). Elevated blood lead levels among internationally adopted children--United States, 1998. MMWR Morb Mortal Wkly Rep 2000; 49:97.
  13. Spring R, Schlaack H, Rice M, et al. Glucose-6-phosphate dehydrogenase deficiency in internationally adopted children. Pediatr Blood Cancer 2018; 65:e26990.
  14. Abdulla RY, Rice MA, Donauer S, et al. Hepatitis A in internationally adopted children: screening for acute and previous infections. Pediatrics 2010; 126:e1039.
  15. Trehan I, Meinzen-Derr JK, Jamison L, Staat MA. Tuberculosis screening in internationally adopted children: the need for initial and repeat testing. Pediatrics 2008; 122:e7.
  16. Staat MA, Rice M, Donauer S, et al. Intestinal parasite screening in internationally adopted children: importance of multiple stool specimens. Pediatrics 2011; 128:e613.
  17. Staat MA, Rice M, Leach K, Rawlings A. Medical Conditions in Internationally Adopted Children from Africa [abstract]. Pediatric Academy Societies Annual Meeting: Boston Massachusetts, 2012.
  18. Stadler LP, Mezoff AG, Staat MA. Hepatitis B virus screening for internationally adopted children. Pediatrics 2008; 122:1223.
  19. Sciauvaud J, Rigal E, Pascal J, et al. Transmission of infectious diseases from internationally adopted children to their adoptive families. Clin Microbiol Infect 2014; 20:746.
  20. Blanchi S, Chabasse D, Pichard E, et al. Post-international adoption medical follow-up at the Angers university hospital between 2009 and 2012. Med Mal Infect 2014; 44:69.
  21. Hénaff F, Hazart I, Picherot G, et al. Frequency and characteristics of infectious diseases in internationally adopted children: a retrospective study in Nantes from 2010 to 2012. J Travel Med 2015; 22:179.
  22. Goutines J, Miller LC, Sorge F. Infections and nutritional status of internationally adopted children in France. Acta Paediatr 2021; 110:1359.
  23. Lange WR, Warnock-Eckhart E. Selected infectious disease risks in international adoptees. Pediatr Infect Dis J 1987; 6:447.
  24. Hostetter MK, Iverson S, Thomas W, et al. Medical evaluation of internationally adopted children. N Engl J Med 1991; 325:479.
  25. Johnson DE, Miller LC, Iverson S, et al. The health of children adopted from Romania. JAMA 1992; 268:3446.
  26. Albers LH, Johnson DE, Hostetter MK, et al. Health of children adopted from the former Soviet Union and Eastern Europe. Comparison with preadoptive medical records. JAMA 1997; 278:922.
  27. Miller LC, Hendrie NW. Health of children adopted from China. Pediatrics 2000; 105:E76.
  28. Saiman L, Aronson J, Zhou J, et al. Prevalence of infectious diseases among internationally adopted children. Pediatrics 2001; 108:608.
  29. Miller L, Chan W, Comfort K, Tirella L. Health of children adopted from Guatemala: comparison of orphanage and foster care. Pediatrics 2005; 115:e710.
  30. Murray TS, Groth ME, Weitzman C, Cappello M. Epidemiology and management of infectious diseases in international adoptees. Clin Microbiol Rev 2005; 18:510.
  31. Miller LC, Tseng B, Tirella LG, et al. Health of children adopted from Ethiopia. Matern Child Health J 2008; 12:599.
  32. Spicer KB, Turner J, Wang SH, et al. Tuberculin skin testing and T-SPOT.TB in internationally adopted children. Pediatr Infect Dis J 2015; 34:599.
  33. Centers for Disease Control and Prevention. International adoption. In: CDC Yellow Book 2020: Health Information for International Travel. Available at: http://wwwnc.cdc.gov/travel/page/yellowbook-home (Accessed on August 07, 2019).
  34. Raabe VN, Sautter C, Chesney M, et al. Hepatitis a screening for internationally adopted children from hepatitis A endemic countries. Clin Pediatr (Phila) 2014; 53:31.
  35. Centers for Disease Control and Prevention. Hepatitis A. In: CDC Yellow Book 2020: Health Information for International Travel. Available at http://wwwnc.cdc.gov/travel/page/yellowbook-home (Accessed on August 07, 2019).
  36. Wilson ME, Kimble J. Posttravel hepatitis A: probable acquisition from an asymptomatic adopted child. Clin Infect Dis 2001; 33:1083.
  37. Fischer GE, Teshale EH, Miller C, et al. Hepatitis A among international adoptees and their contacts. Clin Infect Dis 2008; 47:812.
  38. Sweet K, Sutherland W, Ehresmann K, Lynfield R. Hepatitis A infection in recent international adoptees and their contacts in Minnesota, 2007-2009. Pediatrics 2011; 128:e333.
  39. Nelson NP, Weng MK, Hofmeister MG, et al. Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep 2020; 69:1.
  40. Bekal S, Lefebvre B, Bergevin M, Tremblay C. CTX-M-15 type ESBL-producing Salmonella Havana associated with international adoption in Canada. Can J Microbiol 2013; 59:57.
  41. Mast EE, Margolis HS, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR Recomm Rep 2005; 54:1.
  42. Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine 2012; 30:2212.
  43. American Academy of Pediatrics. Syphilis. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.729.
  44. Centers for Disease Control and Prevention. Final rule removing HIV infection from US immigration screening. www.cdc.gov/immigrantrefugeehealth/laws-regs/hiv-ban-removal/final-rule-technical-qa.html (Accessed on March 22, 2018).
  45. Wolf ER, Beste S, Barr E, et al. Health Outcomes of International HIV-infected Adoptees in the US. Pediatr Infect Dis J 2016; 35:422.
  46. American Academy of Pediatrics. Tuberculosis. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.786.
  47. Mandalakas AM, Kirchner HL, Zhu X, et al. Interpretation of repeat tuberculin skin testing in international adoptees: conversions or boosting. Pediatr Infect Dis J 2008; 27:913.
  48. Mandalakas AM, Kirchner HL, Iverson S, et al. Predictors of Mycobacterium tuberculosis infection in international adoptees. Pediatrics 2007; 120:e610.
  49. Lange WR, Warnock-Eckhart E, Bean ME. Mycobacterium tuberculosis infection in foreign born adoptees. Pediatr Infect Dis J 1989; 8:625.
  50. Curtis AB, Ridzon R, Vogel R, et al. Extensive transmission of Mycobacterium tuberculosis from a child. N Engl J Med 1999; 341:1491.
  51. Centers for Disease Control and Prevention. Technical Instructions for Panel Physicians. Tuberculosis Screening and Treatment. October 2009. Available at: https://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/technical-instructions-panel-physicians.html (Accessed on March 22, 2018).
  52. Hiatt RA, Markell EK, Ng E. How many stool examinations are necessary to detect pathogenic intestinal protozoa? Am J Trop Med Hyg 1995; 53:36.
  53. Cartwright CP. Utility of multiple-stool-specimen ova and parasite examinations in a high-prevalence setting. J Clin Microbiol 1999; 37:2408.
  54. Buonsenso D, Graffeo R, Scarlato L, et al. Intestinal Parasitic Infections in Internationally Adopted Children: A 10-Year Retrospective Study. Pediatr Infect Dis J 2019; 38:983.
  55. Centers for Disease Control and Prevention (CDC). Congenital transmission of Chagas disease - Virginia, 2010. MMWR Morb Mortal Wkly Rep 2012; 61:477.
  56. American Academy of Pediatrics. American trypanosomiasis. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.783.
  57. Murcia L, Carrilero B, Munoz-Davila MJ, et al. Risk factors and primary prevention of congenital Chagas disease in a nonendemic country. Clin Infect Dis 2013; 56:496.
  58. Mora MC, Sanchez Negrette O, Marco D, et al. Early diagnosis of congenital Trypanosoma cruzi infection using PCR, hemoculture, and capillary concentration, as compared with delayed serology. J Parasitol 2005; 91:1468.
  59. Virreira M, Torrico F, Truyens C, et al. Comparison of polymerase chain reaction methods for reliable and easy detection of congenital Trypanosoma cruzi infection. Am J Trop Med Hyg 2003; 68:574.
  60. Gonzalez-Granado LI, Guillen-Fiel G, Rojo-Conejo P. In nonendemic areas, is microscopy better than polymerase chain reaction for diagnosis of congenital chagas disease? Clin Infect Dis 2010; 50:279.
  61. Pinto Dias JC. [Natural history of Chagas disease]. Arq Bras Cardiol 1995; 65:359.
  62. Maguire JH, Hoff R, Sherlock I, et al. Cardiac morbidity and mortality due to Chagas' disease: prospective electrocardiographic study of a Brazilian community. Circulation 1987; 75:1140.
  63. Bern C, Montgomery SP, Herwaldt BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review. JAMA 2007; 298:2171.
  64. Centers for Disease Control and Prevention. Parasites - American Trypanosomiasis (also known as Chagas Disease). Antiparasitic treatment. Available at: https://www.cdc.gov/parasites/chagas/health_professionals/tx.html (Accessed on June 08, 2023).
  65. Centers for Disease Control and Prevention. Presumptive treatment of P. falicparum malaria in refugees relocating from sub-Saharan Africa to the United States. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/malaria-guidelines-domestic.html (Accessed on June 05, 2021).
  66. Adebo SM, Eckerle JK, Andrews ME, et al. Asymptomatic Malaria and Other Infections in Children Adopted from Ethiopia, United States, 2006-2011. Emerg Infect Dis 2015; 21:1227.
  67. Hagleitner MM, Mascini EM, van Berkel S, et al. Foreign adopted children are a source of methicillin-resistant Staphylococcus aureus transmission to countries with low prevalence. Pediatr Infect Dis J 2012; 31:655.
  68. Hendriksen RS, Mikoleit M, Kornschober C, et al. Emergence of multidrug-resistant salmonella concord infections in Europe and the United States in children adopted from Ethiopia, 2003-2007. Pediatr Infect Dis J 2009; 28:814.
  69. Tandé D, Boisramé-Gastrin S, Münck MR, et al. Intrafamilial transmission of extended-spectrum-beta-lactamase-producing Escherichia coli and Salmonella enterica Babelsberg among the families of internationally adopted children. J Antimicrob Chemother 2010; 65:859.
  70. Boisramé-Gastrin S, Tandé D, Münck MR, et al. Salmonella carriage in adopted children from Mali: 2001-08. J Antimicrob Chemother 2011; 66:2271.
  71. Vanhoof R, Gillis P, Stévart O, et al. Transmission of multiple resistant Salmonella Concord from internationally adopted children to their adoptive families and social environment: proposition of guidelines. Eur J Clin Microbiol Infect Dis 2012; 31:491.
Topic 16709 Version 34.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟