Hepatitis B and Adoption from Asia
Part 1 of the FAQ
The Hepatitis B and Adoption from Asia FAQ provides information and resources for adoptive parents about hepatitis B. This article is not intended to replace individual consulation with your doctor. For more information, check our listings of adoption health clinics and hepatitis B information on the Comeunity website.
Part 1 Hepatitis FAQ | Part 2 Hepatitis FAQ
Why should parents adopting
from Asia learn about Hepatitis B?
What are the symptoms of Hepatitis B?
What can parents adopting from Asia do about Hepatitis B?
How do children get Hepatitis B?
Risks and consequences of hepatitis B exposure for Asian children.
Information on hepatitis B infection rates in Asian countries.
Information on hepatitis B infection rates of children adopted from Asia.
Pre-adoption testing for hepatitis B in Asian countries.
Post adoption medical tests for your child.
What do the tests mean?
Hepatitis B vaccinations.
What if my child has Hepatitis B?
Page 1 | Page 2
Hepatitis B is an infectious disease which is more prevalent in Asia than in many other parts of the world. According to the Hepatitis B Foundation, one group at risk of becoming infected with the hepatitis B virus is "adoptive families - especially people who plan to adopt children from Asia, parts of Africa, South America, and Eastern and Mediterranean Europe, because these areas have the largest numbers of people infected with the disease."
Because hepatitis B infection is reported in 2-10% of children adopted from Asia, adoptive parents will want to educate themselves about this virus so that they are prepared to make good decisions in the adoption process and after they are home.
According to the Center for Disease Control,
"HBV infection can cause acute illness that leads to loss of appetite; tiredness; pain in muscles, joints, or stomach; diarrhea or vomiting; and yellow skin or eyes (jaundice). HBV can also cause chronic infection, especially in infants and children, that leads to liver damage (cirrhosis), liver cancer, and death."
However, most infants and children have no signs or symptoms of diesease, that is, you cannot make a diagnosis of hepatitis B by examination alone.
Deborah L. Wexler, MD, Executive Director of the Hepatitis B Coalition explains that,
"A carrier usually has no signs or symptoms of HBV but remains infected with the virus for years or for a lifetime and is capable of passing the disease on to others. Sometimes HBV carriers will spontaneously clear the infection from their bodies, but most will not. Although most carriers have no serious problems with hepatitis B and lead normal healthy lives, some carriers develop liver problems later. Hepatitis B carriers are at significantly higher risk than the general population for liver failure or liver cancer."
Medical and support resources on hepatitis B are available to assist with these essential steps in the adoption process:
1. Learn about Hepatitis B.
2. Immunize yourself and your children before travel. (If possible, start six months ahead of your projected travel date.)
3. Test your child when (s)he returns home (and retest six months later).
4. Begin the inoculation of your newly adopted child for Hepatitis B. (See guidance on innoculations.)
5. If you have concerns or if your child does test positive for HBsAg (the active portion of the virus) - contact the many wonderful resources available to help your child.
Transmission of the hepatitis B virus occurs via contact with infected fluids (ie, blood, semen, etc.), including parental contact inuterine (blood-to-blood).
Infants may be infected by their birth mothers, if they have hepatitis B at the time of birth. This is called perinatal infection and is the major mode of transmission in regions of Asia where hepatitis B is endemic. Of additional concern to adoptive parents, one route of potential exposure to infants and children is vaccinations or tests with syringes under less than sterile conditions. As hepatitis B is prevalent in Asia, exposure may happen any time before the children arrive home.
Babies and children often appear healthy, despite infection by Hepatitis B, and may not have any symptoms.
World wide, Hepatitis B is a serious concern with 300 million people chronically infected. According to the Hepatitis B Foundation, 10 - 30 million people a year will be exposed newly to the Hepatitis B virus. In the United States, 5% of the population has been exposed to Hepatitis B (Center for Disease Control) and about 0.5% of the population have chronic infections.
Drs. Jenista, Johnson, Miller and Murray write that,
"Chronic hepatitis B infection is the most common serious infectious disease affecting children adopted internationally. Approximately 5% of all such adoptees to the United States have active infection at the time of arrival. A somewhat higher percentage of children show evidence of immunity from past infection or from immunization. Exposure to hepatitis B is found in children of all ages and from all countries."
While most adults recover from Hepatitis B, exposure as an infant or young child leads to the highest risk of becoming chronically infected. Dr. Worman (Doctor of Medicine at Columbia University and a specialist of liver pathology), explains that:
"The chances of becoming chronically infected depends upon age. About 90% of infected neonates and 50% of infected young children will become chronically infected...About 90% to 95% of acutely infected adults recover without sequelae."
Dr. Worman explains further (pers.comm.),
"I do not think that there are reliable numbers (and the numbers may be different in different parts of the world, for example, worse in rural China where alflatoxins in food and water also contribute to the development of cancer). What I can say is that the majority of infants and children will probably be chronic carriers without significant liver disease at that time. However, as I stated, even these children are at an increased risk compared to non-infected individuals of developing hepatocellular carcinoma and cirrhosis, probably well into adulthood. I would say that MOST will not develop these complications."
Most experts put life-time risk of any complication at about 25% or 1 in 4. (Dr. Jenista, pers.comm).
Specific information on rates of infection of infants and children from Asian countries is not easy to find because rates are dependent on local conditions and variable from place to place. The chronic infection rate given in general for Asia is 20% and it is predicted to be as high as 30% in China. Many more people have been infected and have recovered.
An article on HepNet describes that in 1984, Taiwan launched a nationwide vaccination program to control hepatitis B. This program reduced the hepatitis B surface antigen carrier rate in children from about 10% to 1% within 10 years of implementation.
Korea has statistics similar to the Taiwan numbers. China is trying to implement universal immunization at birth. (Dr. Jenista, pers. comm.)
Chronic infection by Hepatitis B among children adopted from Asia is given at 5-10% overall. Higher rates occur with older children. The percentages of adopted children from Asia with hepatitis B are: China 5-8%, Korea <1%, Vietnam 10%, Cambodia 5-10%, and Thailand 2-5%. (Dr. Jenista, pers.comm.)
Dr. Grindler, pediatrician and medical epidemiologist with the Center for Disease Control, explains that:
"Hepatitis B is endemic in Asia; about 12% of Chinese women of child-bearing age are Hepatitis B Surface Antigen (HBsAg) positive, meaning that they have been infected and are probably chronic carriers. However, among them, only about 30% are what is known as "e-antigen" positive; these are the women who are most likely to transmit Hepatitis B to the infant at the time of delivery (i.e. 90% risk of transmitting infection, vs. 10% risk for e-antigen negative moms). So the overall risk for a given infant is about 0.12 x 0.3 or about 4% chance of being infected at birth."
Dr. Jane Ellen Aronson, the Chief of Pediatric Infectious Diseases at Winthrop University Hosptial, who studied the the prevalence of Hepatitis B at her International adoption clinic, writes that she "evaluated over one hundred adopted Chinese girls over the past few years; the prevalence of Hepatitis B carriage is about 5-7%."
Dr. Jenista writes that, "The experience of over 40,000 Korean adoptees, approximately 5% of whom are chronically infected, is generally good. ... most Korean children acquired their infections perinatally".
Every parent adopting from Asia faces some risk that their child has been exposed to hepatitis B. This appears to be true even if their child has received negative test results in their country of origin. In most cases, adoption medical professionals ignore vaccine and testing reports from Asia, except those from Korea.
Korea has newborn vaccination and testing is reliable.
In China, many children are tested for the presence of HBsAg prior to being referred, but at ages typically too young to detect most infection.
In Vietnam, policies on testing of children for hepatitis B vary among agencies and orphanages. Some agencies choose not to test for hepatitis B. They believe the risk involved with the tests of exposure to hepatitis B and other illnesses (such as HIV) through contaminated needles is too great. Also, many labs are unreliable. Furthermore, they are concerned that once diagnosed with hepatitis B, the children move into the special needs category and become less adoptable - especially boys. Other agencies test for hepatitis B and then work to find homes for these children as special needs adoptions.
The Center for Disease Control recommends Hepatitis B immunization for travel to east and southeast Asia, "if you might be exposed to blood (for example, health-care workers), have sexual contact with the local population, stay longer than 6 months in the region, or be exposed through medical treatment."
Dr. Jane Aronson recommends that families adopting from Asia should get the series of hepatitis B shots before they travel. If you have other children in the family, it is important that they also receive their hepatitis immunizations, if they haven't already had them.
Full immunizations require 3 injections of vaccine over a 6 month period of time. The first two injections are 1 month apart and the third injection is 6 months after the first injection. Completing the series with all three shots is usually possible within most people's adoption timeframe. Effectiveness of the doses are as follows: First shot 60%, second shot 90% and third shot 95%. Even one dose of vaccine provides substantial protection and the risk of infection is very low (< 1 - 5 %) anyway. (Dr. Jenista, pers.comm.)
Jerri Ann Jenista, MD is a pediatrician and well known author of articles on adoption medical issues.
Allison Martin, MPA is the webmaster of this Adopt Vietnam website and the listowner of the Adoptive Parents of Vietnam mailing list. Formerly she was a biologist with the U.S. Environmental Protection Agency.
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