Hepatitis B and Adoption from Asia
Part 2 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
When you return home with your child, it is essential that he or she receive a battery of tests and inoculations, including Hepatitis B. (A standard "battery" of tests includes: HIV, Hepatitis B panel, parasites, syphilis, TB, complete blood count, and unrinalysis.) In some cases, these tests will be repeated over time and/or follow-up tests may be required.
Most international adoption medical clinics recommend that testing for Hepatitis B include testing for:
- the Hepatitis B surface antibody,
- the Hepatitis B core antibody, and the
- Hepatitis B surface antigen.
(In my personal experience and the experience of other members of the Adoptive Parents of Vietnam mailing list, pediatricians may not include the Hepatitis B core antibody, unless you request it or the antigen is positive.)
Interpretation of hepatitis B testing can be fairly complicated, so you may want to consult a expert if you do get back a report indicating the hepatitis B virus is present in your child (i.e., the Hepatitis B surface antigen test is positive).
You will want to begin medical testing of your child as soon possible after their arrival home. According to Dr. Jenista,
"The follow-up test is important even if your child has already been tested as negative, as there have been reports of adoptive children testing positive after a prior negative test. This is likely due to either inaccurate test results or interpretation, age of the baby, or to subsequent exposure in the orphanage or elsewhere."
As Hepatitis B exposure can occur at any point before adoption and may have a 6 month incubation period, many international adoption medical experts recommend that you test your child again six (6) months after she or he is in your home. Thus, children (including babies) should be tested upon arrival and 6 months later.
The main purpose of these basic tests are to determine 1) if hepatitis B was ever present and 2) if it is still active. In general, these hepatitis tests check for the presence of either:
antigens (test reaction to actual parts of the virus), or
antibodies (test reaction to a substance produced by the human body in response to the virus - either to the core or to the surface of the virus).
Antibodies may be present despite chronic infection with hepatitis B. Thus, a surface antigen test must always be obtained. If surface antigen is positive, the person is infected regardless of presence of any anitbodies (core, surface or "e"). (Dr. Jenista, pers.comm.)
If the antigen test is positive, then additional tests may be undertaken.
Understanding Hepatitis B test results is no easy task, because the interpretation of one test may be dependent on the results of another. Also, doctors, labs, parents and patients often confuse the names of the tests.
The Hepatitis B surface antigen test indicates whether or not your child currently has Hepatitis B. It actually tests for the virus itself. (The hepatitis B"e" antigen (HBeAg) test also indicates the presence of the virus, along with amount of infectiousness.)
The other two tests - the antibody tests (surface and core) - measure either your child's current or your child's past reaction to Hepatitis B.
The most important test is for the hepatitis B surface antigen (HBsAg). The results of this test indicate whether or not your child has the virus now.
A positive (+) hepatitis B surface antigen (HBsAg) test results means that your child has hepatitis B.
A a negative (-) hepatitis B surface antigen (HBsAg) test result means that he or she does not have the virus now.
Dr. Jerri Ann Jenista explains that in the cases of international adoption,
"Immunizations are frequently not given or are poorly documented. Occasionally, records that are 'too perfect'-- for example, with exactly, 1 or 2 month intervals between doses -- merely reflect slavish attention to the vaccine schedule recommendations. Even when vaccines have been given reliably, the immune response may have been inadequate in the severely malnourished or chronically ill child. When in doubt, it is always best to repeat the series of vaccinations, as there is no harm in re-immunization, provided the HIV status is known.
You can finish a series started in another country with a United States brand with no problem. Also, if there is question about the number or efficacy of vaccine, give a booster 6-18 months after the last documented shot."
Dr. Wexler, Executive Director of the Hepatitis B Coalition (pers. comm.), recommends the following strategy with regard to hepatitis B testing and vaccination for children who have been adopted:
"This is the U.S. recommendation: For infants of women who are known to be HBsAg-positive, these high-risk infants should have completed the birth dose of HBIG and 3 doses of hepatitis B vaccine by 6 months of age according to CDC recommendations. (They need HBsAg and anti-HBs testing at 9-15 months of age to document their hepatitis B status.)
For infants and children who are adopted from other countries whose hepatitis B status is unknown or uncertain at the time of arrival, these children should have a hepatitis B panel drawn (see below) at their first physician visit and the child should also receive the first dose in the hepatitis B vaccine series.
The hepatitis B panel includes at least HBsAg, anti-HBs, and anti-HBc. Antibody serology tests (anti-HBc and anti-HBs) for children under 18 months of age may be unreliable in that the results may reflect maternal antibody that was transplacentally passed to the infant and has not yet disappeared from the infant. For this reason, if an infant under 18 months of age appears "immune" according to these test results, continue to give the series of three hepatitis B shots to make sure he or she is adequately protected.
If the child is found to be HBsAg positive, vaccinate no further (for hepatitis B), do additional testing as appropriate, and retest in 6 months."
Dr. Jenista provides the following guidelines for vaccinations for Asian Adoptees:
If child has anti-HBs (surface antibody) and anti-HBc (core antibody) and is over 18 months, he is immune. No need to vaccinate.
If child has anti-HBs and/or anti-HBC and is under 18 months, this may be maternal antibody. Either vaccinate and retest in 6 months or retest in 6 months and vaccinate if antibody is gone.
If child has anti-HBs alone at any age and also a documented history of hepatitis B vaccine, finish hepatitis B series. Can retest at 6 months but probably not necessary.
If child has no markers posistive or interpretation no clear at any age, vaccinate and retest in 6 months.
Excellent references for organizations, email support groups, and free articles on raising a child who has hepatitis B are available at Hepatitis B section of the Comeunity website.
Dr. Worman explains that in neonates and children, acute infection usually not clinically apparent. He writes (pers.comm.):
"I personally would say that children who are HBsAg positive (from Asia or elsewhere) should be treated just like any other children. They should go to school, play and participate in any activities as any other kid would. MOST chronically infected children will not suffer from significant liver disease in their lifetimes, however, they are at an increased risk of developing cirrhosis and hepatocellular carcinoma (I don't know the exact numbers). Such individuals should be considered as potentially infectious to close household contacts and (when they grow up) sexual partners (and as adults, women may pass infection to their children). Close household contacts, and sexual partners of infected adults, should be vaccinated."
In Dr. Jenista's article entitled, "Is There Life after Hepatitis B?", she explains that Hepatitis B is not a "death sentence". Dr. Jenista states that,
"Although complete data are not in, we realize that the majority of chronic carriers will never have any adverse effect of their infection at all. Methods for detecting and treating complications of hepatitis B are improving every year. With careful follow-up, most children with chronic hepatitis B can look forward to a full and normal life."
End of Part 2. Return to Part 1.
Annotated links to the above references for this article may be found at Comeunity's Hepatitis B Resources: Organizations & Links.
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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