Objective

A CPSP Survey on Canadian Paediatricians’ Experience and Knowledge about the Risks of Infectious Diseases in Children Adopted Internationally

ML Lawson1, L Auger2, C Baxter3, JF Chicoine4, TJ Clifford1, S Kahaler5, R Kugelmass6, S Kuhn7, M Naus8, A Simone9, C Hui1

# Confirmed Cases*

Hepatitis B 30

Hepatitis C 4

HIV 3

Syphilis 4

TB Infection 111

59%27%

14%

Methods

Background

Materials & Methods

Discussion

Investigators’ Affiliation

1Children’s Hospital of Eastern Ontario; 2Montreal Children’s Hospital; 3 Royal Alexandra Hospital, Edmonton; 4CHU Sainte-Justine, Montreal; 5Vancouver; 6Montreal; 7Calgary; 8BC Centre for Disease Control; 9Trillium Health Centre, Mississauga

To determine the experience of Canadian paediatricians with children adopted internationally and their knowledge about current recommendations for screening for infectious diseases.

Canadian families have been adopting children internationally at increasing rates over the last 10 years with over 2000 international adoptions annually. Most of these children come from countries and/or social situations with increased risks for specific infectious diseases acquired at birth or in the first years of life and where routine immunization is incomplete or inadequate.

The authors gratefully acknowledge the support of the CPSP Staff and the participating paediatricians from across Canada.

In September 2005, a one-time survey on international adoption was sent to the 2500 participants of the Canadian Paediatric Surveillance Program (CPSP) to determine the following:

• Whether Canadian paediatricians had experience with caring for children adopted internationally,

• Whether they had screened these children for specific high-risk infectious diseases and if they had, the number of confirmed cases they had seen,

• Their knowledge about the method of screening for these disease, including method and timing of testing, and

• Their knowledge and experience with evaluating immunization records of children adopted internationally and whether revaccination was indicated.

Limitations of Survey

• The majority of Canadian paediatricians are seeing children who were adopted internationally.

• Their practice and knowledge about screening for high-risk infectious diseases is suboptimal as is their knowledge about how to determine who needs revaccination.

• These gaps in knowledge and practice may be leading to under-detection of conditions such as HIV, hepatitis B and C and inadequate immunization putting these children and their contacts at risk.

• AAP recommendations are largely consensus based. Further research is required to develop evidence-based recommendations for children adopted internationally and to determine their risk for specific infectious diseases.

Results

• 672 CPSP participants responded (27%)• Analyses were restricted to the 403 respondents (60%) who had seen an internationally adopted (IA) child within the previous 2 years.

Respondents’ Knowledge About Screeningfor Infectious Diseases in IA Children

Qn: How many internationally adopted (IA) children have you seen over the past 2 years?

< 5

>10

5-10

• Only 27% of CPSP participants responded but this is consistent with the response rate to other one-time CPSP surveys.

• Survey was unable to distinguish between primary care/consulting paediatricians and paediatric subspecialists.

• The number of confirmed cases is likely underestimated as the survey did not include family physicians, however the survey method could not exclude duplicate reporting.

• The incidence for these infectious diseases could not be calculated because denominator data was not available.

2003 AAP Red Book Recommendations

CPSP Survey Respondents

Hepatitis B

• Screen all IA children• HBsAg, HBsAb, HBcAb on arrival• Consider retesting in 6 months

• 79% would screen all IA children on arrival• only 25% would include HBcAb• 25% would retest

Hepatitis C

• Screen IA children from specific high-risk countries• HCVAb on arrival• Retesting not required

• 71% would screen all IA children on arrival• 21% would retest

HIV • Screen all IA children• HIV Elisa or PCR on arrival • Consider retesting in 6 months

• 73% would screen all IA children on arrival• 37% would retest

Syphilis • All IA children• VDRL, RPR, ART or MHA-TP, FTA-ABS on arrival

• 67% would screen all IA children on arrival

TB • Screen all IA children• PPD within 3 months of arrival (+ CXR if symptomatic or PPD +ve) • If PPD negative & child is malnourished, consider repeat PPD in 2-3 months• PPD is indicated even if child had previous BCG

• 71% would screen all IA children on arrival• 95% would screen with PPD; 37% also do CXR• 35% would retest• 35% would not do PPD if child had received BCG

• Revaccination of IA children whose adoption records showed previous vaccination

• 77% sometimes, 17% always, 6% never

• Factors affecting respondents’ decision to revaccinate: 86% would examine quality of records 66% would consider child’s country of origin 46% would consider child’s age 34% would consider overall state of child’s health 25% would do serologic testing

Respondents’ Knowledge About Revaccination of IA Children who were Previously Vaccinated

*total # cases seen by all respondents over previous 2 years