Our international adoption practice includes children from parts of the world where tuberculosis is much more prevalent than in the US, and kids from especially high-risk backgrounds for TB, like institutional care. Research on international adoptees reveals that about 1 in 5 children from these backgrounds will have positive skin tests for tuberculosis (called PPDs) on arrival, or at the retest 6 months later. This brief article gives some background on TB, and rationale for testing and treatment.

Tuberculosis is an infection with Mycobacterium Tuberculosis (TB). While the most common site of infection is the lungs, it can affect many parts of the body. It is an atypical infection and most of the time, infection does not cause any symptoms initially. When an individual is infected by TB but has no symptoms, physical findings, or chest x-ray abnormalities, then they have Latent Tuberculosis Infection (LTBI, or "inactive TB"). Patients with LTBI are not ill appearing, have no symptoms, and are not contagious (i.e. they cannot spread the infection to others).

The reason it is very important to treat LTBI is that if not treated, there is a 5-10% lifetime risk of developing Active Tuberculosis, which is a life threatening illness. Some people have an even higher risk of progression to active disease and these include: infants, adolescents, patients who were infected within the previous two years, patients with compromised immune systems (like HIV), patients with chronic illnesses such as diabetes or kidney disease. LTBI is treated with a medication called isoniazid (INH). It is given once daily for nine months. The liquid preparation is hard to tolerate and often causes bad diarrhea so we generally prescribe a tablet that can be crushed.

Tuberculosis is typically diagnosed using a skin test or a PPD. This should be tested at arrival and again 6 months later, regardless of whether they had BCG (TB immunization) previously or not. A positive PPD reading depends on the risk factors for a particular patient and is sometimes a bit difficult to read, so it is important to have it read by someone who does this often. There are some newer blood tests for diagnosing Tuberculosis that can be used in children over 5 years of age, with some providers using them as young as age 2. .

Frequently Asked Questions:

My child had a negative PPD previously, why is it positive now?

This can be for a number of reasons. Your child may have been newly exposed to TB since the previous test. Also the time from infection until the development of a positive PPD can be between 2 and 12 weeks. There are 10-15% of children with normal immune systems who have had culture proven disease with negative PPDs. Reasons for this include young age, poor nutrition, other viral infections, recent TB infection, and disseminated TB (an overwhelming full body form of the illness). Also kids with abnormal immune systems can have a falsely negative PPD. This is why we repeat a PPD on international adoptees and other children at high risk for TB six months later.

My child was given BCG (an immunization against TB), does this always cause a positive PPD?

No. BCG is given in many parts of the world to prevent TB and studies find it about 50% effective on average. It is more effective for preventing some more serious forms of TB in young children and that is why it is given. Typically it is given soon after birth. While it can cause a positive PPD, for those given BCG at less than 2 months of age, 40% have negative PPD by 1 yr of age and more than 95% have a negative PPD by 5 years of age. It is the young kids with the recent exposures that are at increased risk for developing active disease where it is the most unclear and those are the ones it is most important to treat. There are newer blood tests that may help us with this but not in kids under 5 years of age. Both the Centers for Disease Control and The American Academy of Pediatrics recommend ignoring the history of BCG injection when evaluating a PPD. However, a very recent, actively oozing BCG site is one situation where we may defer the PPD until the BCG site is more healed.

Are there any precautions I should take while my child is taking isoniazid?

Yes, there are, but isoniazid is actually very well tolerated in children. Adults over 35 years of age are more likely to have some liver inflammation, and are screened with blood tests, but this is not typically needed in children unless they have known liver issues. If your child develops unexplained abdominal pain, vomiting, or jaundice (a yellowing of the skin and eyes) then you should contact your doctor.

Your child may also experience an unpleasant reaction (headache, large pupils, neck stiffness, nausea, vomiting, diarrhea, sweating, itching, and chest pain) if they eat too much tyramine containing food, so those should be avoided or eaten in moderation. These foods include: aged cheeses, avocados, bananas, figs, raisins, beer, ale, caffeine (coffee, tea, colas), chocolate, meats prepared with tenderizer, liver, bologna, pepperoni, salami, sausage, meat extracts, caviar, dried or pickled fish, and tuna, red wine, sour cream and yogurt, soy products, and yeast. Some of those are childhood standbys (bananas & yogurt), some are not (beer). We've not heard many reports of this reaction, so mild-moderate consumption may be OK.

What is the best way to get my child to take the tablet?

A pill crusher will make the medicine into a powder for kids unable to swallow a pill. It is best to mix it in a small amount of something with a very strong flavor such as chocolate syrup or one of the syrups used for Italian sodas. We have a helpful article on "Taking Your Medicine". One clever family opened an Oreo cookie and mixed the powder with the icing in the middle of it, then replaced the top cookie. Their child really enjoyed the daily cookie for nine months!

Is it important to take this medicine every day?

Yes! In fact, some public health departments use "directly observed therapy" (having a nurse watch the patient take the meds) for TB. If a dose is missed, give the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

Isoniazid usually is taken once a day, on an empty stomach, 1 hour before or 2 hours after meals. However, if isoniazid causes an upset stomach, it may be taken with food. Find a time that works for your family, and set a recurring alarm/reminder.

Will my child need more testing after the isoniazid, or further PPDs?

Not unless they develop symptoms of tuberculosis. Their PPD will likely remain positive, but we will document that they had a clear chest x-ray and completed INH therapy. If TB is suspected later, or needs to be ruled out for job purposes, they can get a chest x-ray.

2019 Update!

There are newer, easier, shorter regimens for treatment of active TB that are currently recommended. These may include daily rifampin for 4 months or once-weekly isoniazid and rifapentine [3HP] for 12 weeks. Please see these WA State Latent TB treatment guidelines for more information.

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A really exciting development we have seen in international adoption in the last few years has been an increasing number of children being adopted from Ethiopia, and wow, are they beautiful! To give you an idea, US government statistics tell us that while there were 42 children adopted in the US from Ethiopia in 1999, the number went up to 2,277 in 2009!

We have definitely felt this trend here at the Center for Adoption Medicine. In addition to our center doing many preadoptive consultations, I have had the pleasure, personally, of taking care of lots of these kids once they have come home. It is an interesting and varied group of children. There seem to be two distinct groups being adopted from Ethiopia. First, the infants who are coming into care soon after birth, and often, coming home even before their first birthdays. Then there are the older kids who come after one or both parents have perished, and these often arrive in sibling groups.

There is a rumor out there that all the kids coming from Ethiopia are healthy and have no issues, and this simply is not the case. The variability in health status and medical/developmental issues uncovered both on preadoptive consultation and after they come home is quite large. As with any country of origin, every child is different. There have been a few interesting trends, however. While we see latent tuberculosis (i.e. requiring treatment and infected but not yet sick or contagious) fairly frequently in all of our adopted kids, we have seen quite a bit of active tuberculosis (a life threatening illness, which can be contagious depending upon type of illness and age of the child) in some of our adoptees from Ethiopia. This has ranged from a child who was very obviously ill upon arrival, to a couple of siblings who passed screening in Ethiopia as having latent TB, looked and acted great, but both had active tuberculosis when rechecked in Seattle. Careful scrutiny of in-country testing, and rescreening once home is definitely prudent; and yes, even the kids who come home looking great are subjected to the same battery of tests that we do on most international adoptees, as we pick up all sorts of things that are not apparent on exam or history!

The other illness we are seeing more of is hepatitis A. This is an interesting one in that most young children can have the illness with no obvious symptoms. They do great. The problem is that it is very contagious and it is a more severe illness the older the patient is. This means that unimmunized contacts such as parents, siblings, cousins, grandparents, etc. are at risk. There was recently a case of a grandma who caught hepatitis A from her totally healthy-appearing 1yo newly adopted grandkids from Ethiopia. She nearly died, and they only found out that the twins had hepatitis A when they were trying to figure out how she became infected. Of note, she did not travel to Ethiopia, she visited them once they got home!

It is currently recommended that all contacts of internationally adopted kids be vaccinated against hepatitis A, not just those that travel. While we have seen more cases in our Ethiopian kids, we only recently have been widely screening for it, and there is a high rate of hepatitis A in all the coutries from which we typically see international adoptees. HIV is another infection that is seen at a high rate in Ethiopia. We have seen a small number of patients with known HIV positivity, but fortunately have not yet been surprised by an undetected case.

Some other issues to think about in Ethiopian adoptees include female circumcision (or female genital mutilation) and transracial adoptive issues. Female circumcision is still practiced in parts of Ethiopia, especially rural areas. It can vary from some ritual cuts to removal of various structures that can significantly affect sexual and reproductive functioning. I have seen only a few cases and only one which was not known to the patient, her older sisters, or the adoptive family. It takes a pretty complete examination of the external genitalia to see some of these. Many older Ethiopian adoptees are frankly horrified at the idea of being fully examined by a doctor, as this is not something typically done in Ethiopia. Sometimes it takes a few visits before a full exam can be comfortably done. Specialized care by an OB-GYN with some knowledge of this will be important for these girls.

Transracial/transcultural adoption issues come up for most of our international adoptees. In kids of African descent adopted by non-black families, it can be a more prominent issue to society as a whole. Then there is the added level that many of our kids will be perceived to be of African-American descent, which is not how many of them see themselves. We are fortunate in Seattle to have a large Ethiopian community (and growing Ethiopian adoption community), so incorporating Ethiopian culture into one's family life is easier. For those living far out from the big city, reaching out to other adoptive families and Ethiopian communities is thought to be really helpful.

Lastly, let's talk about hair. Yes, hair. The care of African hair seems to be a science onto itself. I do not pretend to be an expert but have heard lots of tips, including saturating the hair with grapeseed or olive oil prior to shampooing and not washing it more than once a week. Many of our families have found support on the Adoption Hair and Skincare Yahoo! Group.

All in all, these kids have been a joy to work with. The courage and resilience of the older kids never ceases to amaze me. Every day it seems I think I have seen the most adorable, compeling child ever.