SELECTED ARTICLE
Author
Alla Gordina, MD, FAAP 
Article Title
Post-adoption Vaccinations 
Posted Date
12/15/2005 
 

"We returned with our daughter in late July and our pediatrician has told us to get all her immunization and shots redone because he doesn't trust the Russian records. I guess it's the safe thing to do, although that means 2 needles for the next month for five months. Has anyone else encountered this?" One of the biggest myths and legends of international adoptions is the question about immunizations.

Both myths - that vaccination records can be accepted at their face value and that we should not even pay attention to what written there, ARE DANGEROUSLY WRONG.

1. Vaccination practices in the Former Soviet Union (FSU) did change dramatically in the past 10-15 years. Yes, we still see the cases when the vaccination records were forged and vaccines were stored inappropriately in regions with power failure and other natural and man-made disasters. But overall, the attitude towards proper vaccination practices is changing there to the best.

2. Interestingly enough, home-grown children in the FSU are vaccinated worse, then orphans, the risk of vaccination records falsification is higher in home-grown children and adopted children do have better translation of their vaccination records then home-grown kids. That can be explained extremely simple - there is nobody to request for un-necessary vaccination deferral or even to pay for the forged vaccination record.

3. Most of the children (but not all!), adopted from the FSU, do have reasonably protective levels of antibodies, which do correspond well with the vaccination records provided by the orphanages. We even see now children vaccinated against rubella and H. flu - those vaccines are still not always available for free for the homegrown children in the FSU.

4. Even immunizations, given in the US are reasonably safe for repeated vaccinations; there is one vaccine, which does have a limit on amount of injections that can be given. I am talking about tetanus-containing vaccines (Td, DTaP, DT and the newest one - the Tdap). According to the famous "RED BOOK" (the Report of the Committee on Infectious Diseases, American Academy of Pediatrics) no child should receive more then 6 (six) doses of tetanus toxoid-containing vaccines before the 4th birthday. Therefore, if a 3 yo newly adopted child already had 4 DT/DPT vaccinations, complete re-immunization with 4 more tetanus-containing vaccine can predispose him/her for increased risk of complications. Giving a school-age child a tetanus-containing vaccine sooner then 5 years after previous vaccination can be a cause of significant and pretty painful adverse reactions.

5. Timing of vaccinations and testing can be a very serious issue. Protective titers would not be reliable if a corresponding vaccine was given shortly (within weeks) before testing. This brings the justification for certain rules of post-adoption management

  • Make sure to obtain the latest version of your child's vaccination record. Medical documents can be written weeks, if not months before the actual adoption will take place. The best way to do it - to request the original of so called Form#63 - your child's actual vaccination card. Taking in consideration, that this card BY RUSSIAN LAW belongs to your child and not to the institution and it should accompany your child wherever he/she will go, you do have a pretty good chance of getting this extremely important document
  • Make sure that your child is not getting any vaccinations during the embassy exam.

Taking in consideration, that by the Red Book recommendations, your child should be examined by a physician within 2 weeks after arrival, there is not reason and absolutely no gain to immunize the child just before departure from the country of origin. Even more, vaccinations given in the US most probably will be covered by insurance and vaccinations given in the country of origin - most probably would not.

  • Make sure that during the post-adoption evaluation your child is not getting any vaccinations before the titers are drawn. If your doctor is not drawing blood in the office - don't allow immunizing your child until you will do all the required bloodwork. (And make sure that this bloodwork is done ASAP after adoption, because lead levels can be affected by the time between last contact with contaminated environment and testing)
  • Make sure that the TB (tuberculosis) testing (injection inside the skin or Manoux test/PPD, never allow to use the 4-pronged Tine test) is done at the same time with or before live vaccines administration (MMR and/or Chicken Pox). Doing the TB testing immediately after such vaccinations can affect the results of TB testing.
  • Protective titers against tetanus are not always indicative of protective immunity against diphtheria. Make sure to test at least for both - tetanus and diphtheria immunity.
  • Protective levels of tetanus and diphtheria antibodies are not indicative of pertussus immunity (see below) - Protective titers against measles are not always indicative of protective immunity against rubella and/or mumps. Make sure to test for all 3 or to re-immunize with MMR
  • The history of orphanage placement and older age are not indicative of protective immunity against chicken pox. Make sure to check titers and immunize your child accordingly.

6. We do live in the times of increased cases of pertussus in all countries of the world. Everybody can get infected, and the disease can make you and your family very sick. Pertussus is especially dangerous for younger infants, elderly and those with the chronic medical problems. Healthy teenagers and adults would "just" have 4-6 weeks of severe fatigue and exhausting cough, bad enough to cause sleep deprivation, sprained back and neck muscles, as well as broken ribs. - Unfortunately, we do not have a good test for pertussus immunity.

The test, which is used by the commercial laboratories even pretty sensitive to the presence of the protective antibodies (low rate of false positives) can give a lot of false negative results. This is the reason why that it is not recommended to do this test routinely.

  • Pertussus vaccinations (when given!), are not providing good and lengthy protection even with newer acellular formulations, used in the United States (DTaP vaccine)
  • The whole-cell pertussus vaccine - the only pertussus-containing vaccine currently licensed in the FSU and other similar countries, is known to cause many real complications. It is also feared to cause even more questionable problems and therefore very frequently it is not given to children at all.
  • According to the standard Russian-type vaccination schedule whole-cell pertussus vaccine can not be given after the age of 2, therefore older adopted children are arbitrarily should be considered as not protected against pertussus, unless they have documented protective antibodies.
  • Interestingly enough, children in the orphanages are better immunized against pertussus, then their bio counterparts.
  • There is a new pertussus-containing vaccine (Tdap) approved for administration to everybody between the age 11 and 50. It is highly recommended for everybody, involved in the adoption process (adopted children and adoptive families) to receive this particular vaccine, rather then the old-fashioned Td formulation.

7. Catch-up vaccination schedule. According to the same Red Book, catch-up vaccinations should be done in a timely matter. In the worst-case scenario (when your child is less then 4 years of age and is not vaccinated against tetanus, diphtheria and pertussus), re-vaccination should not take longer then 8 months. Your pediatrician can find all pertinent information in the Red Book, chapter on active immunizations, table "Recommended Immunization Schedules for Children Not Immunized in the First Year of Life". According to those recommendations, complete re-vaccination with 2 shots given monthly for 5 months (as is described in the original question) is impossible.

8. Are we hurting the hurt child?! Yes, vaccinations are extremely important. Yes, we have to re-immunize children, if they don't have adequate protection. But at the same time, all this have to be done the way that those special kids, already hurt so much in their life, would not suffer beyond the reasonable necessity. "You are as bad, as the orphanage nurse", "Why Dr. G always have to give needles" - those unfortunately the pretty common comments, which I do hear from my older adoptive patients. But the most powerful comment came from a 6 yo sister of a newly adopted Ukrainian toddler. She came to me, put her fists on her hips, and asked with poorly controlled royal anger "WHY DID YOU HURT MY BROTHER?!" So, I prefer all necessary vaccinations to be given in a least amount of office visits possible. Up to 4 vaccines can be safely given at the same time and it is a good idea to co-inside those vaccinations with the post-adoption bloodwork and Mantoux testing. Children still will cry, no matter what with 2 shots or 4-6 needles. It is the stress of expectation of a painful visit to a doctor that can be extremely unbearable for any child, especially in the situation of a full or partial post-traumatic stress syndrome, which can be seen in any adopted kid.

The information appearing here is intended for educational purposes only. It should not be used as a substitute for professional medical advice tailored to your child's individual needs. If you have questions or concerns regarding your child's physical or mental health, please seek assistance from a qualified healthcare provider.

References
GLOBAL PEDIATRICS is an international adoption medical support service that has specialized in assisting families adopting from the Former Soviet Union through every step of the adoption process for the past ten years. Dr. Gordina's unique professional background and attention to detail ensure the highest possible level of service. She is recognized by her patients and peers as a leader and pioneer in the field and has presented her adoption-related research at sessions of the AAP, JCICS, NACAS and other meetings. Dr. Gordina has both participated in and organized several humanitarian missions to pediatric clinics and orphanages in the Former Soviet Union. For all questions regarding our services please check www.globalpediatrics.net 
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