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AAP News Vol. 19 No. 5
November 2001, p. 215
Pediatricians grapple with complexities of foreign immunization recordsAlyson Sulaski WyckoffStaff Writer Editor’s note: This is the second in a series of articles exploring the dynamics of an increasingly diverse pediatric population.
In the free clinic where she works in California, Mika Hiramatsu, M.D., FAAP, receives patient immunization records in Chinese, Indian, Korean, Russian, Spanish and other languages. In the Maryland office of Daniel Levy, M.D., FAAP, the patient files represent children from as many as 40 countries. With the surge in foreign adoptions — more than 100,000 in the last decade — pediatricians are grappling with how to read and interpret a growing number of foreign immunization records. "The first step is an appropriate translation of what has been given, but that is only the beginning," said Lisa Albers, M.D., M.P.H., FAAP, assistant professor of medicine at Harvard and director of the adoption program at Children’s Hospital, Boston. The provider, she says, needs to confirm that the immunizations have been appropriately conducted and that the immunologic response is proven to be effective. The AAP 2000 Red Book advises pediatricians to accept written documentation of prior immunizations as adequate (with exceptions) if the vaccines, dates of administration, number of doses, intervals between doses and age of the patient at the time of immunization are comparable to the current U.S. immunization schedule. But because of reliability issues, some pediatricians have questioned the Red Book’s overall recommendation as it applies to the records of children adopted from foreign countries. All say that more research is needed on the care of international adoptees.
"It is only the institutionalized children’s records we are concerned about," said Dr. Jenista. "The other foreign records seem to be reliable as they (the immunizations) are usually administered in the community" (i.e., clinics and doctors’ offices). Problems can result from differences in vaccine manufacturing standards and procedures in other countries, such as improper potency or inadequate storage, as well as differences in immunization schedules, customs, medical practices and terminology. For example:
Not every foreign record needs to be translated, according to Dr. Jenista, unless the child is ill, has a chronic disease or the parents report a serious illness. "If the child is healthy and the parents report the illness was inconsequential, I am not so worried about having every word translated. Immunization records and growth data are usually obvious." At the October 2000 meeting of the U.S. Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), a recommendations work group debated conflicting data from two pediatrician-consultants on the adequacy of immunizations of foreign adoptees. Although the work group discussed altering the current ACIP recommendations on foreign adoptee immunizations at that time, they voted to keep the recommendation as it stands (listed in the Red Book, page 27). Research is continuing on the issue.
When there is any doubt about a child’s immunization status, the Red Book also recommends that evaluation of antibody titers may be reasonable and, if there is any question on whether the immunizations were administered or were immunogenic, the best course is to repeat them. Yet having antibodies tested may be a problem for some pediatricians. Some labs take a long time to return results; the process can become costly (up to $20 to $40 per test); and the evaluation of results may be complicated because the provider needs to know exactly how the lab is reporting its results, said Dr. Jenista. "Most pediatricians are not going to do this in a busy practice," she said. Dr. Jenista’s approach to the test vs. re-immunize dilemma is to apply a simple equation. "I count up how many injections are needed to get the patient up to speed vs. how many blood tests I have to draw and then pick the lesser of two evils," she said. But if a child’s records show he or she has had polio and DTP and still needs to be immunized against hepatitis, Haemophilus influenzae type B, varicella and MMR, "by the time I’ve given all those, I might as well have given polio and DTP as well. In addition, some of the new ones that have to be given have DTP and polio in them. So why bother drawing blood?"
If antibody testing is to be done, Dr. Jenista often will give the first set of shots at the same appointment when she is drawing blood, so the child is able to attend school or go to day care. "We stand on our heads to make sure a child is protected," said Dr. Jenista, who explains the immunization requirements to the family and even involves them in some of the decision-making. "We tell parents that we’ll look carefully at the records and evaluate them and do what it takes for their child to be protected." It’s especially important for foreign adoptees to be adequately immunized, she said, because they are the ones most likely to be traveling internationally again. One pediatrician said it’s almost easier if a patient from another country has no record at all because then you don’t have to spend any time to decipher it. You just start over. While most pediatricians seem to have little problem convincing families that a child needs additional immunizations, occasionally there is some resistance. They may become suspicious about why more shots are needed here, said Dr. Hiramatsu.
There are tremendous differences in the cultures and health care systems in Latin and South American countries, Dr. Handal said. While Chile and Cuba have impressive immunization records, pediatricians should be more suspicious when evaluating records from countries like Nicaragua, Venezuela, Colombia and Ecuador, especially if the children are from rural areas in the latter two countries. In contrast, a number of pediatricians noted that records from Korea generally are considered to be highly complete and reliable. On the opposite end of the scale is an immunization record that has been falsified. Records may appear to be copied over; indicate that a vaccine was given on the 31st of every month (when every month does not have a 31st day); show growth data that could not possibly describe the current child; actually belong to an older sibling (who was born in this country, unlike the younger one); and list a name that does not even match the patient. Some records might show an immunization on, say, the 16th of every month, which could be accurate because some other countries have national immunization days when everyone receives the same vaccine. In the end, the issue of translating and accepting records becomes one of balance. "What most of us believe is that (providing) immunizations is one of the most important roles pediatricians have in protecting the health of a child against potentially fatal disease," said Dr. Albers. "But immunizing can be painful and costly. We have to balance ensuring a child is appropriately immunized with trying to rely on the data so as not to overimmunize, which adds more cost to the family and to society in general." Dr. Jenista said that for international adoptees, sometimes immunizations are the least of the problems. More pressing concerns are whether the children have tuberculosis, giardiasis, dental problems and appropriate growth and development, including mental health. "Ten years from now, are they and their families well-adjusted? We have to put it in the proper perspective."
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A child’s record from Russia can show as many as 10 or 12 polio and diphtheria-tetanus-pertussis (DTP) shots, yet the child actually may not be immune to those diseases. 
