Outbreaks of pediatric hepatitis of unknown cause continue to rise, with 348 possible cases and 70 additional cases investigated in five regions of the World Health Organization (WHO) as of April 10. Typical symptoms of the disease include nausea, vomiting, abdominal pain and jaundice, while severe hepatitis with acute liver failure is rare in healthy children. However, in this outbreak, several cases experienced additional more serious complications, including liver failure.
As of May 6, 109 cases have been identified among children in 24 US states and Puerto Rico. In the United States, five children under the age of 10 have died and another 15 children have needed a liver transplant. Without an understanding of the nature and origin of the outbreak, which is crucial to disease control efforts, there is a risk that the outbreak will continue to escalate.
Hepatitis is an inflammation of the liver and in children is usually caused by viral hepatitis type A, B, C, D and E. In addition to elevated levels of liver enzymes, gastrointestinal symptoms, including abdominal pain, have been reported in many cases. diarrhea and vomiting. Studies conducted in the United Kingdom, where the outbreak was first identified, ruled out viral types of AE, in addition to other known causes of acute hepatitis.
Although hepatitis AE has been ruled out, it still makes sense to investigate the extent of hepatitis A, the most common type of hepatitis affecting children. In the UK, epidemiologists at GlobalData predict that diagnosed cases of hepatitis A at all ages are expected to reach nearly 500 cases by the end of this year. With this figure providing context, it is worrying that the unknown cases of hepatitis in the UK have already exceeded 150. In addition, as children do not qualify for the Covid-19 vaccine, this is also ruled out as a potential cause.
Supported by the WHO, public health authorities around the world are currently investigating possible causes, examining clinical and case exposures, toxicological tests, and microbiological and virological tests. One hypothesis is that the adenovirus may be potentially associated with the outbreak. Adenoviruses that cause respiratory diseases are spread through respiratory droplets, close personal contact, and contact with fomites. Following low levels of circulation in the early stages of the Covid-19 pandemic, the United Kingdom has recently seen an increased transmission of adenoviral infections in the community.
The United Kingdom’s Health Security Agency (UKHSA) has tested pathogens on confirmed hepatitis samples to look for co-infections. A UKHSA report published on April 25 found that adenovirus was the most common pathogen found in 40 of the 53 cases tested. One subtype, 41F, was particularly common after being identified in all tested samples. Similarly, in the United States, adenovirus was detected in approximately half of patients as of May 6, according to the Centers for Disease Control and Prevention (CDC). In addition, many cases have been identified with current Covid-19 infection or Covid-19 antibodies present.
The frequency of adenovirus and hepatitis coinfections observed in this outbreak requires further investigation. However, the adenoviral subtype 41F was not previously associated with the clinical symptoms observed in this outbreak. There have been isolated reports of immunocompromised children with hepatitis and adenovirus co-infection, but it is not known that this adenovirus causes hepatitis in healthy children. Additional factors such as the potential emergence of a new adenoviral strain or the role of hepatitis and co-infection with SARS-CoV-2 should be further considered.
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