US and UK investigate unusual cases of hepatitis in young children

PPublic health officials in the United States and United Kingdom are investigating a number of unusual cases of severe hepatitis in young children, the cause or causes of which are currently unknown.

Evidence from the UK and Alabama – where nine cases have been recorded since last fall – points to the possible involvement of an adenovirus. Adenoviruses typically attack the airways, causing cold-like illnesses. But they have been linked to inflammation and infection of the bladder, and sometimes hepatitis, although rarely in children who are not immunocompromised.

In a statement released late Thursday, the Centers for Disease Control and Prevention said they were working with Alabama on its investigation of the cases and were working with other health departments in the state to see if there were other cases elsewhere. In an alert to physicians the Alabama Department of Public Health issued in early February, it mentioned being aware of a case in another state, but did not provide details.

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“The CDC is aware of and is working with the Alabama Department of Public Health to investigate nine cases of hepatitis in children – ages 1 to 6 – who have also tested positive for adenovirus since October. 2021,” agency spokeswoman Kristen Nordlund said in a statement.

“The CDC is working with state health departments to see if there are other cases in the United States and what may be causing these cases. Right now, adenovirus may be the cause, but investigators are still learning more, including ruling out the most common causes of hepatitis,” she said.

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Karen Landers, a district medical officer with the Alabama Department of Public Health, said the cases were discovered in various parts of the state and investigations to date have not found any links between the children. Investigators in the UK have not found any links between the cases there either.

“It’s not common to see children with severe hepatitis,” Landers, a 45-year-old pediatrician, told STAT in an interview. “Seeing children with severe [hepatitis] in the absence of serious underlying health problems is very rare. That’s what really stood out for us in the state of Alabama.

There is a range of adenoviruses that can infect people. Genetic sequencing is underway to try to identify if one or more types of adenovirus are involved. To date, five of the children have tested positive for type 41, Landers said.

As word of the condition spreads, additional cases may be found. The El País newspaper reported on Wednesday that Spain had detected three cases, all in children between the ages of 2 and 7. One of the children required a liver transplant, the newspaper said.

As in the UK, children in Alabama were very sick, said Helena Gutierrez, medical director of the pediatric liver transplant program at the University of Alabama at Birmingham. “We saw a full spectrum of cases ranging from severe hepatitis to acute liver failure,” she told STAT in an email.

Nirav Shah, director of the Maine Center for Disease Control and president of the Association of State and Territorial Health Officers, said the organization was aware of the cases in the UK, but had not been told there were had similar cases in this country. “We contacted the US CDC to learn more and discuss how states can undertake surveillance for such cases,” he said.

In the UK, where around 75 cases have been reported in England and Scotland, a small number of children have had or may need liver transplants.

A number of affected children in the UK have tested positive for adenoviruses and for SARS-CoV-2, the virus that causes Covid-19. But the former appears to be the main suspect, according to a scientific paper on the Scottish cases published Thursday in the online journal Eurosurveillance.

Still, even if the cause is an adenovirus infection, there may be a link to the pandemic, the authors suggested, noting that young children — many cases are under 5 — who have not been exposed to the normal range of germs during the pandemic may have been made more vulnerable when masks fell off and social distancing measures were lifted.

“At the time of publication, the main hypotheses revolve around the adenovirus – either a novel variant with a distinct clinical syndrome, or a regularly circulating variant that more severely affects young children who are immunologically naïve,” the authors wrote, from Public Health Scotland, the Royal Hospital for Children Glasgow and the University of Glasgow Center for Virus Research.

“This latter scenario may be the result of restricted social mixing during the Covid-19 pandemic,” they said. Five of the 13 children described in the article tested positive for adenovirus infection.

Hepatitis – inflammation of the liver – is a condition that can be caused by a number of factors, although often viral infections are the cause. A number of hepatitis viruses – A, B, C, D and E – are common causes of hepatitis, but they have been ruled out in these cases.

The European Center for Disease Prevention and Control issued an alert on Tuesday urging doctors to seek out and report cases of acute hepatitis in children aged 16 and under when tests rule out infection with hepatitis viruses. A, B, C, D or E.

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