CDC: Investigation ongoing, need time to evaluate evidence for acute hepatitis in children
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The CDC reported during a media telebriefing that it is investigating cases of acute hepatitis of unknown etiology among children in the United States but warns it will take time to evaluate evidence.
The agency’s investigation currently includes 109 cases of acute hepatitis in children in 25 states over the past 7 months. More than 90% of these patients were hospitalized and 14% received liver transplants; there have been five deaths. Cases have been reported in Alabama, Arizona, California, Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New York, North Carolina, North Dakota, Ohio, Pennsylvania, Puerto Rico, Tennessee, Texas, Washington and Wisconsin.
“Although rare, children can have serious hepatitis, and it's not uncommon for the cause to be unknown,” Jay Butler, MD, CDC deputy director for infectious diseases, said during the briefing. “The 109 patients under investigation were identified as having been ill within the past 7 months. Some may ultimately wind up not being linked to the current investigation, and based on a preliminary analysis of limited data, there has not been a significant increase in pediatric hepatitis cases or liver transplant, including from before the COVID -19 pandemic.”
No link to COVID-19 vaccine
Some of the hepatitis cases identified in Alabama between October 2021 and February 2022 had adenovirus type 41 infection, which is not known to cause hepatitis in otherwise healthy children. Other causes, including hepatitis A, B, C, D and E, were considered but were not found. Investigators also ruled out a possible link to the COVID-19 vaccine.
“We know that none of the children in Alabama had received the COVID-19 vaccine prior to being hospitalized for hepatitis,” Butler said. “The children affected are young, with a median age of 2 years, which means that most are not eligible to receive the COVID-19 vaccine. COVID-19 vaccination is not the cause of these illnesses, and we hope that this information helps clarify some of the speculation circulating online.”
According to Butler, the CDC is currently unaware of any cases of children with acute hepatitis and documented COVID-19 infection.
“That certainly is true among that initial nine cases in Alabama, but it's a question that I think is still unanswered,” Butler said. “We are working to be able to assess whether or not some of the kids have serologic evidence of past infection that may not have been clinically apparent. Regarding the assessment of adenovirus infections, that's also ongoing work.”
Adenovirus remains a possible cause
Although the adenovirus has been detected in several cases in the U.S. and around the globe, it is not yet known whether that is the cause of acute hepatitis, Butler said. In addition, it is not known whether other factors, such as environmental exposures, medications or other infections, might play a role.
“We’re actively engaging with public health partner organizations to share information and make sure we're prepared to diagnose and treat additional cases,” Butler said. “But I want to caution that it may take time to assess the evidence and to learn more. We're also examining national data sources to look at pediatric hepatitis trends, as well as possible patterns and the adenovirus infection over the past several years, even prior to the COVID-19 pandemic.”
Butler’s colleague Umesh Parashar, MD, chief of viral gastroenteritis at the CDC, noted that during COVID-19, infectious disease transmission was low due to social distancing measures. As restrictions ease, transmission may increase for enteric diseases such as adenovirus.
“Is it because of greater transmission this year compared to even pre-COVID seasons?” Parashar asked. “Potentially many children were not being exposed during the past 2 years and therefore you have a larger number of susceptible people.”
According to Parashar, the CDC will need to investigate the viral detection of hepatitis as well as look at the baseline rates of children who do not have it, which could point to an etiologic correlation.
“We really are casting a broad net and keeping an open mind in terms of whether the adenovirus data may reflect an innocent bystander or whether there may be cofactors that are making the adenovirus infections manifest in a way that's not been commonly seen before,” Butler said, noting there has not been an uptick of adenovirus infections in the U.S.
“It's still a very rare occurrence as we look across the country over the past 7 months.”
CDC guidance
Clinicians are being urged to continue performing standard diagnostic workups for children with acute hepatitis, as well as testing patients for the adenovirus. Symptoms include nausea, vomiting, diarrhea and general malaise, which may progress to jaundice of the eyes and skin, dark urine and pale stools.
Further, the CDC recommends that children be up to date on all vaccinations and that parents and caregivers follow everyday actions already recommended for prevention of common infections, such as washing hands, avoiding people who are sick, covering coughs and sneezes, and avoiding touching the eyes, nose or mouth.
“We know this update may be of concern, especially to parents and guardians of young children,” Butler said. “It's important to remember that severe hepatitis in children is rare, even with the potential increase in cases that we’re reporting today. While this investigation is ongoing, we encourage parents and caregivers to be aware of the symptoms of hepatitis.”
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Butler J, et al. CDC Media Telebriefing: Update on Acute Hepatitis of Unknown Cause. Presented: May 6, 2022.
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