The Centers for Disease Control and Prevention (CDC) is now investigating 109 cases of unexplained pediatric hepatitis cases in 25 US states and territories, the public health agency said today. Nearly all the children (90%) required hospitalization and 14% needed a liver transplant. While the majority of affected children have recovered, officials said, there have been five reported deaths.
On May 4, the World Health Organization reported that worldwide there are at least 228 probable cases in 20 countries.
More than half of US cases have tested positive for adenovirus, but officials noted that they did not yet know if the virus is the cause of these cases. Other factors continue to be considered, such as environmental exposures, medications, and other infections. These children have tested negative for other more common viruses that may cause acute hepatitis, like Hepatitis A, B, C, D, and E. And officials said the illnesses are unrelated to COVID-19 vaccination. The median age of affected children is 2 years, officials said, meaning that most are too young to be eligible for the COVID-19 vaccine.
Any links between these cases and COVID-19 remain unclear. “We are not aware of any cases that are occurring in kids that have documented COVID-19,” said Jay Butler, MD, Deputy Director for Infectious Diseases at the CDC, in a media briefing. An analysis published in the CDC’s Morbidity and Mortality Weekly Report (MMWR) on April 29 found that all nine cases then known in Alabama had no history of COVID-19 infection. “We are working to be able to assess whether or not some of the kids have serologic evidence of past infection,” he added.
CDC “Casting a Very Wide Net”
The public health agency noted that they are using a broad definition for pediatric hepatitis cases, which includes children under age 10 who have elevated liver enzyme levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels above 500 IU/L). “We’re casting a very wide net to help broaden our understanding,” Butler said. “Those are the cases that we want to do a deeper dive on in terms of etiologic workup as well as collecting epidemiological data.” Not all these cases could therefore be linked to the current investigation, he added.
The CDC is investigating cases in Alabama, Arizona, California, Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Louisiana, Michigan, Minnesota, Missouri, North Carolina, North Dakota, Nebraska, New York, Ohio, Pennsylvania, Puerto Rico, Tennessee, Texas, Washington, and Wisconsin. The agency did not specify where the deaths occurred, citing patient confidentiality issues. These cases have all occurred in the past 7 months, so some may not be recent, Butler said.
Officials noted that there has not been a significant increase in pediatric hepatitis or liver transplants in the United States compared with prior to the pandemic, but this conclusion was based on an early analysis of limited data, and it may change. There has been an uptick in hepatitis cases in children in the United Kingdom, but case numbers in other European countries have remained “relatively small,” Butler said.
The CDC advises clinicians to continue their standard workup for children with acute hepatitis and consider testing for adenovirus in these cases. Parents and caregivers should be aware of the symptoms of hepatitis, which include vomiting, dark urine, light-colored stools, and jaundice.
“We know this update may be of concern, especially to parents and guardians of young children,” he added. “It’s important to remember that severe hepatitis in children is rare, even with the potential cases that we are reporting today.”
For more background information on the international extent of the pediatric hepatitis outbreak click here.