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Explainer: What we know about the recent spate of acute hepatitis in children

There have been six probable cases of the illness in Ireland, and one child has sadly died.

IN APRIL, REPORTS began emerging of cases of acute hepatitis of an unknown origin in children in Britain.

Within weeks, there were reports of the hepatitis (which is liver inflammation) in Ireland, Denmark, the Netherlands, and Spain.

Today, the HSE confirmed that one child has died after receiving treatment for this acute hepatitis, while a second child being treated for the illness received a liver transplant.

It’s unusual to have acute hepatitis occur in a child who was previously healthy – hepatitis is usually linked to hepatitis viruses, or things like autoimmune hepatitis, or due to medications, toxins or heavy alcohol use. 

There is still a lot unknown about this illness and what appears to be its sudden emergence in clusters, but here’s what we know so far. 

How many cases have occurred in Ireland so far?

The HSE said today that six probable cases of children with this hepatitis of unknown cause have been identified here over the past 10 weeks.

This is unusual – the HSE said that the number is “more than would usually be expected over this period of time”.

The children are aged between one and 12 years of age, and all had to be hospitalised. None of them are connected to each other.

In addition, a small number of children are under investigation to see if they too had the illness. 

The HSE also said that no single virus has been identified in the cases, and investigations are underway to identify the cause. 

What about cases in other countries?

The first cases emerged in March in Scotland - on 5 April there were 10 cases, by 8 April a total of 74 cases had been identified across the UK.

The European Centre for Disease Control (ECDC) said on 11 May (yesterday) that approximately 450 cases have been reported worldwide.

We know that the majority - 163 cases as of 3 May – were identified in the UK, and 11 children in the UK have received a liver transplant. 

The ECDC says that 35 cases have been identified in Italy and 22 in Spain, as well as smaller numbers in countries like Denmark, France, Cyprus, Austria and Belgium. Outside the EU, cases have been reported in countries including Israel, Japan, Panama, Palestine and Argentina.

Globally, the cases have affected children from one month to 16 years old. 17 children have required a liver transplant and at least one death has been reported.

The World Health Organisation says that international travel and links to other countries have so far not been identified as factors. 

It’s not recommending restriction on travel or trade to any of the countries where cases have been identified, based on what’s currently known.

What do we know about the cause?

The common viruses that cause acute viral hepatitis – the hepatitis viruses A, B, C, D and E – have not been detected in any of the cases globally, the WHO says. 

On 15 April, when the total number of cases was lower, it said that adenovirus had been detected in at least 74 cases. Adenoviruses can cause illnesses like the common cold, sore throat, acute bronchitis, pneumonia, and acute gastroenteritis. 

Covid was identified in 20 cases of the hepatitis patients who were tested by that April date, said the WHO, and 19 had both Covid and an adenovirus co-infection.

Over in the UK, a technical briefing from the government in early May said that of 163 cases, 126 were tested for adenovirus, of which 91 had adenovirus detected. Covid was detected in 24 out of 132 cases.

The Netherlands also reported “concurrent increasing community adenovirus circulation”, the WHO said. 

But it said that because of enhanced lab testing for adenovirus, these results could show the adenovirus being picked up at levels not previously shown, due to increased testing.

In the UK, the link to adenovirus is undergoing a formal epidemiological study.

The WHO also said that while adenovirus is one hypothesis as to the cause, it “does not fully explain the severity of the clinical picture”. The type of adenovirus (type 41) being picked up hasn’t been linked to this kind of hepatitis illness before. This type isn’t known to be a cause of hepatitis in otherwise healthy children.

The UK government said that among the hypotheses being pursued are a normal adenovirus due to:

  • Abnormal susceptibility which allows an adenovirus infection to
    progress more frequently to hepatitis, for example from lack of exposure during the coronavirus (COVID-19) pandemic
  • An exceptionally large wave of normal adenovirus infections, causing a very rare or under-recognised complication to present more frequently.
  • Abnormal susceptibility to adenovirus due to priming by a prior infection with Covid (including Omicron restricted) or another infection.
  • Abnormal susceptibility or host response to adenovirus due to a coinfection with Covid or another infection.
  • Abnormal susceptibility or host response to adenovirus due to a toxin, drug or environmental exposure

Other lines of investigation are: a novel variant adenovirus; a post-infectious Covid-19 syndrome; a drug/toxin/environmental exposure; a novel pathogen; a new variant of Covid-19.

It’s important to underline that these are all just hypotheses being investigated, and none of them have been in any way confirmed. 

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Could the pandemic have anything to do with it?

The WHO says that there are some factors on this topic that need to be investigated, such as if there has been increased susceptibility among young children to adenovirus because of the lower level of it circulating during the pandemic.

What also needs to be investigated is if Covid co-infection has a link – but this is just at the investigation stage and not confirmed. The WHO says it should also be investigated if a novel (new) adenovirus has emerged.

It says that the vast majority of the affected children didn’t receive a Covid-19 vaccination, so any hypotheses claiming that had something to do with it are not supported.

What symptoms are children showing?

The WHO said that those with acute hepatitis – which is liver inflammation – have “markedly elevated” liver enzymes.

Symptom wise, they tend to report gastrointestinal symptoms, like abdominal (stomach) pain, diarrhoea and vomiting. This tends to be followed by signs of jaundice, like a yellowing of the skin and the whites of the eyes yellowing.

Most cases didn’t have a fever.

What advice is there for parents?

The HSE says that parents are advised to go to their GP if their child develops symptoms of hepatitis.

Symptoms of hepatitis can include:

  • pale, grey-coloured poo (stools)
  • dark urine
  • yellowing of the eyes and skin (jaundice)

“If their child has any of these 3 symptoms, they should contact their GP without delay. The GP will assess the child and refer on for further assessment as indicated,” said the HSE.

Other symptoms include:

  • muscle and joint pain
  • a high temperature
  • feeling and being sick
  • feeling unusually tired all the time
  • a general sense of feeling unwell
  • loss of appetite
  • tummy pain
  • itchy skin

If your child is unwell with respiratory or diarrheal or hepatitis symptoms, keep your child at home and do not send to crèche/preschool/school until they are better, the HSE advises.

The HSE also says that good respiratory and hand hygiene, including supervising hand washing in young children, can help to prevent adenovirus and also other infections that can cause hepatitis.

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