INFANTILE HEPATITIS. A mysterious epidemic of hepatitis is raging in particular in Europe (England, France …), alerted the WHO. Nearly 200 children were affected and one death was reported. Covid, adenovirus… The hypothesis of a virus remains the preferred track. Summary of the facts and opinion of our hepatologist.
[Mis à jour le 2 mai 2022 à 10h10] At least 169 cases acute hepatitis of unknown origin have been reported in 11 European countries, the United States and Japan, in young children, between 1 month and 16 years, indicates the WHO in a report from Saturday, April 23, 2022. There has been at least one death. In France, two cases were detected at University Hospital of Lyon. That “does not show, at this stage, an excess of cases in France. Given the active search for cases that has been launched by the health authorities, other reports are likely to be expected in the coming days“reassured Public Health France. This is a mysterious “strange and alarming” epidemic of “new” childhood hepatitisof unknown cause, observed between March and April 2022. “The increase is unexpected and the usual causes have been ruled out“, indicates the Regional Office of the World Health Organization (WHO) for Europe in a press release dated April 15, 2022. “Early epidemiological investigations of cases in the UK based on trawl questionnaires failed to identify any notable common exposure (including food, drugs or toxins),” it said. European Center for Disease Control and Prevention (ECDC), 28 April 2022. Based on these investigations, the current primary assumption is thata cofactor affecting young children with adenovirus infection, which would be mild under normal circumstances, triggers a more serious or liver infection. Other infectious or toxic agents (e.g. Covid) are still under investigation and have not been ruled out but are considered less plausible. “Hepatitis of undetermined origin still exists. Even if we carry out all the examinations and sweep all the known causes, there are always unexplained cases. But it is necessary to eliminate the most important causes, to find a treatment and to guarantee a good vital prognosis.“, indicates Pr Patrick Marcellin, hepatologist, whom we interviewed on Friday April 22, 2022. Among the warning symptoms that were mentioned, we find: jaundice, diarrhea, vomiting and abdominal pain… What do we know about the origin of these hepatitis?
How many cases of childhood hepatitis in the world?
As of April 21, 2022, at least 169 cases of acute hepatitis of unknown origin had been reported in 11 countries in the WHO European Region, one country in the WHO Region of the Americas and one in Japan, says the WHO report of April 23, 2022. Cases have been reported in children aged between 1 month and 16 years.
- 144 in the United Kingdom of Great Britain and Northern Ireland (UK)
- 13 in Spain
- 12 in Israel
- 9 in the United States of America
- 6 in Denmark
- Under 5 in Ireland
- 4 in the Netherlands
- 4 in Italy
- 2 in Norway
- 2 in France
- 1 in Romania
- 1 in Belgium
- 1 in Japan
Given the increase in reported cases over the past month and improved case-finding activities, more cases are likely to be reported in the coming days, WHO said. Member States are strongly encouraged to identify, investigate and report potential cases that meet the case definition. Cases meeting the case definition should be reported to the European Surveillance System (TESSy) as soon as possible. Case records may be updated as more test results become available.
Two cases of acute hepatitis whose etiology is still undetermined have been reported by the Lyon University Hospital
How many cases of childhood hepatitis in France?
“Two cases of acute hepatitis whose etiology is still undetermined have been reported by the Lyon University Hospital“, confirmed Public Health France on April 19. These two cases concerned children under the age of 10 and are being investigated by medical teams. “Cases of acute hepatitis of undetermined etiology in children are not uncommon. The occurrence of these two cases is not unexpected and does not, at this stage, indicate an excess of cases in France. Given the active search for cases that has been launched by the health authorities, other reports are likely to be expected in the coming days.“, continues the health authority.
Are these cases of hepatitis serious?
“This is’a serious phenomenon [qui touche] healthy children“, insisted Deirdre Kelly, pediatric hepatologist at Birmingham Children’s Hospital in the United Kingdom, quoted by the journal Science. Among all the cases identified, 17 children needed a liver transplant. At least a death has been declared.
“The adenovirus or the Covid virus are not viruses known to attack liver cells and cause real hepatitis”
Half of children with hepatitis in the UK have tested positive for adenovirus
The hepatitis viruses (A, B, C, E and D, as appropriate) have been excluded after laboratory tests while further investigations are underway to understand the etiology of these cases, the WHO says. No other epidemiological risk factor has been identified to date, including recent international travel. According to the WHO, these cases of hepatitis are more likely to be linked to an adenovirus (in England and Scotland, 75.5% and 50% of cases respectively tested positive for adenovirus), a family of viruses that usually only cause a bad cold. A statistical overrun compared to positive tests in previous years, according to the European Center for Disease Control and Prevention (ECDC). “Although adenovirus is currently hypothesized as the underlying cause, it does not fully explain the severity of the clinical picture. Adenovirus type 41 infection, the type of adenovirus involved, has not previously been linked to such a clinical presentation. Adenoviruses are common pathogens that usually cause self-limiting infections. They spread from person to person and most often cause respiratory illnesses“, says the WHO. Indeed, half of children with hepatitis in the United Kingdom have tested positive for this virus, as have all the cases spotted in Alabama. The United Kingdomwhere the majority of cases have been reported to date, recently observed a significant increase in adenovirus infections in the community (notably detected in faecal samples from children) following low levels of circulation at the start of the COVID-19 pandemic. The Netherlands also reported a concurrent increase in community circulation of adenoviruses. The WHO recommends that blood tests (with initial anecdotal experience indicating that whole blood is more sensitive than serum), serum, urine, stool and respiratory specimensas well as samples liver biopsy (when available) be undertaken, along with further characterization of the virus, including sequencing. Other infectious and non-infectious causes should be thoroughly investigated.
The Covid at the origin of these hepatitis?
the Sars-CoV-2, virus responsible for Covid, was also detected in several children (at least in 20 cases among the children tested). However, this is only a guess:the evidence is too thin to solve the mystery“, say researchers and doctors. “The adenovirus or the Covid virus are viruses that can give a small elevation of transaminases, reflecting the impact of viral infection. On the other hand, these are not viruses known to attack liver cells and cause real hepatitis“details Pr Patrick Marcellin, hepatologist, interviewed by the Journal des Femmes Santé on April 22, 2022. Indeed, the clinical syndrome among the cases identified is acute hepatitis (inflammation of the liver) with markedly elevated liver enzymes (aspartate transaminase (AST) Where alanine aminotransaminase (ALT) greater than 500 IU/L). Many cases have reported gastrointestinal symptoms, including abdominal pain, diarrhea and vomiting preceding the presentation of severe acute hepatitis and jaundice. Most cases had no fever. Genetic characterization of viruses should be undertaken to determine any potential association between the cases. This hepatitis epidemic is still under active investigation.
An adenovirus and Covid co-infection at the origin of these hepatitis?
The track of an adenovirus and Covid co-infection has also been put forward by the WHO. Among the cases of acute hepatitis identified, 19 were detected with co-infection by SARS-CoV-2 and adenovirus, underlines the WHO in its report.
Can we travel despite these cases of hepatitis?
Yes. In its statement of April 15, 2022, the WHO does not recommend no restrictions on travel and/or trade, especially with the United Kingdom, or any other country where cases are identified, based on currently available information.
What prevention to avoid hepatitis?
Faecal-oral exposure to viruses such as adenoviruses is more likely in young children, says the European Center for Disease Control and Prevention (ECDC). “We therefore recommend reinforcing general good hygiene practices (including careful hand hygiene, surface cleaning and disinfection) in environments frequented by young children”
Sources: Acute hepatitis of unknown aetiology – the United Kingdom of Great Britain and Northern Ireland, WHO, April 15, 2022 / Mysterious hepatitis outbreak sickens young children in Europe as CDC probes cases in Alabama, Science, April 15, 2022