The Centers for Disease Control and Prevention (CDC) is investigating an apparent outbreak of severe viral hepatitis among young children. On May 18, the CDC reported 180 patients in the United States were being investigated as possible cases; 14 of the children required liver transplants, and five died. The World Health Organization has reported more than 650 probable cases in 33 countries.
Hepatitis occurs any time the liver becomes inflamed and its functions are impaired. Acute hepatitis refers to inflammation of the liver that comes about quickly.
The disease is often caused by a viral infection but can also be caused by toxins, medications, immune attacks on the liver, or other medical conditions. Though many people with mild cases of hepatitis do not know they have the disease, severe cases can lead to liver damage, liver failure (requiring a liver transplant), or death.
We spoke with Mercedes Martinez, MD, professor of pediatrics and medicine at Columbia University Vagelos College of Physicians and Surgeons, about the outbreak and about what parents should know. Martinez is medical director of the intestinal transplant program in the Center for Liver Disease and Abdominal Organ Transplantation at Columbia University Irving Medical Center/NewYork-Presbyterian.
Is this outbreak cause for alarm?
Even in a puzzling outbreak like this one, severe hepatitis in children is extremely rare. So, no, there is no cause for alarm.
It is important to keep in mind that we don't have a precise idea of how many cases of severe hepatitis usually occur every year. Severe hepatitis is not what we call "a reportable condition." For example, when doctors see instances of chickenpox or hepatitis B, they must report them to the CDC. But that has not been the case with severe hepatitis, which can have many different causes.
That said, the CDC is right to draw attention to these cases, to investigate the true nature of these clusters. But it's not clear if these cases represent a true increase in hepatitis or an increase in reporting due to greater awareness.
What is causing these cases?
That's a large part of the puzzle. In Alabama, where the first cluster was seen, the CDC has ruled out the most common types of viral hepatitis. Some scientists think an adenovirus may be involved. Adenoviruses, which usually cause respiratory ailments such as the common cold, sometimes cause hepatitis but usually only in immunocompromised children. None of the children in Alabama were immunocompromised.
It's possible we're seeing a new adenovirus, but it is still early in this outbreak. Nevertheless, researchers are gathering data, and within the next few weeks we should have a better understanding of what is going on.
We can't say that these cases of hepatitis are directly linked to COVID-19, though we have reported a direct link of SARS-CoV-2 to hepatitis in healthy and immunocompromised children in other cases.
We often don't know what causes a case of hepatitis or even liver failure. In the most extensive multicenter study focusing on pediatric liver failure, the cause was never identified in almost half the cases. Liver failure can be caused by drugs, toxins, and thousands of viruses. Only a limited number of tests are available to identify the specific virus.
Are some kids more susceptible to hepatitis in general than others?
Hepatitis and acute liver failure can present at any age, and the causes significantly vary by age. Children with decreased immunity (due to a medical condition or medications) are at increased risk of infections in general and are more likely to have a more severe presentation when hepatitis is caused by a virus.
When should parents call their pediatrician or take their children to the ER?
The symptoms during this outbreak are the usual ones seen with liver problems: nausea and vomiting, diarrhea, fever, dark-colored urine, light-colored stools, and jaundice (yellow skin and eyes).
Though we sometimes see hepatitis without jaundice, jaundice will appear in more severe cases of acute hepatitis and could be a sign that the child has liver failure.
Any child who has jaundice should be seen immediately by a doctor.
Are we seeing an increase in cases in New York City?
Right now, we haven't heard of any uptick in cases in the city, and we have not seen an uptick at the medical center.
Can the COVID-19 vaccine cause hepatitis?
No, there is no connection between the COVID-19 vaccine and hepatitis.
I want to stress the importance of getting health information from reliable sources, such as government websites and major medical centers. We all know misinformation is too readily available, especially on health matters.
References
Mercedes Martinez, MD, provides state-of-the-art care at NewYork-Presbyterian and Columbia University Irving Medical Center for children with many liver and intestinal issues, including liver failure and intestinal failure that require transplantation.
She has co-authored several research papers on severe hepatitis and liver failure, including:
- "Liver involvement in children with SARS-CoV-2 infection: Two distinct clinical phenotypes caused by the same virus," Liver International, 2021
- "SARS-CoV-2 infection in children with liver transplant and disease of the native liver: Results from an international registry study," Journal of Pediatric Gastroenterology and Nutrition, 2022
- "North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure," Journal of Pediatric Gastroenterology and Nutrition, 2022
