The Centers for Disease Control and Prevention has identified and received reports of a cluster of pediatric cases of significant liver injury with positive adenovirus infection since November 2021. The CDC says the cause of hepatitis (inflammation of the liver) impacting the children is not known.

There have been 246 children who are under 10 years old with hepatitis cases of unknown origin included in the CDC's investigation since Oct. 1, 2021. It's not unusual for the cause of hepatitis in children to remain unknown; some estimates suggest 30-50% of all hepatitis cases in children are from unknown causes, the CDC says.

A possible association between these pediatric hepatitis cases and adenovirus infection is currently under investigation. Lab tests showed “adenovirus type 41” infection in several of the cases under investigation. Adenovirus type 41 is primarily spread via the fecal-oral route and predominantly affects the gut, the CDC says. It is a common cause of pediatric acute gastroenteritis typically with diarrhea, vomiting and fever, often accompanied by respiratory symptoms.

There have been no reported deaths since February 2022, and the proportion of patients requiring liver transplants has gone down from 15% to 9% since May 5, the CDC said on May 18.

So what does this news mean for your child? Nicholas Rister, M.D., of the Cook Children's Infectious Disease team shares what parents and caregivers need to know.

It’s important to note that severe hepatitis in children remains rare. However, we encourage parents and caregivers to be aware of the symptoms of hepatitis – particularly jaundice, which is a yellowing of the skin or eyes – and to contact their child’s pediatrician with any concerns.

How concerned should I be as a parent about this cluster of hepatitis cases? Why do some patients need transplants?

These cases remain rare despite adenovirus infection being very common. This is reassuring that the vast majority of children are likely to have no issues. However, in these rare cases, the inflammation in the liver is so severe that the liver is unable to recover and requires a transplant. This is somewhat remarkable since healthy children typically possess a large capacity for their liver to recover on its own after injury.

How is hepatitis spread?

The cause of hepatitis determines how it is spread. Damage to the liver from toxins (alcohol or drugs) or autoimmune disease does not spread between people. Infectious hepatitis depends on the type of infection. Hepatitis A and E are spread through body fluids and contaminated foods/surfaces. Hepatitis B, C, and D are spread through blood (injection drug use) and rarely through sexual contact.

However, most viruses, including adenovirus, can cause some degree of hepatitis and are spread through combinations of close contact and respiratory routes. Adenovirus is typically spread through respiratory droplets and/or contact with bodily fluids.

What are hepatitis A, B, C, D and E? Which is related to this outbreak?

Hepatitis A-E are grouped together because they all primarily cause liver issues but are very different infections otherwise. Hepatitis A is a diarrheal illness. Hepatitis B and C are chronic infections that often go unnoticed for decades following IV drug use (or due to blood transfusions in the past although we screen blood supply now) but eventually lead to liver failure and cancer. Hepatitis D and E are less a consideration in the general population. Hepatitis D can cause problems for folks if they are already infected with other types of hepatitis and hepatitis E is a cause of bad liver disease in pregnant women.

What is adenovirus?

Adenovirus is a common viral cause of febrile illness in children. Many different types lead to different diseases that are all common in children. These include conjunctivitis (pink eye), upper and lower respiratory infections, and diarrhea. The vast majority of adenovirus types have not been linked to this hepatitis outbreak and most children with adenovirus type 41 do not develop severe hepatitis. However, the infection remains suspected and is being investigated in these rare cases.

What can my family do to protect ourselves?

Hepatitis A and B have vaccines that are given to all children as part of the routine vaccine series.

Otherwise, let your pediatrician know immediately if you note yellowing of the eyes or skin consistent with jaundice which can be an early warning sign of liver disease.

Continue healthy habits like hand hygiene, covering coughs and avoiding people who are sick.

What is jaundice?

Jaundice is a buildup of bilirubin in the soft tissues of the skin/eyes. Bilirubin is secreted by your liver into your intestines as a part of bile normally. When the liver is sick, bilirubin can build up in the blood and soft tissues leading to discoloration.

Watch for symptoms of liver inflammation:

• jaundice (yellowing of the skin)
• fever
• fatigue
• loss of appetite
• nausea
• vomiting
• abdominal pain
• dark urine
• light-colored stools (poop)
• joint pain

Keep your child up to date on all their vaccinations.

Help your family prevent disease:

• wash hands often
• avoid people who are sick
• cover coughs and sneezes
• avoid touching the eyes, nose, or mouth

Because of the opioid crisis in the United States, the rate of hepatitis C virus infection among pregnant women increased 60 percent between 2006 and 2014. Sadly, only 30 percent of infants exposed to the virus were screened for infection.

Hepatitis C can be passed from affected mom to their babies. If left untreated over many years, hepatitis C causes cirrhosis of the liver, liver cancer and even death.

The recent study published in the latest edition of Pediatrics says the recent increase in the disease is most likely due to the opioid epidemic in the United States.

The researchers looked at a database of 87,924 pregnant women who delivered at Pittsburgh University Medical Center. The doctors who performed the study recommended universal hepatitis C screening during pregnancy, especially in high prevalence areas.

“This study is important because it shows the importance of proper screening, prior to pregnancy,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s. “Without proper screening, children run the risk of going undiagnosed with hepatitis C until they show symptoms. Hepatitis C doesn’t cause symptoms at first, but can lead to irreversible liver disease if not treated.”

Because of the serious nature of the disease, Cook Children’s has been involved in the research of new drugs that could change the lives of teenagers with hepatitis C.

The Food and Drug Administration (FDA) has approved the use of Harvoni and Sovaldi in the treatment of young people between the ages of 12 and 17. The drugs have proven to be more than 95 percent effective in the treatment of hepatitis C for those who have used the drugs.

Dr. Whitworth calls her research into the effectiveness of these drugs the “most rewarding thing I’ve done in the last 20 years. Hands down.”

Click to learn more about her work.

Facing these devastating complications, parents are desperately seeking a treatment for their children. Imagine the relief of being part of a life-changing study using an experimental combination of ledipasvir and sofosbuvir, Harvoni, that has resulted in undetectable levels of the virus in these children.

“This is the most rewarding thing I’ve done in the last 20 years. Hands down,” said Dr. Whitworth, who came to Cook Children’s in 1995 and is the medical director of Infectious Diseases at Cook Children’s. “We have helped these kids. These children who had this infection will now, hopefully, be cured. Ten years ago, we did not think this could happen.”

The research comes at a crucial time. The Centers for Disease Control and Prevention released data last week that states that hepatitis C related deaths reached an all-time high in 2014, more than doubling from 2010. More people have died (2,194 cases reported in 2014) from hepatitis C than 60 other infectious diseases including HIV, pneumococcal disease and tuberculosis.

The CDC says the increase in deaths is frustrating because of the advancement in medications to treat the disease. The increase in deaths includes lack of testing and diagnosis, especially for those using injectable drugs.

Twenty years ago, because of the focus on adults taking injectable drugs, the diagnosis of hepatitis C in children was relatively new. Over the next five years, Dr. Whitworth and staff began to see more and more children diagnosed with the infection. Unfortunately, users of injectable drugs can pass the disease on to their children at birth.

The only way to acquire hepatitis C as a child is at birth or through bloodborne transmission. In the early 2000s, a treatment protocol with two different drugs to try and cure this infection was established.

Over the course of time, the success rate of this regimen was nearly 60 percent but it was associated with numerous side effects.

Then in March 2014, Cook Children’s began participating in a new study. There is great hope that this study will be permanently successful for all of these children.

Because our Infectious Diseases team was proactive, Cook Children’s enrolled two of the 10 teens in the world to participate in the initial trial. Later, they were able to enroll five more patients to fill in available slots.

The trend continued as the study moved to treating younger children, getting three out of the 10 worldwide slots for kids 6 to 11 years. In total, Cook Children’s had more than 15 kids participating in the trial, ranging from age 6 to 17. And so far, the results have been successful.

“I’ve never seen the kind of results to a drug as we’ve seen so far for this infection,” Dr. Whitworth said. “These children, if they are permanently cured, will now have a normal quality of life and be healthy. They can go to school and play sports. When you have cancer, you can brag to the world that you are cured. That’s not the case with hepatitis C because many of these kids don’t want others to know about their diagnosis. Their friends often don’t know. Fortunately, now they may never need to know. “The emotional part for the families is that their viral load is now undetectable. When families hear this, they just break down because they have carried the weight of this infection for so long. They have often been anxious since the child was born and now they don’t have to feel that way anymore.”

Hepatitis A is an infection of the liver. It can be passed easily from contaminated food, water or close contact with an infected person.

"Hepatitis A can cause outbreaks in day care which infect many children and last for several months,” Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases. “Good hand washing techniques can prevent outbreaks and decrease the spread of the disease, but the best protection for your child is to have them vaccinated.”

Hepatitis A usually goes away on its own within two months. There are no lasting effects in most once the infection passes. Symptoms include:

• Tiredness
• Loss of appetite
• Fever
• Nausea and vomiting
• Abdominal pain or discomfort
• Yellowing of the eyes and skin—jaundice
• Darker colored urine
• Light or chalky colored stools
• Rash

Medical treatments that may help prevent infection include:

• Immune (Gamma) Globulin—temporary protection from hepatitis A. It can last about 3-6 months. It must be given before exposure to the virus or within 2 weeks after exposure.
• Hepatitis A vaccine—highly effective in preventing infection. It provides full protection 4 weeks after the first injection. A second injection provides long-term protection. The vaccine should be considered for:

• All children aged 12-23 months.
• Children aged 24 months or older who are at high risk and have not been previously vaccinated.
• People traveling to areas where hepatitis A is prevalent (The Centers for Disease Control and Prevention's http://wwwnc.cdc.gov/travel/ shows which areas have a high prevalence of hepatitis A).
• People with chronic liver disease.
• People with blood-clotting disorders, such as hemophilia. 
• People who desire immunity to hepatitis A.

About the source

Mary Suzanne Whitworth, M.D. is the medical director of Infectious Diseases at Cook Children’s, which offers care for children and teens with diseases caused by bacteria, parasites, fungi or viruses. Our team provides a broad range of services including diagnosis, inpatient and outpatient consultations, immune deficiency evaluations and treatment of recurring infections.