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

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.

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I understand the fear. Ebola is a terrifying disease. Symptoms start off similar to flu and progress to liver and kidney failure, followed by internal and external bleeding and then often times by death (about 60 percent of the cases).

So, I get it, it’s scary. The way people die from Ebola is very unpleasant which makes it even scarier. But it shouldn’t be the scariest infectious disease to us. Here are three reasons why:

Reason No. 1 – It’s actually not that contagious.

Ebola is transmitted via blood and body fluids. Contrast that with measles and flu, which are spread via droplets. Obviously, doctors are using extreme caution when treating patients with Ebola and I agree with that. However, the likelihood of catching Ebola from being in the same room with a person with it is not that high. If someone with measles or flu coughs or sneezes near you, it’s very possible that you will contract the disease.

Hepatitis A is another virus that can spread quickly because it is spread via a pathway called the fecal-oral route (yes, it’s as gross as it sounds). It causes vomiting and in severe cases, liver failure. Outbreaks of Hepatitis A often occur when a food worker unknowingly spreads the disease by handling the food with contaminated hands.

Meningococcal meningitis is another illness that commonly spreads quickly and anyone who has been in the room with an infected person is at risk. Outbreaks used to occur commonly on college campuses prior to the introduction of universal vaccination. Health care workers who are exposed to a patient with meningitis have to undergo treatment to try to prevent contracting the disease. So remember that when the person next to you in a room looks sick; it’s probably not Ebola, but it could be any of these other scary things.

Reason No. 2 - People with Ebola are not contagious until the affected person is sick.

Because patients with Ebola are very sick, they are unlikely to be walking around infecting everyone in their path. There will not be people walking around looking fine, unknowingly spreading the disease to everyone they meet. This is not the case for many other infections. See my example for Hepatitis A above.

Pertussis, or whooping cough, is another disease where many infected people (usually adults) can walk around contagious for weeks at a time coughing the bacteria on everyone they meet. Pertussis is not that serious in adults (aside from an occasional broken rib here and there), but it can be deadly in small babies. Despite being sick, many people with flu suck it up and trudge into work or school because they think flu isn’t that big of a deal. The problem is that while one person may not have trouble with flu, they may have contact with small infants, pregnant women or older adults who can have significant complications from it.

Another disease that affects 1/3 of sexually active teenagers and adults is human papilloma virus (HPV). Most often boys and girls who carry HPV do not know they are infected and thus spread it to their sexual partners. HPV by itself is a troubling problem, but even more troubling is the fact that HPV is the leading cause of cervical cancer (about 99.7 percent of cases).

Reason No. 3 - Ebola is not that common and has not been transmitted in the United States.

The world-wide, all-time death total from Ebola sits in the thousands … the world-wide death toll from measles was 122,000 in 2012 alone. Ebola has a very high rate of death and severe illness, much more so than measles, but because measles is much more common it affects many, many more people. There has never been a case of Ebola transmitted from person to person in the United States. There have been over 600 cases of measles in the United States thus far in 2014. What about deaths? Fortunately, there were no deaths from measles, but in 2012 there were 52 deaths from the flu just in pediatric patients. It’s a simple reminder that we sometimes forget how dangerous things are when we have not heard about them for a while.

Now what?

If you aren’t convinced that many of these other infectious diseases are a more immediate concern for you than Ebola, I understand. When things are new and sound scary they tend to take over your mind. But after reading all the points I’ve made above, know there is something you can do to protect your child from the other diseases I’ve mentioned …

Every single bolded disease has a vaccine! While vaccines are not perfect and getting a vaccine in some cases does not protect you 100 percent, they significantly decrease your chances of contracting any of these diseases. In many cases, if vaccines don’t completely prevent the disease, they make the case milder and less serious. If you agree with my concerns about these other diseases, give your child the best chance by having them vaccinated.

I hope I’ve addressed all of your questions or concerns. Maybe, you still have questions about the diseases mentioned here or the vaccines to fight them? If so, please talk to your pediatrician.