As concern about the growing cases of hepatitis in children around the world intensifies, with our country, however, not being on the "map" with cases of the disease, LSE Professor Elias Mosialos, through 20 questions and answers, attempts to clarify the currently blurred landscape around the disease.
In his Facebook post, he notes that symptoms include anorexia, catarrh, change in skin colour (jaundice), gastrointestinal symptoms such as abdominal pain, diarrhoea and vomiting that preceded the onset of acute hepatitis, while many cases also had a fever.
He refers to the country where most cases of hepatitis in children have been recorded, and points out the following: "So far the number of cases worldwide is extremely low. We do not yet know the exact causes of this form of hepatitis."
He also explains how to avoid catching it and answers the question of whether existing vaccines protect against the disease.
Analysing the entire post by Ilias Mosialos
20 questions and answers about hepatitis in children
1. Is there a correlation between the coronavirus vaccine and the hepatitis of as yet undetermined etiology that about 200 children around the world have developed?
No. First of all because the majority of cases are under 5 years of age. Children under 5 years of age are not vaccinated for coronavirus.
2. Is the proportion of children with this hepatitis of as yet undetermined etiology higher than expected in all countries where such cases have been recorded?
Not in all countries. In Scotland yes they have more cases than expected but not in Israel or Spain.
3. Where are there the most recorded cases?
In the UK, 145 cases have been recorded (in a report published on 29 April). 108 are in England and 17 in Scotland. 17 according to the ECDC have also been observed in Italy, 12 in Spain, 6 in Denmark, and correspondingly small numbers in various other countries.
4. Is there a geographical correlation of cases?
No. The incidents occur in different regions and are not 'stuck' together.
5. What are the symptoms of hepatitis?
Anorexia, catarrh, change in skin colour (jaundice) gastrointestinal symptoms such as abdominal pain, diarrhoea and vomiting are reported to precede the onset of acute hepatitis and many cases had fever.
6. Had all these children previously been ill with coronavirus?
No, but a very large proportion of them have a documented history of illness. At the same time, however, it should be said that not all cases have been thoroughly analysed. There is of course a record of those who had active disease on admission. But we must remember that very often children are asymptomatic or mildly ill, some of them may not have gone to nurseries to be examined frequently, so the parents may not have been aware of this.
7. Did all of these children have active adenovirus infection on admission?
No. For example, none of the 6 children in Denmark tested positive for adenovirus. At the same time, however, it should be said that the literature reports that young children who contract adenovirus can also be diagnosed positive for several months after infection
8. What new information do we have from yesterday's reporting of cases in Alabama according to the U.S. Centers for Disease Control and Prevention (CDC)?
There is a report of 9 pediatric patients who were diagnosed adenovirus positive and coronavirus negative. (http://dx.doi.org/10.15585/mmwr.mm7118e1external icon). At the same time, however, it is not mentioned that a specific analysis was performed to confirm the absence of previous coronavirus infection. Also liver biopsies from 6 patients showed various degrees of hepatitis but without (immunohistochemical) evidence of adenovirus or other viral particles (as identified by electron microscope analysis). In addition, 7 patients had concurrent infection with other viral pathogens such as Epstein-Barr virus, enterovirus/renovirus, respiratory syncytial virus, human coronavirus OC43, and others. Interestingly, no viral particles were detected in the livers of these children.
9. What do we know from the literature about cases of acute liver failure caused by adenovirus?
There are reports in the literature describing cases of hepatitis from adenovirus infection leading to transplantation in 8 pediatric patients before the pandemic (DOI: 10.1097/PAS.0000000000000834). 7 of them were under 18 months of age. However, this publication reports detection of the virus in the liver in all patients. Furthermore, those patients were diagnosed with adenovirus type 2 or 5 and not type 41 as in the Alabama cases or those in the UK. Infection due solely to adenovirus type 41 causing acute liver failure appears to be extremely rare
10. Is there literature linking coronavirus infection to hepatitis in children?
There are many reports of hepatitis following coronavirus infection in adults during the pandemic, as far as we know. A case has also been documented in a 10-month-old infant in Italy who developed MIS-C multi-inflammatory syndrome and acute liver failure after infection. (DOI: 10.3389/fped.2021.780258). In addition from India, a retrospective case-control study (pre-publication) of pediatric patients presenting with hepatitis from April 2021 to mid-June 2021 in India documented an increase in the features of acute hepatitis during the second wave of coronavirus infections (doi: https:/doi.org/10.1101/2021.07.23.21260716).
11. What did the study in India show?
According to data recorded at a coronavirus reference hospital in a district of India, 33 children and adolescents developed acute hepatitis of sudden onset with no history of pre-existing liver disease, or other etiology of acute hepatitis. However, the patients had a recent history (3-6 weeks) of a positive molecular test or retrospectively proven Covid-19 infection and a high SARS CoV-2 antibody titer. All these patients underwent laboratory tests and were negative for hepatitis A, B, C and E. Among these 33 patients who presented with hepatitis, 25 had unique features of hepatitis associated with coronavirus infection (Covid-19 Associated Hepatitis in Children: CAHC). They had no typical symptoms of Covid-19 infection and all recovered with supportive therapy without complications or mortality.
This study of course reported on the alarming emergence of the Delta variant that caused the huge surge of Covid-19 in India. The possibility of the occurrence of coronavirus infection-associated hepatitis has great weight though at present.
12. What do the UK health authorities consider to be the most likely causes?
At present working hypotheses are oriented around adenovirus infection in an area of increased susceptibility. That is, that due to some as yet unclear factor affecting young children, adenovirus infections progress differently than usual and can cause the immunopathology in question. Previous exposure to coronavirus or other infection, concurrent adenovirus infection with coronavirus, a new variant of adenovirus, a new pathogen that either acts alone or as a concurrent infection with adenovirus and/or coronavirus, or even a new variant of coronavirus could also be responsible
13. How is it transmitted if it is adenovirus or coronavirus or a combination of the 2?
In the same way as coronavirus, i.e. aerogenically. Adenoviruses are mainly carried by droplets. In addition, they can also be transmitted via the faecal-oral route and can also be spread to the eyes by hand. It is therefore advisable to supervise young children to ensure that they wash their hands properly.
14. How do we avoid catching it?
For now, the way to take precautions is to follow the health protocols as they were and are applicable to COVID, for example frequent hand washing, wearing a mask indoors, and paying attention to surfaces. Also, let's avoid people with the symptoms listed as indicative
15. Can lockdowns be to blame for children's increased susceptibility to adenoviruses if adenovirus is related to hepatitis?
Increased susceptibility is being considered but at the same time doubts are being expressed. The highest number of cases has been identified in the UK which does not have a zero-dispersal policy. Also children were not wearing masks in schools as in other countries. In contrast, no large number of cases have so far been reported in countries that have implemented much stricter measures and lockdowns compared to HB. And no cases have been reported in times that until recently had a zero-dispersal policy for coronavirus, such as New Zealand.
16. If liver transplantation is needed in children, can it be done in Greece?
Unfortunately not. But our country has a cooperation with Italy for the transport of children who will need a transplant and the transplantation procedures are very fast.
17. Will transplants also be performed in Greece in the coming years?
We need to acquire sufficient infrastructure for liver transplants (both adult and pediatric) in our country as well. The National Plan for Transplantation that I have prepared, at the initiative of the Onassis Foundation, in collaboration with Professor Vasilios Papaloys of Imperial College, contains specific proposals for strengthening and upgrading existing services.
18. Do existing vaccines address this particular hepatitis?
No, because none of the known viruses cause this hepatitis of as yet unclear etiology.
19. Will there be a vaccine for the new hepatitis?
Without knowing the cause, we cannot talk about a vaccine at this time. If the cause is coronavirus then consideration will be given to extending vaccinations to young children.
20. Should we be very worried?
So far the number of cases worldwide is extremely low. We do not yet know the exact causes of this form of hepatitis.
As the UK and Israel and other countries have reported, acute hepatitis of undetermined cause in children may be related to previous coronavirus infection or coexistence of adenovirus and coronavirus infection. But there may be other factors as well.
We will wait for the analyses and the corresponding correlations in other countries and hope for a better evolution of these cases.
Source: Proto Thema
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