As the concern about the increasing cases of hepatitis in children around the world intensifies, with our country not being on the “map” with the incidence of the disease, the LSE professor, Elias Mosialos, through 20 questions and answers tries to unravel the cloudy, temporary, landscape around the disease.
In his Facebook post, he notes that as symptoms Anorexia, diarrhea, change in skin color (jaundice) Gastrointestinal symptoms such as abdominal pain, diarrhea and vomiting that preceded the onset of acute hepatitis were reported, and many cases had fever.
Refers to the country where most cases of hepatitis in children have been reported, while noting the following: “So far the number of cases worldwide is extremely small. We do not yet know the exact causes of this form of hepatitis. ”
Detailed post by Elias Mosialos
20 questions and answers about the still unexplained hepatitis in children
< strong>1. Is there a correlation between the coronavirus vaccine and the as yet unexplained hepatitis that has affected about 200 children worldwide?
No. Firstly because the majority of cases are under 5 years old. Children under 5 years of age have not been vaccinated against coronavirus.
2. Is the rate of children with this still unexplained hepatitis higher than expected in all countries where such cases have been reported?
Not in all countries. In Scotland yes they have more cases than expected but not in Israel or Spain.
3. Where are the most recorded incidents?
A total of 145 cases have been reported in the United Kingdom (in a report published on 29 April). 108 are in England and 17 in Scotland. 17 according to the ECDC have been observed in Italy, 12 in Spain, 6 in Denmark, and corresponding small numbers in various other countries.
4. Is there a geographical correlation between the incidents?
No. Incidents occur in different areas and are not 'stuck' with each other.
5. What are the symptoms of hepatitis? fever.
6. Did all these children get sick with coronavirus before?
No, but a very large percentage of them have a history of disease. At the same time, however, it should be said that a thorough analysis has not been made of all the incidents. There is of course the recording of those who had active disease at the time of admission. But remember that very often children get sick asymptomatically or slightly, some of them may not have gone to daycare to be examined often, whenever the parents may not have known.
7. Did all these children have an active adenovirus infection when they were admitted?
No. For example, none of the 6 children in Denmark tested positive for adenovirus. At the same time, it should be noted that the literature states that young children who contract adenovirus may be positively diagnosed for several months after infection.
8. What new information do we have from yesterday's incident report in Alabama according to the US Centers for Disease Control and Prevention (CDC)?
Reference is made to 9 pediatric patients who were diagnosed positive for adenovirus and negative for coronavirus. (http://dx.doi.org/10.15585/mmwr.mm7118e1external icon). At the same time, however, it is not reported that a specific analysis was performed to confirm the absence of an older coronavirus disease. Liver biopsies from 6 patients also showed varying degrees of hepatitis but no (immunohistochemical) evidence of adenovirus or other viral particles (as identified by electron microscopy). In addition, 7 patients had co-infection with other viral pathogens such as Epstein-Barr virus, enterovirus/rhinovirus, respiratory syncytial virus, human coronavirus OC43, and others. It remains interesting that no viral particles were detected in the liver of these children.
9. What do we know from the literature about cases of acute hepatic insufficiency caused by adenovirus?
There are references in the literature describing cases of hepatitis from adenovirus infection that resulted in transplantation of 8 pediatric patients before the pandemic (DOI: 10.1097/PAS.0000000000000834). 7 of them were under 18 months old. However, this publication refers to the detection of the virus in the liver in all patients. In addition, those patients were diagnosed with type 2 or 5 adenovirus rather than type 41 as in Alabama or the United Kingdom. An infection caused solely by adenovirus type 41 and causing acute liver failure appears to be particularly rare.
10. Is there a literature linking coronavirus infection to hepatitis in children?
There are many reports of hepatitis after coronavirus infection in adults during the pandemic as we know it. There has also been a case of a 10-month-old infant in Italy who, after infection, developed MIS-C syndrome and acute liver failure. (DOI: 10.3389/fped.2021.780258). In addition to India, a retrospective case study (pre-published) in pediatric patients presenting with hepatitis from April 2021 to mid-June 2021 in India recorded an increase in the characteristics 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 an area of India, 33 children and adolescents developed acute onset hepatitis with no history of pre-existing liver disease, or any other cause of acute hepatitis. Patients, however, had a recent history (3-6 weeks) of positive molecular test or retrospectively proven Covid-19 infection and a high SARS CoV-2 antibody titer. All of these patients underwent laboratory tests and were negative for hepatitis A, B, C, and E. Among these 33 patients with hepatitis, 25 showed unique characteristics 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 care without complications or mortality.
This study, of course, referred to the alarming appearance of the Delta variant caused by the huge wave of Covid-19 in India. The likelihood of developing coronavirus-related hepatitis infection is very high at present.
12. What do the British health authorities consider to be the most probable causes?
For the time being, the working hypotheses revolve around adenovirus infection in highly susceptible soil. That is, because of some still unclear factor affecting young children, adenovirus infections develop differently than usual and can cause this immunopathology. Previous exposure to coronavirus or other infection, concomitant adenovirus infection with coronavirus, a new adenovirus variant, a new pathogen that either acts alone or as a concomitant adenovirus and/or coronavirus infection, or even a new coronavirus variant.
13. How is it transmitted if it is adenovirus or coronavirus or a combination of the two?
In the same way as the coronavirus, ie aerogenously. Adenoviruses are mainly transmitted through droplets. In addition, they can be transmitted through the fecal-oral route, while it can be spread to the eyes with the hands. That's why it's good to supervise young children to wash their hands properly.
14. How do we avoid getting stuck?
For the time being, the precautionary measure is to follow the sanitary protocols, as they were and still are for COVID, for example the frequent washing of the hands, the use of a mask indoors, and the attention to the surfaces. Also, avoid people with symptoms that are reported as indicative.
15. Could it be that lockdowns are to blame for children's increased susceptibility to adenoviruses if the adenovirus is linked to hepatitis?
Increased sensitivity is examined but at the same time doubts are expressed. The highest number of cases has been identified in the United Kingdom which does not have a zero dispersion policy. Also children did not wear masks in schools, as in other countries. By contrast, not a large number of cases have been reported so far in countries that have implemented much stricter measures and lockdowns compared to HB. And no cases at times that until recently had a policy of zero spread of the coronavirus, such as New Zealand.
16. If a liver transplant is needed in children, can it be done in Greece?
Unfortunately, no. Our country also cooperates with Italy for the transportation of children who will need a transplant and the transplant procedures are very fast.
17. Will there be transplants in Greece in the coming years?
We need to have adequate infrastructure for liver transplants (both adult and pediatric) in our country as well. The National Transplant Plan that I prepared, on the initiative of the Onassis Foundation, in collaboration with Imperial College Professor Vassilios Papaloi, contains specific proposals for the strengthening and upgrading of existing services.
18 . Do existing vaccines treat this particular hepatitis?
Not because none of the known viruses cause this as yet unexplained hepatitis.
19. Will there be a vaccine for the new hepatitis?
Without knowing the cause we can not talk about a vaccine at the moment. If the cause is the coronavirus then the extension of vaccinations to young children will be considered.
20. Do we have to worry too much?
So far the number of cases worldwide is extremely small. We do not yet know the exact causes of this form of hepatitis.
As reported by the United Kingdom and Israel and other countries, acute hepatitis from unknown causes in children may be related to a previous infection from coronavirus or from coexistence of adenovirus and coronavirus infection. But there may be other factors.
We will wait for the analyzes and the corresponding correlations in other countries and we hope for the better development of these cases.
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