Is "unexplained" hepatitis in children more terrible? What do parents need to be wary of?

"'Unexplained' does not mean 'terrible', I hope parents and friends understand this first." 'Unknown Cause' is just a commonly used medical term to refer to a disease whose cause is not yet clear and does not directly reflect the severity of the disease. On April 28, Ou Qian, founder of Zhibei Medical and attending physician of pediatrics, said in an interview with the surging news that she hoped that parents would rationally understand the recent international reports of children's unexplained hepatitis, avoid panic, and respond scientifically.

According to the World Health Organization, as of April 21, 169 children in 12 countries in Europe and the United States have been infected with unexplained hepatitis, aged between 1 month and 16 years old, of which the United Kingdom has the largest number of people, 114. After infection, children develop gastrointestinal symptoms such as abdominal pain, diarrhea, vomiting, and elevated levels of liver enzymes and jaundice. At present, 1 person has died and 17 people need liver transplants.

On April 25, the UK Health Security Agency (UKHSA) issued a technical briefing on the investigation, saying that the main hypothesis at present is that hepatitis is related to adenovirus. In this regard, Osie analyzed that it is not uncommon for children to be infected with adenovirus, and pediatricians often encounter upper respiratory tract infections, conjunctivitis, and otitis media caused by adenovirus in clinical practice, similar to this liver damage is relatively rare; the cause is only highly suspected of adenovirus, and the final results still need to be investigated.

Ou Qian suggested that parents should still "calmly" deal with this hepatitis, and measures to prevent the new crown such as wearing masks, washing hands frequently, paying attention to coughing and sneezing etiquette are still applicable to the prevention of this hepatitis. "Parents should also pay attention to observe whether their children have yellowing of the whites of their eyes, yellow skin and urine, etc., which is a manifestation of jaundice and needs to be consulted in time."

How does hepatitis in unexplained children point to adenovirus?

In the shadow of the new crown, the emergence of hepatitis in children of unknown cause has caused many parents to worry.

According to the World Health Organization, as of April 21, 169 children in 12 countries in Europe and the United States have been infected with unexplained acute hepatitis, of which the United Kingdom has the largest number of people, with 114 people. The children are between the ages of 1 month and 16 years, and one has died and 17 (about 10%) need a liver transplant. The clinical syndrome of the case is acute hepatitis with a significant increase in liver enzymes. Many cases of acute hepatitis have reported gastrointestinal symptoms such as abdominal pain, diarrhea, vomiting, and elevated levels of liver enzymes and jaundice. Most cases do not have a fever.

Domestic cases have also been analysed in the UK. On 25 April, the UK Health Security Agency (UKHSA) released a technical briefing on the investigation. From 1 January to 20 April 2022, there were 111 cases of unexplained hepatitis in children under 16 years of age in the UK mainland, no cases died, 43 children living in England have recovered and 7 have received liver transplants, the briefing said. These cases are predominantly under 5 years of age, and the clinical syndrome usually begins with gastroenteritis-type symptoms followed by jaundice.

The briefing also states that there is no known travel history association in the cases and that no hepatitis virus (A to E) has been detected among them. Of the 53 cases tested, adenovirus was detected in 40. Based on blood sample data, the initial classification of adenovirus is type 41F, but other types of adenovirus have also been found in non-blood samples. Whole genome sequencing of multiple cases is essential before determining viral characteristics. Although low levels of adenovirus in the blood are a challenge to data quality, this work is ongoing.

In an interview with The Paper on April 28, Ossie said she should pay attention to the statistics on a group of adenovirus infections in the briefing.

In the UK, positive adenovirus results from routine clinical tests are recorded in the SGSS (Second Generation Surveillance System, i.e. National Laboratory Reporting System) and can be analysed by the UK Health Security Agency (UKHSA). In the briefing, data from SGSS show that comparing adenovirus positive cases found between 1 and 4 years of age in England between 1 January 2017 and 17 April 2022, the number of positive cases reported to SGSS between November 2021 and March 2022 (recent data) is about 200-300 cases per week; before the COVID-19 pandemic, the number of cases reported per week was about 50-150 cases; and from March 2020 to May 2021 (during the pandemic), Fewer than 50 cases are reported per week. The increase in reported cases in the lower age group began in November 2021.

Statistics of adenovirus infection in England from 1 January 2017 to 17 April 2022.

In this regard, Osie analyzed, "From this map, we can see that after the outbreak of the new crown epidemic in 2020, for about 1 year, the number of cases of adenovirus infection in children aged 1 to 4 years old is very low." This reason is that during the epidemic period, people go out less, wear masks, wash their hands frequently, and maintain social distancing, which significantly reduces the probability of respiratory transmission of the new crown virus and the probability of adenovirus transmission. ”

The briefing concludes that there are significant adenovirus overruns in routine laboratory data, which are primarily driven by intestinal samples and the 1-4 age group. Other common gastrointestinal and respiratory viral infections are also exceeded, possibly due to changes in human behaviour and population susceptibility after the low incidence period of the pandemic.

"The low incidence during the pandemic indicates that there are relatively fewer children who have been infected with adenovirus and thus develop immunity to adenovirus," Ossie said. In the near future, there may be a lot of concentrated infection in children who have not yet developed immunity to adenovirus. Of course, this is not yet conclusive, it is just a reasonable extrapolation of this report. ”

The briefing concludes that the main current hypothesis is that hepatitis is associated with adenovirus, and that the mechanism of action of liver damage may be virus-mediated or immune-mediated.

In this regard, Osie explained, "These two mechanisms of action are different, the former is that the pathogen directly causes harm to the human body, and the latter refers to the fact that when the pathogen invades, the body mobilizes the immune system to fight, and in the process of fighting and removing the pathogen, the immune response itself may also cause a certain negative impact on the body."

Osie said that it is not uncommon for children to be infected with adenovirus, and pediatricians often encounter upper respiratory tract infections, conjunctivitis, and otitis media caused by adenovirus in clinical practice, and liver damage similar to this time is relatively rare. "The cause of this time is only highly suspected of being an adenovirus, and the final result remains to be investigated."

Is unexplained hepatitis related to COVID-19?

Is unexplained hepatitis in children related to COVID-19? This is a concern for many parents.

The UK briefing notes that 10 of the 60 patients have been tested for COVID-19, and other pathogens have lower levels of physical examination. Given the community epidemic throughout the survey and the fact that there is no evidence of a new variant of the coronavirus based on limited available information, this level of COVID-19 detection is not surprising.

The briefing also notes that acute hepatitis is not a common feature of COVID-19 infection in children.

According to the BBC on April 26, the UK Health Security Agency (UKHSA) said it was studying the child's previous infection with the new crown and the possibility of a new variant of adenovirus, and it is continuing to investigate the wider possibility and cause of infection.

Some studies have shown that in countries such as the United States, Brazil and India, a small proportion of covid-19-infected babies and children need to be treated for hepatitis, and in most cases, patients recover quickly and are discharged within a few days.

On April 23, 2022, the World Health Organization issued a notification saying that although adenovirus is currently a hypothesis of a root cause, this does not fully explain the severity of clinical symptoms. Factors such as increased susceptibility in young children after the reduction of adenovirus prevalence during the COVID-19 pandemic, the potential for the emergence of novel adenoviruses, and co-infection with COVID-19 are needed.

Osie said that at present, there is no direct evidence that the study of acute hepatitis is related to the new crown virus infection, and there are still many possibilities for the cause of hepatitis to be investigated. "Generally speaking, there are many causes of hepatitis, which is different from pneumonia. Pneumonia is usually caused by infection, and for hepatitis, in addition to infectious factors, autoimmune factors, poisoning, etc. may cause hepatitis, which needs to be further investigated. ”

So, is this hepatitis related to the new crown vaccine?

The WHO notification said that since the vast majority of children have not been vaccinated against COVID-19, the hypothesis that acute hepatitis is related to the side effects of the COVID-19 vaccine is not currently supported.

According to the BBC on April 26, the hepatitis was not related to COVID-19 vaccination, because most of the children were not vaccinated. In the UK, only COVID-19 vaccines are offered to children over the age of 5, and most of the children in the ABOVE UK survey brief are under the age of 5, which means that many children are not yet of vaccination age.

Osie said that for some of the current acute hepatitis and COVID-19 vaccine-related concerns, parents should be rational, "Globally, children have been vaccinated against COVID-19 for a long time, if the side effects of the vaccine will lead to hepatitis, there should be a large-scale outbreak earlier, rather than a recent one." ”

What should parents do in the face of new-onset diseases?

Although the pathogenesis of acute hepatitis in this child is not yet clear, parents still need to pay attention.

Osie said that given the possible link between the disease and adenovirus, which can be transmitted through close personal contact, droplets, object contact and fecal contact, it would still be beneficial to adhere to some routine infectious disease protection measures.

"It is recommended that everyone must do a good job of prevention, especially respiratory hygiene and hand hygiene." For example, wash your hands frequently with soap and water for at least 20 seconds, avoid touching your eyes, nose, or mouth with dirty hands, and avoid close contact with the patient. Osie said that wearing a mask and paying attention to coughing and sneezing etiquette also need to be paid attention to.

In addition, Osie specifically proposed that parents should be cautious about some of the current remarks about the relationship between the disease and the new crown, and maintain an objective and rational attitude as much as possible, "do not be trapped by panic" and "do not be trapped by panic"

"'Unexplained' does not mean 'terrible', I hope parents and friends understand this first." 'Unknown Cause' is just a commonly used medical term to refer to a disease whose cause is not yet clear and does not directly reflect the severity of the disease. "Since the outbreak of the new crown epidemic, we should have a more mature mentality to look at each new disease." ”

She also advises parents to observe their children's daily performance.

"Parents should pay attention to observe whether the child has yellowing of the whites of the eyes, yellow skin and urine, etc., which is a manifestation of jaundice and needs to seek medical treatment in time." In addition, if your child has symptoms such as tiredness, reluctance to eat, nausea, vomiting, and diarrhea, he or she should also seek medical attention in time. ”

At the same time, Ossie suggested that if the child has the above symptoms, parents should let the child rest at home, observe diligently, and do not have to rush back to school, "this is responsible for themselves, but also responsible for others."