The U.S. Centers for Disease Control and Prevention said Friday that it’s investigating 109 cases of severe and unexplained hepatitis in children in 25 states and territories that may be linked to a worldwide outbreak.
Among them, 14 per cent needed transplants, and five children have died.
Nearly all the children — more than 90 per cent — needed to be hospitalized.
Dr. Jay Butler, the CDC’s deputy director of infectious diseases, stressed that the investigation — a partnership between the CDC and state health departments — is an evolving situation. Not all the hepatitis cases they are studying now may ultimately be caused by the same thing.
“It’s important to note that this is an evolving situation, and we are casting a wide net to help broaden our understanding,” Butler said.
Hepatitis, or swelling of the liver, can be caused by infections, autoimmune diseases, drugs and toxins. A family of viruses well known for attacking the liver causes hepatitis A, hepatitis B and hepatitis C.
It’s not clear what’s driving these cases in young children. Butler said some of the common causes of viral hepatitis have been considered but were not found in any of the cases.
Adenovirus has been detected in more than 50 per cent of cases, although its role isn’t clear.
EARLY HEPATITIS REPORTS
On April 21, the CDC alerted doctors to a cluster of unusual cases of hepatitis in nine children in Alabama.
It asked doctors and public health officials to notify the agency if they had similar cases of children under the age of 10 with elevated liver enzymes and no apparent explanation for their hepatitis going back to October.
Since then, health departments have been working with pediatric specialists in their states to identify possible cases. The numbers shared at Friday’s news briefing are the first national look at cases.
Cases are under investigation in Alabama, Arizona, California, Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Louisiana, Michigan, Minnesota, Missouri, North Carolina, North Dakota, Nebraska, New York, Ohio, Pennsylvania, Puerto Rico, Tennessee, Texas, Washington and Wisconsin.
The CDC’s alert followed reports of children from England, Wales, Scotland, and Northern Ireland going to hospitals with unexplained hepatitis.
As of May 1, there are 228 probable cases linked to the outbreak in 20 countries, with more than 50 cases under investigation, Dr. Philippa Easterbrook, a senior scientist in the World Health Organization’s Global Hepatitis Program, said in a briefing Wednesday. Among these cases, one child has died, and about 18 have needed liver transplants, she said.
Most of the children were healthy when they developed symptoms that included fatigue, loss of appetite, vomiting, diarrhea, belly pain, dark urine, light-colored stools and yellowing of their skin and eyes — a sign called jaundice.
UNUSUALLY SEVERE LIVER INFLAMMATION
Pediatric gastroenterologist Dr. Heli Bhatt of M Health Fairview Masonic Children’s Center in Minneapolis has treated two children who are part of the CDC’s investigation. One, a 2-year-old from South Dakota, had a liver transplant this week.
Bhatt says liver failure in kids is “super rare.” And even before scientists started tracking this outbreak, half of cases were never explained.
Doctors who have treated these children say their cases stood out.
“Even during the first case, I thought it was weird,” says Dr. Markus Buchfellner, a pediatric infectious disease specialist at the University of Alabama at Birmingham, where staffers started seeing cases in October.
“And then when the second one came in, that’s when I said, ‘OK, we need to talk to someone about this.’ ” He reached out to senior physicians in his department, who contacted the state health department and the CDC.
Buchfellner says the cases stood out because the liver inflammation was so severe.
Sometimes, common viruses like Epstein-Barr or even SARS-CoV-2 will raise a child’s liver enzymes a little, indicating what Buchfellner calls “small bits of hepatitis,” but the kids typically recover as their bodies fight off the infection.
“But it’s very odd to see a child who’s healthy come in with the amount of liver injury that these kids had,” he said.
Initially, UAB saw nine kids with unexplained hepatitis, and all nine tested positive for adenovirus in their blood. None of them tested positive for COVID-19 during their hospitalization or had a documented history of COVID-19, Butler said at the news briefing.
Since those cases were reported, two more children in Alabama have been identified. Their cases are under investigation, bringing the state’s total to 11, said Dr. Wes Stubblefield, medical officer for Alabama’s Northern and Northeastern Districts.
There are about 100 kinds of adenoviruses. About 50 of them are known to infect humans, so experts needed a closer look at the virus to try to figure out if all the children had the same one.
When researchers tried to read the genes of the adenovirus in infected kids, only five had enough genetic material to get a full sequence. In all five, the virus was a particular kind called adenovirus 41. It typically causes diarrhea and vomiting in kids, sometimes with congestion or a cough, but has never before been associated with liver failure in otherwise healthy children.
Butler said Friday that adenovirus 40 and 41 have been linked to hepatitis but almost exclusively in immunocompromised children.
CLUES FROM THE U.K.
Also Friday, researchers with the UK Health Security Agency posted a new technical briefing with an update on its hepatitis investigation. Of 163 cases, 126 patients have been tested for adenovirus, and 91, or 72 per cent, were positive for that pathogen.
Investigators have tried to sequence the entire genome of an adenovirus from one of the patients but have not been able to get a sample with enough of the virus to do that. There were 18 cases in which where they were able to partially sequence the genome, and all of them have been adenovirus 41F, the same one found in the US cases.
Many have wondered whether the cases may somehow be related to SARS-CoV-2, the virus that causes COVID-19.
UK investigators say they’re still looking at that possibility, but only 24 out of 132 patients tested — 18 per cent — had SARS-CoV-2 detected.
The report says they are not ruling out some role for a COVID-19 infection in these cases. Perhaps a prior COVID-19 infection somehow primed the immune system to make these children unusually susceptible, or maybe a co-infection of the two viruses together overwhelms the liver.
Researchers also want to know if the hepatitis is part of some kind of syndrome that strikes kids after a SARS-CoV-2 infection, like the rare complication called multisystem inflammtory syndrome in children, or MIS-C.
Another working theory from UK investigators is that there’s some kind of outsized or irregular immune response in these children, perhaps because they were sheltered more than usual during the pandemic.
Yet another theory is that the adenovirus may have always caused liver failure in a tiny percentage of children who were infected, and these rare cases are coming to light only because it is causing an exceptionally large wave of infections.
And investigators in the UK say they are still testing for drugs, toxins or perhaps an environmental exposure, even though some kind of infection is probably more likely to be the cause.
SORTING OUT ROLE OF ADENOVIRUS 41
Another thing that’s puzzled doctors, Buchfellner says, is that they found adenovirus in blood samples but not in samples of liver tissue taken during biopsies of the patients in Alabama.
“All nine of them have liver biopsies that were showing lots of inflammation and hepatitis. But we did not find the virus in the liver. We only found the virus in the blood,” he said.
Bhatt’s case, a child from South Dakota, was also positive for adenovirus in her blood but not in her liver.
If adenovirus 41 is somehow responsible in these cases — and that’s still a big if — Buchfellner says he doesn’t know why it would only show up in the blood but not in heavily damaged liver tissue. But he has some theories.
“Maybe the liver is clearing the virus before it’s been cleared in the blood,” he said. “And so by the time that the damage has been done to the liver and we do the biopsy, the immune system has already cleared the virus from the liver. And what’s left over is just inflammation.”
His second theory is that it’s not the virus itself that’s responsible for the liver damage, but perhaps the immune system overreacts when trying to fight off the virus and ends up damaging the liver.
Adenovirus infections are common, so maybe finding the virus in some of these patients is just a coincidence. “We are not 100 per cent sure that this is just that adenovirus. There’s still a lot to be known,” Bhatt said.
ACTIVE INVESTIGATION
In an April 29 statement on the cases, the CDC wrote, “we believe adenovirus may be the cause for these reported cases, but other potential environmental and situational factors are still being investigated.”
Butler said Friday that experts are considering a range of possibilities, including exposure to animals.
“We really are casting a broad net and keeping an open mind in terms of whether the adenovirus data may reflect an innocent bystander or whether there may be cofactors that are making the adenovirus infections manifest in a way that’s not been commonly seen before,” he said.
Investigators say they know that this news may worry parents.
Butler says investigators still believe these cases are very rare. They have not seen an increase, for example, in children coming to emergency rooms with hepatitis.
“We are still telling at least our families here in Alabama — and I would encourage other families the same way — not to be too concerned about this just yet.” Buchfellner said. “I mean, at the end of the day, this is still a pretty rare phenomenon.”
Buchfellner says adenoviruses are commonly passed around day cares and schools. They typically cause nothing worse than something that feels like stomach flu for a few days.
“it’s been around for a long time, and it’s gonna continue to go around. And in total, we only have around 200 cases that have been reported across the globe. So this isn’t a COVID pandemic-like situation where everybody needs to be really concerned about this,” he said.
The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
