Health Advisory: Updated Recommendations for Adenovirus Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology

| May 18, 2022

Dear Kitsap healthcare colleagues,

  • Please be aware of a May 11 CDC Health Advisory with UPDATED Recommendations for Adenovirus Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology (linked and text included below)
    • As of May 5, 2022, CDC and state partners are investigating 109 children with hepatitis of unknown origin across 25 states and territories, more than half of whom have tested positive for adenovirus with more than 90% hospitalized, 14% with liver transplants, and five deaths under investigation. Because this investigation is ongoing and includes reviewing cases of hepatitis of unknown cause with onset since October 2021, patients under investigation are not limited to current or newly diagnosed pediatric hepatitis illnesses.
  • The Kitsap Public Health District and Washington State Department of Health (DOH) request that healthcare partners report suspected cases to the Kitsap Public Health District 24/7 by calling 360-728-2235 or use the Reportable Disease Fax Form and fax to 360-813-1168 with any corresponding lab results.

CDC Updated Health Advisory: https://emergency.cdc.gov/han/2022/han00465.asp

Updated Recommendations for Adenovirus Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology

Summary
The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Update to provide clinicians and public health authorities with updated information about an epidemiologic investigation of pediatric cases of hepatitis of unknown etiology in the United States. This investigation focuses on collecting information to describe the epidemiology, etiology, clinical presentation, severity, and risk factors related to illness and to identify any relationship between adenovirus infection or other factors and hepatitis. As of May 5, 2022, CDC and state partners are investigating 109 children with hepatitis of unknown origin across 25 states and territories, more than half of whom have tested positive for adenovirus with more than 90% hospitalized, 14% with liver transplants, and five deaths under investigation. Because this investigation is ongoing and includes reviewing cases of hepatitis of unknown cause with onset since October 2021, patients under investigation are not limited to current or newly diagnosed pediatric hepatitis illnesses.

This HAN Health Update also provides updated recommendations for testing specimens from patients under investigation. It is an update to a HAN Health Advisory that CDC issued on April 21, 2022, that initially notified clinicians and public health authorities of children identified with hepatitis of unknown origin and adenovirus infection.

Background
A cluster of pediatric cases of hepatitis without an apparent etiology was identified and reported to CDC in November 2021. A possible association between pediatric hepatitis and adenovirus infection is under investigation after laboratory testing identified adenovirus infection in all nine patients in the initial cluster; the five specimens that could be typed were all adenovirus type 41. Investigators continue to examine the role of other possible causes and identify contributing factors.

Recommendations for Clinicians

  • Clinicians should continue to follow standard practice for evaluating and managing patients with hepatitis of known and unknown etiology.
  • Clinicians are recommended to consider adenovirus testing for patients with hepatitis of unknown etiology and to report such cases to their state or jurisdictional public health authorities.
  • Because the potential relationship between adenovirus infection and hepatitis is still under investigation, clinicians should consider collecting the following specimen types if available from pediatric patients with hepatitis of unknown cause for adenovirus detection:
    • Blood specimen collected in Ethylenediaminetetraacetic Acid (EDTA) (whole blood, plasma, or serum); whole blood is preferred to plasma and serum)
    • Respiratory specimen (nasopharyngeal swab, sputum, or bronchioalveolar lavage [BAL])
    • Stool specimen or rectal swab; a stool specimen is preferred to a rectal swab
    • Liver tissue, if a biopsy was clinically indicated, or if tissue from native liver explant or autopsy is available:
      • Formalin-fixed, paraffin embedded (FFPE) liver tissue
      • Fresh liver tissue, frozen on dry ice or liquid nitrogen immediately or as soon as possible, and stored at ≤ -70°C

Nucleic acid amplification testing (NAAT), such as polymerase chain reaction (PCR), is preferred for adenovirus detection (currently not available for FFPE liver biopsy or native liver explant). Testing whole blood by PCR is more sensitive to and is preferred over testing plasma by PCR.

Where possible, clinical specimens should be tested locally to ensure timely results for patient care. For any diagnostic testing needs beyond the local capacity, CDC recommends that clinicians contact their state public health laboratory.

For More Information

The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national and international organizations.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HAN Message Types

  • Health Alert: Conveys the highest level of importance; warrants immediate action or attention.
  • Health Advisory: Provides important information for a specific incident or situation; may not require immediate action.
  • Health Update: Provides updated information regarding an incident or situation; unlikely to require immediate action.
  • Info Service: Provides general information that is not necessarily considered to be of an emergent nature.

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This message was distributed to state and local health officers, state and local epidemiologists, state and local laboratory directors, public information officers, HAN coordinators, and clinician organizations.
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Additional Resources