Explainer |

Everything You Need to Know About the Hepatitis Outbreak Among Children

Is the number of cases in Israel unusually high, what are the symptoms of the disease and is it linked to the coronavirus? Haaretz explains

Ido Efrati
Ido Efrati
Children's ward at Sheba Medical Center in Tel Hashomer in January
Children's ward at Sheba Medical Center in Tel Hashomer in JanuaryCredit: Avishag Shaar-Yashuv
Ido Efrati
Ido Efrati

The Health Ministry said on Tuesday that it is looking into 12 cases of children hospitalized in recent months with severe hepatitis. The investigation had been recommended by the World Health Organization after dozens of similar cases were discovered in Britain, the United States and Spain. Following is an explanation of the disease, its spread and whether it is related to the coronavirus.

When and how was this new outbreak of hepatitis discovered in children?

On April 5, the WHO announced that dozens of cases of severe hepatitis from an unknown source had been found in children under age 10 in Scotland. By April 8, 74 additional cases had been found in Britain.

Lab tests on the infected children ruled out the possibility that these infections stemmed from any of the known viruses – hepatitis A, B, C, D and E. The source of the infections is still being investigated.

“Given the increase in cases reported over the past one month and enhanced case search activities, more cases are likely to be reported in the coming days,” the WHO said in a statement on April 15. And indeed, similar cases have since been discovered in America and Spain, most in children age 2 to 5. Some of these children even needed a liver transplant, but so far, there have been no deaths.

In light of the growing number of cases and the WHO’s recommendation, other countries, including Israel, have started monitoring cases of hepatitis in children from an unknown source.

What are the disease’s diagnosed characteristics?

Hepatitis is a liver infection characterized by acute liver failure – a situation in which the liver is destroyed very rapidly. In some cases, it could result in a need for transplant within days, or even death when not treated in time.

“Cases of hepatitis in children from an unknown source aren’t uncommon; they’ve been known even before now,” said Dr. Yael Mozer-Glassberg, head of the pediatric liver transplantation unit at Schneider Children’s Medical Center in Petah Tikva. “In the vast majority of cases, the source of the infection remains unknown and it’s simply treated – either with supportive treatment until recovery or with a transplant when necessary.

In Israel, of the12 cases that came in the last four months, two of the children suffered from liver failure, prompting doctors to carry out liver transplants. The condition of the other children improved quickly after treatment with steroids, and they were released from the hospitals.

“In 50 percent of cases of this type of infection, transplantation of a liver lobe is needed,” she added. “So the two babies who needed a transplant in the cases at hand aren’t considered statistically anomalous.”

What are the disease’s clinical symptoms?

In the cases identified to date, the symptoms have been severe liver infection and significantly elevated liver enzymes. Often, this is accompanied by jaundice, and in some cases, it is preceded by gastrointestinal symptoms (primarily in children up to age 10).

What time period is covered by the cases reported in Israel, and are any children currently hospitalized?

So far, 12 cases of hepatitis in children that could meet the WHO’s description of the current outbreak have been found in Israel, but no child is currently known to be hospitalized with this disease. At this point, however, these are only initial reports of cases that could match the description. Now, each case is being investigated in depth to determine which ones actually match the cases found in other countries.

The Health Ministry says these cases have occurred in recent months. But in fact, they occurred over a longer period of time. According to Mozer-Glassberg, the seven cases found at Schneider’s were discovered over the course of 14 months.

“The first case was identified in February 2021,” she said. “We had two cases of young babies with this infection, and soon afterward, two more young adults. As far back as eight months ago, we’d started investigating these cases obsessively, and we looked into every possible cause – viruses, various types of toxins, autoimmune factors and family and genetic diseases.”

Is the number of cases higher than normal?

Because hepatitis in children isn’t routinely reported to the Health Ministry, there’s still no numerical evidence that the number of cases of hepatitis in children from an unknown source has risen. The determination that there has been such an increase is based mainly on the feelings of doctors at the hospitals where cases were discovered.

Nevertheless, the fact that 12 cases have been discovered in 14 months indicates that this isn’t an epidemic.

Children's ward at Kaplan Hospital in Rehovot in January Credit: Ilan Assayag

“In recent months, we’ve seen a rise in the number of children arriving with anomalous liver function, more than we’re used to, and with greater frequency,” said Prof. Eyal Shteyer, head of the Pediatric Liver Unit at Jerusalem’s Shaare Zedek Medical Center, where five of the 12 cases were discovered.

In contrast, Mozer-Glassberg said she had seen no such increase at Schneider’s. “I can’t say that if we compare it to the pre-coronavirus period, there are more cases than usual,” she said. “If we had the clinical feeling that we were seeing more cases, it would have been passed on to the Health Ministry long ago.”

Do these cases have any connection to the coronavirus?

At this stage, there is no unequivocal evidence pointing to the coronavirus as a direct causal factor in the disease. Nevertheless, doctors who have treated these children suspect that there is a connection.

“After we ruled out all the various possibilities, the common denominator in all the cases we found was that all had come down with the coronavirus around three and a half months before the infection appeared,” Mozer-Glassberg said. “This certainly raises the question. But I don’t think it’s possible to say yet that all these cases are a post-COVID phenomenon.”

What is Israel doing now in light of the discovery of these cases?

Due to the discovery of the cases here, a Zoom conference took place on Wednesday among liver specialists from the hospitals and Health Ministry officials. In addition, the hospitals are still doing retroactive investigations into the cases and will likely uncover additional ones treated over the last year.

Nevertheless, the doctors sought to reassure the public.

“This is a disease we’re familiar with,” said Prof. Rifaat Safadi, head of the Liver Disease Unit at Jerusalem’s Hadassah Ein Karem hospital. “It’s a liver disease that resembles an autoimmune liver disease, except it doesn’t have the blood tests characteristic of autoimmune disease.

“This is a familiar disease that usually appears following an instigating infection that we don’t always manage to catch. What happens in such cases is that after the person recovers from the infection, the immune system in some cases attacks the liver. This is a familiar problem and it responds to treatment with steroids.”

“Our impression is that there has been a rise in such cases,” he continued. “Abroad, they’re talking about early 2022, but our experience in Israel shows an increase as far back as early 2021.

“The cases investigated in Israel show that most of the cases are children who didn’t get the [coronavirus] vaccine. It’s possible that the source is another instigating infection and not the coronavirus, but the major instigating infection of the past year has been the coronavirus, so there are grounds for assuming this is connected to the coronavirus.”

Safadi stressed that “there’s no need to go into a panic. But it’s worth remaining alert, especially with regard to children below age 10, and particularly below age 5.”

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