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Global cause for concern

As the world sees an unexplained rise in cases of sudden onset hepatitis in children aged 10 and under, how can pharmacy teams help parents spot the signs something might be wrong?

Active cases of acute (sudden onset) hepatitis – a condition that affects the liver and can be caused by infection with a virus – have been increasing in young children in a worldwide outbreak since the start of this year

The UK Health Security Agency (UKHSA) says it has detected 222 cases in the UK in children aged 10 and under since January 2022, at time of writing, but that the viruses that normally cause hepatitis (hepatitis viruses A to E) have not been found in the children affected recently. Other possible causes, including some medications and toxins, are also being investigated, but the UKHSA says “so far a link has not been found”. 

Almost all of the cases have been seen in children under 10, with most cases aged between three and five years. According to UKHSA, most of the children affected were previously healthy, with only a very small number of cases linked to another case of hepatitis. 

Explaining hepatitis

Hepatitis is the term used to describe inflammation of the liver, usually the result of a viral infection or liver damage caused by drinking alcohol.

There are several types of hepatitis – but, as mentioned, the viruses that normally cause it (hepatitis viruses A to E) have not been found in the children affected recently. 

Different types of hepatitis

Usually caught by consuming food and drink contaminated with the faeces of an infected person, Hepatitis A is most common in countries where sanitation is poor. It usually passes within a few months, although it can occasionally be severe and even life threatening. There’s no specific treatment for it, other than to relieve symptoms of pain, nausea and itching.

Caused by the hepatitis B virus, which is spread in the blood of an infected person, Hepatitis B is common worldwide – though uncommon in the UK.

It is usually spread from infected pregnant women to their babies, or from child-to-child contact. In rare cases, it can be spread through unprotected sex and injecting drugs. 

Most adults infected with hepatitis B fully recover within a couple of months, but most people infected as children develop chronic hepatitis B, which can lead to cirrhosis and liver cancer. 

Antiviral medication can be used to treat it, and in 2017 the hepatitis B vaccine was added to the routine immunisation programme so all children can benefit from protection from this virus.

The most common type of viral hepatitis in the UK, it is usually spread through blood-to-blood contact with an infected person, mostly through sharing needles used to inject drugs. Hepatitis C often causes no noticeable symptoms, or only flu-like symptoms, so many people are unaware they’re infected.

Around one in four people will fight off the infection and be free of the virus. In the remaining cases, it’ll stay in the body for many years. This is known as chronic hepatitis C and can cause cirrhosis and liver failure. Chronic hepatitis C can be treated with very effective antiviral medications, but there’s currently no vaccine available.

Hepatitis D only affects people already infected with hepatitis B, as it needs the hepatitis B virus to be able to survive in the body. Hepatitis D is usually spread through blood-to-blood or sexual contact. Long-term infection with hepatitis D and hepatitis B can increase the risk of developing serious problems such as cirrhosis and liver cancer. There’s no vaccine specifically for hepatitis D, but the hepatitis B vaccine can help protect people from it.

This is now the most common cause of acute hepatitis in the UK. The virus has been mainly associated with the consumption of raw or undercooked pork meat or offal, but also with wild boar meat, venison and shellfish. Hepatitis E is generally a mild and short-term infection that does not require any treatment, but it can be serious in some people, such as those who have a weakened immune system. There’s no vaccine for hepatitis E.

Alcoholic hepatitis is caused by drinking excessive amounts of alcohol over many years. Stopping drinking will usually allow the liver to recover. People can reduce the risk of developing alcoholic hepatitis by controlling how much they drink, and not regularly consuming more than 14 units of alcohol a week.

Autoimmune hepatitis is a rare cause of long-term hepatitis in which the immune system attacks and damages the liver. Eventually, the liver can become so damaged that it stops working properly. Treatment involves medicines that suppress the immune system and reduce inflammation. It’s not clear what causes autoimmune hepatitis and it’s not known whether anything can be done to prevent it.

What could be causing the outbreak?

One possible cause being explored by public health teams is whether the cases are linked to an increase in infections triggered by adenovirus, a common cause of childhood illness, which are on the rise now that children are mixing more as the Covid-19 pandemic restrictions have eased.

“At the moment, the evidence appears to suggest that the most probable cause is a particular type of adenovirus called subtype 41,” says Graham Cooke, professor of infectious diseases at Imperial College London’s Faculty of Medicine. 

“This subtype hasn’t previously been associated with severe liver disease, so it’s unclear as to how it could now be causing hepatitis. One possibility is that this adenovirus subtype may have changed in some way and work is going on to sequence the viruses to understand this.” 

Is there a Covid-19 link?

The UKHSA is also investigating other possible causes of the hepatitis outbreak, such as previous Covid-19 infection.

According to UKHSA data, some of the children with acute hepatitis have recently had a Covid-19 infection, but with a high number of Covid-19 infections in this age group anyway the Agency says, “this is not unexpected, [although] we are investigating whether there could be a link to previous Covid-19 infection”.

Similarly, UKHSA says there is no link between these hepatitis cases and the Covid-19 vaccine, explaining: “None of the current cases aged under 10 years old in the UK is known to have been vaccinated.” 

“There were no Covid-19 vaccinations recorded in cases under five, the age group which makes up over 75 per cent of hepatitis cases [and] there are fewer than five older case-patients recorded as having had a Covid-19 vaccination prior to hepatitis onset.”

Community pharmacy help

The widespread coverage of this story is alarming for parents and carers but there is much that pharmacy teams can do to allay their fears, as well as helping them spot the signs and symptoms that something might be wrong.

For starters, Dr Tassos Grammatikopoulos, chair of UK’s paediatric Liver Steering Group, says “it is important to remember that cases of severe hepatitis in children are extremely rare”.

UKHSA says this means that even if there has been a case among a person’s family or friends, or if a case has occurred at their child’s nursery or school, their child is “still at low risk” of developing hepatitis.

Hepatitis signs and symptoms

Symptoms of hepatitis include: 

  • Yellowing of the white part of the eyes or skin (jaundice)
  • Dark urine
  • Pale, grey-coloured faeces 
  • Itchy skin
  • Muscle and joint pain
  • A high temperature
  • Feeling and being sick
  • Feeling unusually tired all the time
  • Loss of appetite
  • Tummy pain.

Most children who develop the common mild symptoms that could be due to a viral infection, such as symptoms of a cold, vomiting or diarrhoea, will soon recover following rest and plenty of fluids, and UKHSA stresses that the chance of them developing hepatitis is “extremely low”. 

Nonetheless, pharmacy teams should remind parents of the signs and symptoms of possible hepatitis infection that they need to look out for in their children.

Dr Elizabeth Whittaker, honorary clinical senior lecturer and consultant in Paediatric Infectious Diseases and Immunology at Imperial College Healthcare NHS Trust, says the children who have developed hepatitis in this outbreak have “usually been presenting with vomiting, tummy pain and diarrhoea over a two-week period, then becoming unwell with yellow eyes or skin. A few cases have other symptoms like headaches and sore throats, and a very small proportion have a fever”. 

Signposting and support

As gastrointestinal symptoms are common in children, the challenge is not to worry every parent who has a child who is vomiting that something serious is going on. 

Pharmacy teams can remind parents that they do not need to contact the NHS unless their child is very unwell (for example, has breathing difficulties or is not eating or drinking) or develops jaundice (yellowing of the eyes or skin), but if their child is getting rapidly worse or they are worried they should trust their instincts and contact their GP or call NHS 111. 

World Hepatitis Day on 28 July also gives community pharmacies an opportunity to increase customer awareness of hepatitis, its risks, and actions people can take to avoid it. 

In the meantime, as the so far unexplained incidents of hepatitis in children continue to rise, Katherine Myles, interim chief executive of the Children’s Liver Disease Foundation (CLDF) adds: “We would encourage any family who is affected by this outbreak to contact us to access CLDF’s specialist family support for children and parents who have just received a liver disease diagnosis.”

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