Three children in Indonesia have died of mysterious hepatitis which, if confirmed, would bring the global death toll to at least four.
The country’s health ministry said the victims died of “suspected acute hepatitis” last month and were all in the capital, Jakarta.
Their symptoms included nausea, vomiting, profuse diarrhea, fever, jaundice, seizures and loss of consciousness – all telltale signs of the deadly liver disease.
Tests are underway to confirm their cause of death. Indonesia has not officially recorded any cases of hepatitis since the start of the epidemic.
The children’s ages were not revealed and it is unclear whether they had any underlying health conditions.
More than 200 cases of hepatitis in children of unknown origin have been confirmed worldwide during the mysterious outbreak – which experts say is just the “tip of the iceberg”.
Most cases have been detected in the UK and US, which have some of the strongest surveillance systems.
The World Health Organization confirmed one death, although it did not reveal the location. One death in the United States is being investigated, along with the three in Indonesia. At least 18 of the youngsters needed liver transplants.
None of the cases tested positive for the normal viruses that cause hepatitis, which has left scientists baffled as to the origins of the disease.
A virus that normally causes the common cold, known as the adenovirus, is thought to be involved.
But there are a number of theories as to why the normally harmless virus causes severe illness in previously healthy young children.
More than 200 children have been sick across the world in up to 14 countries since last October * cases in Canada, Japan and Wisconsin, Illinois and New York have yet to be confirmed
The Indonesian Ministry of Health has urged parents to be on the lookout for symptoms of the disease, which include jaundice – yellowing of the skin and whites of the eyes – as well as abdominal pain, vomiting, diarrhea and dark urine.
He urged people to see a doctor if their child developed symptoms and encouraged his people to maintain good hand hygiene, ensure food is clean and well cooked and avoid contact with sick people.
Q&A: What is the mysterious global hepatitis epidemic and what is behind it?
What is hepatitis?
Hepatitis is an inflammation of the liver that is usually caused by a viral infection or liver damage caused by alcohol consumption.
Some cases resolve on their own with no lingering problems, but a fraction can be fatal, requiring patients to need liver transplants to survive.
Why are experts concerned?
Hepatitis is generally rare in children, but experts have already spotted more cases in the current outbreak than they would normally expect in a year.
The cases are of “unknown origin” and are also serious, according to the World Health Organization. It has caused at least one death and 18 liver transplants.
What is the scope of the cases?
Inflammatory liver disease has been identified in more than 200 children aged one month to 16 years.
less than five
Number not specified
*cases in Canada, Japan and Illinois, Wisconsin and New York have yet to be confirmed
What could trigger it?
None of the cases were caused by one of five typical strains of the virus – hepatitis A, B, C, D and E – leaving experts baffled by the outbreak.
Some children have tested positive for adenovirus, which commonly causes the common cold, while others have been infected with Covid – but no clear theme has emerged.
The UKHSA has ruled out the Covid vaccine as a possible cause, with none of the UK cases so far having been vaccinated due to their age.
What are the symptoms?
Hepatitis often has no noticeable symptoms, but it can include dark urine, pale gray feces, itchy skin, and yellowing of the eyes and skin.
Infected people may also experience muscle and joint pain, high temperature, feel and be sick, and be abnormally tired all the time.
How is it treated?
Treatment depends on the severity, with some patients able to fight the disease on their own.
In more dangerous cases where the liver fails, children may be placed in an induced coma to deal with brain swelling caused by ammonia buildup.
A liver transplant may be needed if the liver has been damaged to repair itself, although this is extremely rare.
Officials are investigating the cause and reviewing the epidemiology of the outbreak, the ministry said.
UK health chiefs believe adenovirus may be behind the sudden-onset cases of hepatitis.
The 145 children affected in Britain, who were mostly aged five and under, first suffered from diarrhea and nausea, followed by jaundice.
But the UK Health Security Agency (UKHSA) said it’s not typical to see this pattern of symptoms in adenovirus, so it continues to probe other causes, including Covid itself.
He also noted that the lockdowns may have weakened children’s immunity and made them more susceptible to the virus, or it could be a mutated version of the adenovirus.
The UK agency is working with scientists and doctors across the country to “answer these questions as quickly as possible”.
Indonesia did not impose a nationwide lockdown, but instead implemented local restrictions that required people to work from home, go to school online and not dine in restaurants .
Experts are also investigating whether a new variant of the coronavirus is responsible or whether it could be a case of prior or concurrent Covid infection.
Dr Meera Chand, director of clinical and emerging infections at UKHSA, said parents might be worried, but the chance of their child developing hepatitis is “extremely low”.
“However, we continue to remind parents to be alert for signs of hepatitis – especially jaundice, which is easier to spot as a yellow tinge to the whites of the eyes – and to contact your doctor if you’re worried,” she said.
Dr Chand added: “Normal hygiene measures, including washing hands thoroughly and ensuring children wash their hands properly, help reduce the spread of many common infections.
“As always, children with symptoms such as vomiting and diarrhea should stay home and only return to school or nursery 48 hours after symptoms resolve.”
Hepatitis is generally rare in children, but experts have already spotted more cases in the UK since January than they would normally expect in a year.
The cases are of “unknown origin” and are also serious, according to the World Health Organization.
Scientists have previously suggested the cases could be just the ‘tip of the iceberg’, with more likely to be there than has been spotted so far.
Professor Alastair Sutcliffe, a leading pediatrician at University College London, told MailOnline that health chiefs may not know the cause until the end of the summer.
He said: “With modern methods, computing, advanced computing, real-time PCR and whole-genome screening, I think finding the cause with reasonable reliability will take three months.”
Professor Sutcliffe said finding the cause could be slowed by bureaucracy across international borders, with difficulties transporting biomaterials across countries.
Parental consent, data protection and laws governing the use of human tissue in the UK could all slow down research, he said.
Finding an unknown cause is particularly difficult because cases may have multiple factors behind them that are not consistent across all illnesses.
British health officials have ruled out the Covid vaccine as a possible cause, with none of the sick British children having been vaccinated due to their young age.
Liver experts described the spate of cases as ‘worrying’ but said parents shouldn’t worry about the disease affecting their children.
The head of the European Center for Disease Prevention and Control (ECDC) said the disease was ‘fairly rare’ but rated the risk to children as ‘high’ due to the potential impact.
The risk to European children cannot be accurately assessed because evidence of human-to-human transmission was unclear and cases in the European Union were “sporadic with an unclear trend”, he said.
But given the unknown causes of the illness and the potential severity of the illness caused, the ECDC said the outbreak “constitutes a concerning public health event”.
The spike in hepatitis cases was first recorded in Scotland on March 31, with a child hospitalized in January with the illness. The Scottish affair dated back to January.
WHAT CAUSES CASES OF HEPATITIS?
Experts say the cases may be linked to adenovirus, commonly associated with the common cold, but more research is ongoing.
This, in combination with Covid infections, could be behind the spike in cases.
Adenovirus reported by WHO was detected in at least 74 of the cases. At least 20 of the children have tested positive for coronavirus.
British experts investigating the wave of illness believe the endless cycle of lockdowns may have played a contributing role.
The restrictions may have weakened children’s immunity due to reduced social mixing, leaving them at increased risk of adenovirus.
This means that even the “normal” adenovirus could be the cause of the serious consequences, because children do not react to it as they did in the past.
Other scientists said it may have been the adenovirus that had acquired “unusual mutations”.
This would mean that it might be more transmissible or better able to circumvent children’s natural immunity.
New Covid Variant
UKHSA officials included “a new variant of SARS-CoV-2” in their working hypotheses.
Covid has caused inflammation of the liver in very rare cases during the pandemic, although these have been in all ages rather than isolated in children.
The UKHSA noted that environmental triggers are still being researched as possible causes of illnesses.
These could include pollution or exposure to particular drugs or toxins.