Trending Clinical Topic: Hepatitis

A worldwide outbreak of acute, severe hepatitis in children has made headlines recently. This is in part because the precise cause has remained elusive (see Infographic below). The growing case count, along with updated recommendations for vaccination by the Centers for Disease Control and Prevention (CDC) and new findings about a scoring system and treatment for alcoholic hepatitis, resulted in this week's top trending clinical topic.

Affected children range in age from 1 month to 16 years, according to the World Health Organization. Approximately 10% (17 children) have required liver transplantation, and at least one death has been reported. In late April, the CDC issued a Health Alert Network Health Advisory warning clinicians and public health authorities about the outbreak. From October 2021 to February 2022, nine pediatric cases of acute hepatitis were identified in Alabama, a rate much higher than expected. All children tested positive for adenovirus.

In considering the information available, F. Perry Wilson, MD, MSCE, ruled out the hypothesis that the increase in pediatric acute hepatitis cases may be a "clustering illusion." He finds the theory that adenovirus is the causative agent to be plausible, pointing to the high number of children with acute hepatitis in whom the virus has been identified. Adenoviruses had been established previously as a cause of acute hepatitis, but most cases were in immunocompromised individuals. Because the current outbreak is such a departure, Wilson suggests that considering the role of SARS-CoV-2 is reasonable, perhaps in combination with adenovirus.

In regard to other recent hepatitis-related news, the CDC updated its guidance on who should receive vaccination for hepatitis B. All adults aged 19-59 years are advised to get vaccinated, and adults aged 60 years or older without known risk factors may also get vaccinated. The move was made to address increasing incidence. Among adults aged 40-49 years, the rate of cases increased from 1.9 per 100,000 people in 2011 to 2.7 per 100,000 in 2019. Among adults aged 50-59 years, the rate increased from 1.1 to 1.6. Among adults aged 19 years or older, only 30% reported that they'd received the three recommended doses of the vaccine. The rate was 40.3% for adults aged 19-49 years and 19.1% for adults aged 50 years or older. Even among adults with chronic liver disease, the vaccination rate is only 33%.

Recent findings have also emerged regarding alcoholic hepatitis. A new scoring system, the Mortality Index for Alcohol-Associated Hepatitis (MIAAH), proved more accurate than other models at predicting 30-day mortality risk for patients with alcohol-associated hepatitis. Compared with several currently available prognostic models for assessing disease severity, which have poor accuracy (area under the curve between 0.71 and 0.77), the new model has an accuracy of 86% in predicting 30-day mortality.

When it comes to treatment for alcoholic hepatitis, a new study confirmed that early liver transplantation improved survival but also boosted the likelihood of alcohol relapse. Three groups of patients were included in the study: 68 with severe alcohol-related hepatitis unresponsive to medical treatment who received early liver transplantation; 93 with alcohol-related cirrhosis who received standard-timing transplantation; and 47 with severe alcohol-related hepatitis who were not eligible for early transplantation. A historical control group of people who were not transplanted was also included. The primary outcome was noninferiority of alcohol relapse at 2 years post-transplant. It was not met, as 34% of patients in the early-transplantation group and 25% in the standard-timing group relapsed. Two-year post-transplant survival was similar between the two groups but was higher in the early-transplantation group.

An alarming worldwide pediatric outbreak, a new prevention strategy, and concerns about alcoholic hepatitis combined to result in this week's top trending clinical topic.