The U.S. Centers for Disease Control and Prevention (CDC) pointed to adenoviruses as the likely cause of an outbreak of childhood hepatitis in Alabama in February. All 9 children with severe acute hepatitis tested positive for adenovirus and none had a history of SARS-CoV-2 infection.

The CDC released on Friday its most detailed findings on the cases to date, after issuing a nationwide health alert last week. Adenovirus infection may be an underappreciated factor in liver damage in healthy children, but further investigation is needed, the CDC said.

While hepatitis is not uncommon in children, the cluster of cases in Alabama surprised doctors because the children with severe symptoms were otherwise healthy and did not test positive for the hepatitis virus.

Public health authorities in the United States and Europe are closely tracking cases of severe hepatitis in children. It follows the UK alerting the World Health Organization to a cluster of cases earlier this month. The WHO has so far identified 169 cases worldwide, the vast majority in the UK.

All nine children in the U.S. were patients at Alabama Children’s Hospital, and they ranged in age from about 2 to 6 years old, according to the CDC. Three of the patients developed liver failure and two required liver transplantation. All of these people have either recovered or are recovering.

All children tested positive for adenovirus, a common infection that can cause respiratory problems, stomach upset, pink eye and bladder inflammation, or, in rarer cases, neurological disorders. Adenovirus is a known cause of hepatitis in children with weakened immune systems, but the patients in Alabama had normal immune systems and no apparent health problems, the CDC said.

Although six of the children tested positive for Epstein-Barr virus (human herpesvirus type 4), the CDC does not consider these to be acute infections because they tested negative for antibodies. The children tested negative for hepatitis A, B and C, and none of them had a history of coronavirus infection, the CDC said.

Last fall, doctors in Alabama identified the first five cases. The CDC and Alabama Department of Public Health began investigating in November 2021. By February of this year, they had found four more cases in Alabama. No other cases have been detected in Alabama since February.

The CDC said it is monitoring the situation closely to better understand why children develop severe hepatitis and to find ways to prevent the disease. The public health agency told doctors to note that a whole blood test, rather than a plasma test, may be better at detecting the presence of adenovirus.

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