Indonesia probes another hepatitis-linked child death as more cases emerge

JAKARTA (The Jakarta Post/Asia News Network): The Health Ministry is investigating another death thought to be connected to an ill-understood form of hepatitis in children as more cases are reported across the country.

The Tulungagung Health Agency in East Java reported on Saturday (May 7) that a 7-year-old girl had died after exhibiting symptoms of hepatitis, which include jaundice, fever, vomiting and diarrhea.

Agency head Kasil Rokhmat said the patient had received intensive treatment at the Dr Iskak Regional Hospital and another private hospital in Tulungagung before she died on Friday.

“Lab reports showed that the patient tested negative for hepatitis A, B, C, D and E,” Kasil said on Saturday, as reported by Tempo.

Health Ministry spokesperson Siti Nadia Tarmizi told The Jakarta Post on Sunday that the ministry was conducting laboratory tests to determine the cause of the infection and whether the East Java case and three other deaths previously reported in Jakarta were cases of an acute form of hepatitis of unknown origin that had been affecting children abroad.

Between April 15 and 30, three children, aged 2, 8 and 11, died at Jakarta’s Cipto Mangunkusumo Hospital after being treated for liver inflammation. All three had been vaccinated against hepatitis and had tested negative for hepatitis A through E.

A two-month-old with acute hepatitis symptoms also died last week at Hermina Hospital in Padang, West Sumatra. The Health Ministry has not said whether it will investigate the death further.

According to Health Minister Budi Gunadi Sadikin, Indonesia has detected 15 confirmed cases of acute hepatitis of unknown origin in children since launching an investigation into the illness recently.

“We are working together with the World Health Organization and health authorities in the United States and United Kingdom to quickly determine the cause of the disease. There’s a big possibility that it was caused by Adenovirus type 41. However, the virus has not been detected in a lot of patients,” Budi said at a press conference on Monday.

Adenoviruses are common pathogens that usually spread from person to person and typically cause respiratory illness, according to the WHO.

More than 50 types of adenovirus can infect humans. Adenovirus type 41 typically presents as diarrhoea, vomiting and fever, often accompanied by respiratory symptoms. While there have been reports of hepatitis in immunocompromised children with adenovirus infections, adenovirus type 41 is not known to be a cause of hepatitis in otherwise healthy children.

Public health expert Tjandra Yoga Aditama of the University of Indonesia has urged the health ministry to release details of lab results relating to the 15 acute hepatitis cases, including whether hepatitis A to E, Covid-19, an adenovirus or the Epstein-Barr virus had been detected in the patients.

“It would be better if the government told the public whether the patients had autoimmune diseases or not,” Tjandra said on Tuesday.

Global outbreak Cases of acute hepatitis of unknown origin were first identified at an Alabama hospital in October 2021, when five children were admitted with liver damage. Since then, more cases have been reported from around the globe, with more than 200 suspected and probable cases recorded in children across 20 countries.

More than half of the cases were in the UK, prompting the WHO to declare the illness an outbreak on April 15. The children affected were as young as 1 month old and as old as 16 years.

Although the case numbers are still relatively low globally, their severity has health professionals worried.

In the 200 patients, liver inflammation occurred rapidly and abruptly. Some 10 per cent of patients required a liver transplant. The most commonly found pathogen among the patients was the adenovirus, particularly subtype 41F.

Experts are looking into whether the adenovirus involved has mutated, since the virus does not typically cause hepatitis in healthy children. Will Irving, Professor of Virology at the University of Nottingham in the UK told The Lancet that it was possible that Covid-19 lockdowns had weakened children’s immunity because they had been less exposed to common pathogens while in isolation, meaning they might now have more severe immune responses.

Another hypothesis, Irving said, was that Covid-19 itself was a factor. A UK Health Security Agency (UKHSA) study reported that several children with acute hepatitis had tested positive for SARS-CoV-2 either in recent weeks or upon hospital admission.

“Perhaps, prior infection with SARS-CoV-2 is doing something to the immune system such that when it meets what would otherwise be a perfectly normal, trivial virus infection, it is triggering a damaging response to the liver,” said Irving, adding that the idea of a toxin from the environment or food had not been ruled out.

Scientists have, however, ruled out a link between cases and the Covid-19 vaccine, since most of the children had not received a vaccine and were not yet eligible for it.

Muzal Kadim of the Indonesian Paediatrician Association (IDAI) said that good personal hygiene, such as frequent handwashing and mask wearing, as well as food safety, remained critical to preventing acute hepatitis in children.

“Hepatitis viruses generally spread through saliva droplets and eating food contaminated by the virus,” Muzal said.

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