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6. Hepatitis: increase in acute cases of unknown aetiology in children
(https://www.gov.uk/government/publications/hepatitis-increase-in-acute-cases-of-unknown-
aetiology-in-children)

UK Health

Security

Agency
(https://www.gov.uk/government/organisations/uk-health-security-agency)

Guidance
Increase in acute hepatitis cases of
unknown aetiology in children
Published 8 April 2022
© Crown copyright 2022

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This publication is available at https://www.gov.uk/government/publications/hepatitis-increase-in-acute-

cases-of-unknown-aetiology-in-children/increase-in-acute-hepatitis-cases-of-unknown-aetiology-in-
children
UKHSA is working with the NHS and public health colleagues across the UK to investigate the potential
cause of an unusually high number of acute hepatitis cases being seen in children from England,
Scotland and Wales in the past few weeks. There is no known association with travel, and hepatitis
viruses (A to E) have not been detected in these children.

The clinical syndrome in identified cases is of severe acute hepatitis with markedly elevated
transaminases, often with jaundice, sometimes preceded by gastrointestinal symptoms including
vomiting as a prominent feature, in children up to the age of 16 years. In England, there are
approximately 60 cases under investigation with most cases being 2 to 5 years old. Some cases have
required transfer to specialist children’s liver units and a small number of children have undergone liver
transplantation. Based on reports from the specialist units, no child has died. The underlying cause of
this increase in presentation since early 2022 currently remains unknown.

Clinicians are asked to be alert to this emerging situation, and to be vigilant to children presenting with
signs and symptoms potentially attributable to hepatitis that may require liver function testing. These
include:

discolouration of urine (dark) and/or faeces (pale)

jaundice
pruritis
arthralgia/myalgia
pyrexia
nausea, vomiting or abdominal pain
lethargy and or loss of appetite

GPs should be alert to children presenting with symptoms compatible with acute hepatitis and seek
advice from their local Trust.

Clinicians are asked to be aware of potential new cases of unexplained acute hepatitis in children aged
16 years or under, with a serum transaminase >500 IU/L (AST or ALT). All staff involved in the care of
these children should use standard IPC precautions with optimal placement in a single en-suite room
whilst the patient is considered infectious and until resolution of symptoms. Follow protocols that would
normally apply in the investigation of acute hepatitis and handling of specimens. There should be a low
threshold for seeking expert clinical support from, or specialist referral to one of the three paediatric
liver centres (King’s College, Birmingham Women’s and Children’s and Leeds Teaching Hospitals) for
children who are clinically unwell or deteriorating.

Cases of acute hepatitis in children up to the age of 16 years with a serum transaminase >500 IU/L, in
which hepatitis A to E has been excluded, should be notified to local health protection teams
(https://www.gov.uk/health-protection-team) by telephone between 9am and 5pm, including weekends.

The following investigations should be performed locally where available. Referral for specialist testing
(https://www.gov.uk/government/publications/virus-reference-department-vrd-user-manual) should be via normal
arrangements:

Sample type Test Pathogen

 Sample type Test Pathogen

Adenovirus, Enterovirus, CMV, EBV, HSV, Hepatitis A,

Blood* PCR
Hepatitis C, Hepatitis E, HHV6 and 7

Hepatitis A, B, C, E, CMV, EBV, SARS-CoV-2 anti-S, SARS-CoV-

Blood* Serology
2 anti-N (only if locally available)

Standard culture for bacteria/fungi (only if clinically indicated

Blood Culture
i.e. fever)

Respiratory virus panel (including

Throat swab* PCR
adenovirus/enterovirus/influenza, SARS-CoV-2)

Adenovirus, sapovirus, norovirus, enterovirus Standard

Stool* PCR bacterial stool pathogen panel to include Salmonella spp (or
stool culture depending on local test availability)

Blood* (whole blood in Local investigations according to history

EDTA and plasma Toxicology Store samples locally - UKHSA will contact laboratories to
separated specimens) request samples

Local investigations according to history

Urine* Toxicology Store samples locally - UKHSA will contact laboratories to

request samples

*earliest possible sample.

Positive results should be reported following usual process.

In addition, please consider the following additional tests if relevant clinical history: leptospirosis PCR
(blood and urine) and serology (blood), throat swab for group A streptococci, serum for anti-streptolysin
O titre (ASOT).

Further testing may be required. If possible, the following additional samples should be stored for future
testing as soon as an acute case of unexplained hepatitis with serum transaminase >500 IU/L (AST or
ALT) in a child aged 16 years or under is identified:

serum and EDTA samples

nose and throat swabs (bacterial and viral)
faecal sample for further testing as required
urine sample for further testing as required

Any sample positive for a pathogen should be stored for typing.

Clinicians wishing to discuss testing for any acute case of unexplained hepatitis with serum
transaminase >500 IU/L (AST or ALT) in a child aged 16 years or under should contact the Imported
Fever Service on 0844 778 8990.
Please see UKHSA (https://www.gov.uk/government/news/increase-in-hepatitis-liver-inflammation-cases-in-
children-under-investigation) for the latest updates on this emerging incident.

All content is available under the Open Government Licence

v3.0, except where otherwise stated © Crown copyright