Yesterday in Emerging Infectious Diseases, Centers for Disease Control and Prevention (CDC) researchers described the cases of eight US children who died of acute hepatitis of unknown cause—half of whom tested positive for adenovirus—from October 2021 to June 2023.

A total of 392 pediatric hepatitis cases of unknown origin were reported during the period. Of the eight who died, two had weakened immune systems, and one of the four who tested positive for adenovirus had no underlying medical conditions. Adenoviruses typically cause mild flu- or cold-like symptoms.

Hepatitis is an inflammation of the liver caused by genetic, drug-related, metabolic, infectious, or immune-mediated conditions. Before these cases, adenovirus had been associated with hepatitis only in people with impaired immune systems. Another 1,010 similar cases were later reported by other countries.

In April 2022, the CDC issued a healthy advisory that recommended testing affected children younger than 10 years for adenovirus.

Two children required liver transplant

The median patient age was 2.4 years, 62.5% were boys, and 62.5% were Hispanic. Emergency department or hospital admission occurred after a median 7 days of symptoms. Seven of eight children had received at least two doses of hepatitis B vaccine, and five had been given one or two doses of hepatitis A vaccine.

Investigation into whether Hispanic/Latino children are at higher risk for diseases and death is needed.

The median length of hospitalization was 14 days. Seven children had acute liver failure as noted on their medical abstraction form, and two received a liver transplant. The causes of death for seven children with available information were liver-related, cardiopulmonary causes, cerebral herniation (displacement of part of the brain due to increased intercranial pressure), and multiorgan failure. Of the four children who tested positive for adenovirus, three had adenovirus noted in their death certificate or autopsy report. 

"Our findings emphasize the importance of continued investigation to determine the mechanism of liver injury and appropriate treatment," the researchers wrote. "Testing for adenovirus in similar cases could elucidate the role of the virus. Investigation into whether Hispanic/Latino children are at higher risk for diseases and death is needed."

Incidence of Candida auris infection or colonization tripled at a large New York City hospital during the COVID-19 pandemic, researchers reported yesterday in Open Forum Infectious Diseases.

The retrospective chart review by researchers at Mount Sinai Hospital, a 1,018-bed academic tertiary hospital that was on the front lines of treating COVID-19 patients from the earliest days of the pandemic, looked for all incident cases of C auris at the hospital from 2019 through 2022. Since the multidrug-resistant fungus was first identified in the United States in 2016, hospitals in New York City have been among the hot spots for infection and colonization, though the spread was initially gradual through 2019.

The researchers defined an incident case as a patient without a known history of infection or colonization with C auris who had a positive surveillance or clinical culture identified during the study period. Overall, they identified 64 cases, 34 by surveillance culture and 30 by clinical culture. Total incidence, including clinical and surveillance cases, from 2019 through 2022 was 4.9 cases per 10,000 admissions, with incidence rising from 2.6 cases per 10,000 admissions in 2019 to 7.8 in 2022.

Increase could reflect impact of pandemic, increased surveillance

The study authors say the increase in C auris incidence mirrors national and international trends and could be attributed in part to multiple factors associated with the pandemic that have been linked to increases in other multidrug-resistant organisms (MDROs). Those factors include staffing and supply shortages, overuse and misuse of personal protective equipment, and lapses in infection prevention and control practices.

But they also note that Mount Sinai's C auris surveillance plan expanded during the study period to target high-risk patients from nursing homes and skilled-nursing facilities, which resulted in a doubling of patients screened and fivefold increase in positive patients identified.

"Our results highlight the potential impact the COVID-19 pandemic had on the spread of MDROs and the potential for targeted admission surveillance to serve as a valuable tool to combat the increasing spread of C. auris," they wrote.

The World Health Organization (WHO) said today in an outbreak notice that 13 countries in Africa have reported confirmed or probable yellow fever cases since the start of 2023. It urged countries to increase surveillance because of the potential for onward transmission through travel and the presence of mosquitoes in neighboring countries that are capable of spreading the disease.

The countries are Burkina Faso, Cameroon, the Central African Republic, Chad, Republic of the Congo, Ivory Coast, the Democratic Republic of the Congo (DRC), Guinea, Niger, Nigeria, South Sudan, Togo, and Uganda. During the last quarter of 2023 through February 25, eight of the countries have reported active yellow fever transmission and have started response planning: Cameroon, Chad, Congo, DRC, Guinea, Niger, Nigeria, and South Sudan.

Niger and Nigeria reported cases in January, and investigations are still under way. An outbreak in South Sudan, first reported in December 2023 and centered in West Equatoria state, has grown to 64 cases that fit the case definition, of which 6 were fatal.

Urban spread in Cameroon's biggest city

The WHO also warned that Aedes mosquitoes in urban areas can amplify outbreaks. It said that, of Cameroon's nine lab-confirmed cases, six were from a densely populated area of Douala, the country's largest city.

Preliminary information for 2023 shows a case-fatality rate of 11%.

Though progress has been made with vaccination, suboptimal vaccine coverage in some areas and persistent population immunity gaps pose a high risk and threaten progress toward elimination. The WHO put the regional risk at moderate and kept the global risk low.