Acute Hepatitis in children which is currently sweeping the world is thought to have entered Indonesia after three children were reported to have died at RSCM Jakarta as a result of being infected with this mysterious disease. The pediatric patients who died were aged 2, 8 and 11 years. The team from the Ministry of Health, FKUI and IDAI (Indonesian Pediatrician Association) immediately moved quickly to carry out an investigation through a complete virus panel examination and epidemiological investigation to find out more about the causes of this disease so that its spread does not continue. What exactly is hepatitis?
Hepatitis is an inflammatory condition of the liver or liver. Hepatitis can be caused by viral infections (most often hepatitis A, B, C), bacteria, parasites, chemicals, drug abuse, certain medications, and immune disorders.
Inflammation of the liver that occurs as a result of the above can cause injuries that impair liver function acutely (less than 6 months) or chronically (more than 6 months). The stages are after the liver becomes inflamed and then undergoes fibrosis, if left untreated it progresses to cirrhosis and the final stage can become a tumor (carcinoma). At the stage of inflammation, liver function has begun to decrease, which is indicated by an increase in liver enzymes, namely SGOT/SGPT. If it has increased 10 times from normal, namely > 500 u/L, it is classified as severe. It is said to be fulminant (liver failure) if the INR (International Normalized Ratio) examination, namely the international standard normal ratio recommended by WHO which is often used for measurement of prothrombin mass) increases > 1.5 times accompanied by encephalopathy (a term used for brain damage or malfunction. Symptoms can vary, from mild to severe, such as confusion, seizures, tremors, difficulty swallowing, memory loss, difficulty focusing and concentrating, Easy drowsiness, uncontrollable eye movements (if it is severe can lead to coma) after injection of Vitamin K (to rule out the cause of Vitamin K deficiency) or increase in INR more than 2 times without accompanied by encephalopathy.
The cause of this mysterious hepatitis is still being investigated. In the UK, 163 cases of mysterious acute hepatitis have now been identified and 11 children have received liver transplants. Cases have been detected in 20 countries around the world with nearly 300 children affected.
Until now, scientists suspected that the most likely cause was adenovirus (a family of viruses that have a vertebrate host, including the DNA virus family Adenoviridae, this virus is icosahedral in shape with a virion diameter of 70-100 nm and a genome of 36-38kb) but it is still possible that other causes are actually adenovirus usually does not make children seriously unwell. Genetic analysis of samples from some children has found a strain of the virus called AAV-2 but that also doesn't usually cause disease. Scientists are still monitoring this type of adenovirus, namely type F41. The spread of acute hepatitis transmission is possible through faecal-oral (contaminated food/drink consumed by the patient).
Hepatitis sufferers usually don't feel symptoms until several weeks or there has been impaired liver function. In patients with hepatitis due to viral infection, symptoms will appear after the incubation period, which is around 2 weeks to 6 months.
Common symptoms that appear in people with hepatitis are: nausea and vomiting, fatigue, pale stools, dark urine, abdominal pain, joint pain, loss of appetite, yellow sclera/skin and weight loss.
Three classifications of cases of severe acute hepatitis are now being reported in various countries. This classification comes from the WHO. The first classification is confirmed cases which clearly state that there is no definition yet. This classification occurs because until now the world does not know for sure what causes hepatitis which is currently spreading, maybe there is a change in the adenovirus; whether there are other viruses that also play a role in causing disease; as well as whether there are other factors such as toxins, food contamination or environmental aspects or whether there may be certain things in patients affected by this disease whether there may be an increased susceptibility of children after the relatively low circulation of adenovirus during the Covid-19 pandemic.
The second classification is probable , namely patients who show symptoms of acute hepatitis (without the presence of hepatitis viruses A to E). Then, this patient also has a serum transaminase level >500 IU/L (AST or ALT), who is under 16 years old, occurring since October 2021.
The third classification is "epi-linked" or there is an epidemiological relationship. The condition included in this group is someone who shows symptoms of acute hepatitis (without the presence of hepatitis viruses A to E). Any age, who has close or direct contact (close contact) with probable cases.
To diagnose hepatitis, it is necessary to ask questions and answers about the patient's symptoms and medical history (anamnesis) followed by a physical examination. On physical examination, there is a discoloration in the whites of the eyes (sclera) and pressing on the right upper abdomen. After that, further tests were carried out to confirm the diagnosis, including: liver function tests, to check levels of protein (albumin/globulin), enzymes (SGOT/SGPT), blood sugar in the bloodstream which can indicate liver function damage, hepatitis virus antibody tests (Hepatitis AE, it is difficult to do Hepatitis DE examination in some places), to find out the type of hepatitis virus antibodies in the blood and determine whether hepatitis is acute or chronic, check coagulation factors (PT/INR, APTT), PCR test to detect non-AE viruses , Abdominal ultrasound, to determine the type of abnormalities in the liver, such as liver damage, liver enlargement, or liver tumors, liver biopsy, to determine the cause of damage to the liver parenchyma tissue (inflammation-fibrosis-cirrhosis).
The treatment for this mysterious hepatitis cannot be done with certainty because the cause is still unclear. In the early stages it is better to carry out close observation of the symptoms that are obtained. If you have symptoms of nausea, vomiting, diarrhea, at the initial stage, we will give ORS to prevent dehydration. If symptoms persist, it should be taken to a complete facility for further examination.
The prognosis for this mysterious hepatitis disease depends on the speed at which you are brought to a health facility and examined. When severe symptoms are found, it can usually cause death. For the ability of liver transplantation in Indonesia, it cannot be done for cases of acute liver failure.
In terms of handling mysterious hepatitis, you should pay attention to the following:
- Be alert, the initial symptoms of acute hepatitis are usually in the form of gastrointestinal disturbances which can be followed by a low-grade fever. The initial symptoms are symptoms of the gastrointestinal tract, such as diarrhea, nausea, vomiting, abdominal pain, and low-grade fever.
- Get checked immediately if there is. In order not to panic if you find symptoms of acute hepatitis in a child, immediately take the child to the nearest health facility (Puskesmas or health care facility including hospital) so that they can be treated appropriately.
- Don't wait for further symptoms (don't be late to the health facility if the child has early symptoms of acute hepatitis). Don't wait until further symptoms appear, such as skin and eyes, be referred to the hospital, don't be with symptoms that are already severe, such as yellow in the eyes or all over the body or until the patient is unconscious before being brought to the hospital.
- Take him to the ICU immediately if your consciousness decreases. If you experience a decrease in consciousness, immediately rush to a hospital that has ICU facilities for children.
To avoid getting infected, how to prevent mysterious hepatitis in children. In addition to early detection of hepatitis symptoms, it is also necessary to take steps to prevent it. Here are the steps:
- Washing hands. This is done to prevent the transmission of germs or viruses that cause this. Because hands are often the 'means of transportation' for various germs. Through hands, germs can move to the eyes, nose, mouth.
- Drink clean and boiled water. Generally, the virus that causes hepatitis E is found in boiled water. So that the water consumed is always clean and cooked. Cooked here means the water has been cooked until it boils so that the germs in the water die. Water is also safe for consumption.
- Eat clean, fully cooked food. The hepatitis A virus is mostly transmitted by mouth when consuming food contaminated with the virus. People who consume food or drink that has been contaminated with the faeces of an infected person will contract hepatitis. Apart from washing your hands before eating, make sure the food is clean and cooked before consumption.
- Dispose of stools or disposable diapers in their place. Disposable stools or diapers must be disposed of in its place. This step is taken to prevent the environment from being polluted by feces and urine. Some of the viruses that cause hepatitis are transmitted through contact with the feces and urine of an infected person.
- Use your own cutlery. It is better if children's cutlery is separated from the adults around them. The virus that causes hepatitis can be transmitted through the mouth where an infected person forgets to wash their hands after using the toilet and then eats with other people's cutlery.
- Wear a mask and keep your distance. I suspected acute hepatitis was related to Covid-19. Even though this has not been fully proven, we still encourage parents to continue to strictly implement health protocols. Children need to be reminded to wear masks and keep their distance.
Article written by dr. Sumardi Francis S, Sp. A (K), M. Biomed (Children Specialist Consultant Digestive, Liver and Biliary Tract EMC Sentul Hospital).