# No apparent increase in cases of severe acute hepatitis of unknown etiology with fulminant liver failure in children in Germany, 2022

## TL;DR

This study found no significant increase in severe hepatitis cases with liver failure in German children in 2022, unlike reports from the UK and US.

## Contribution

The study provides evidence against a similar outbreak in Germany and highlights the importance of surveillance systems for rare pediatric liver diseases.

## Key findings

- Germany reported nine cases of severe acute hepatitis with fulminant liver failure in children in 2022, consistent with historical averages.
- Hospital discharge data showed no significant increase in pediatric liver-related diagnoses or transplants in 2022 compared to previous years.
- The authors recommend improved syndromic surveillance for early detection of rare pediatric liver conditions.

## Abstract

In April 2022, the United Kingdom and the United States reported alarming increases in cases of severe acute hepatitis of unknown etiology in children, indicating a multicountry outbreak. We aimed to determine if Germany was affected by the outbreak.

Cases were defined as patients 0–16 years with severe acute hepatitis (aspartate transaminase and/or alanine transaminase > 500 IU/l), with adenovirus detection or unknown etiology. Severely impaired liver function resulting in listing for liver transplant, undergoing liver transplant or death was defined as “fulminant” pediatric acute liver failure (pALF). We compared the 2017–2021 case numbers reported by German pediatric liver transplant centers (pLTxCs) with 05/2022–05/2023. Numbers of pediatric inpatients diagnosed with any of 12 selected hepatological ICD‐10 codes and number of liver transplants from national hospital discharge data in 2022 were compared with 2015–2021, using a two‐sample Poisson test.

From 5/2022–5/2023, eight pLTxCs reported nine hepatitis cases with fulminant pALF, compared to 5–14 cases annually from 2017 to 2021, and a total of 26 hepatitis cases without pALF (no baseline data available). The number of pediatric inpatients diagnosed with any of 12 selected hepatological ICD‐10 codes was 373 in 2022, compared to 333–422 annually in 2015–2021. There were 85 liver transplants in 2022, compared to 91–114 annually in 2015–2021.

According to available data, there was no apparent increase in severe acute hepatitis cases of unknown etiology with fulminant pALF in children in Germany, 2022. We recommend implementing syndromic surveillance at pediatric emergency units and timely access to hospital discharge data.

In April 2022, public health authorities in the United Kingdom reported a steep increase in severe acute hepatitis cases in previously healthy children of whom several required liver transplants.There was concern that similar outbreaks could exist undetected in other countries.

In April 2022, public health authorities in the United Kingdom reported a steep increase in severe acute hepatitis cases in previously healthy children of whom several required liver transplants.

There was concern that similar outbreaks could exist undetected in other countries.

Our findings indicate that, based on the available data, there was no apparent increase in cases of severe acute hepatitis of unknown etiology with fulminant liver failure in children in Germany during 2022.Close collaboration between public health authorities and clinicians is crucial for effective surveillance, especially when investigating conditions not previously subject to routine monitoring.

Our findings indicate that, based on the available data, there was no apparent increase in cases of severe acute hepatitis of unknown etiology with fulminant liver failure in children in Germany during 2022.

Close collaboration between public health authorities and clinicians is crucial for effective surveillance, especially when investigating conditions not previously subject to routine monitoring.