Curiculum vitae

Dr. Anggraini Alam, dr., SpA(K)

anggialam@yahoo.co.id
Consultant of Infection & Tropical Diseases,
Child Health Department, Faculty of Medicine
Universitas Padjadjaran/Hasan Sadikin General Hospital

Education:
1993 Medical Doctor from Medical Faculty Universitas Padjadjaran
2005 Pediatric Specialist from Medical Faculty Universitas Padjadjaran
2009 International Training Courses in Tropical Medicine in Faculty of Tropical Medicine, Mahidol University, Thailand
2010 Fellowship on Infectious Diseases in KK Women & Children Hospital Singapore
2011 Infection and Tropical Diseases Consultant from Indonesian College of Pediatric
2017 Doctor (PhD) in Pediatric from Medical Faculty Universitas Padjadjaran

Current Organization:
Ketua UKK Infeksi dan Penyakit Tropis IDAI
Anggota Komite Ahli Penyakit Infeksi Saluran Pencernaan Kemenkes RI
Wakil Ketua PINERE RSHS
Board Member of Asia Society of Pediatric Infectious Diseases (ASPID)
Member of the SAG on Covid-19, Antimicrobial Resistance, and Infectious Disease of the IPA
 UKK Infeksi & Penyakit Tropis IDAI

Acute, severe hepatitis

of unknown origin in children

Anggraini Alam
• Since the WHO Disease Outbreak News on Acute hepatitis of unknown aetiology – the United
Kingdom of Great Britain and Northern Ireland was published on 15 April 2022, there have been
continuing further reports of cases of acute hepatitis of unknown origin among young children.
• It is not yet clear if there has been an increase in hepatitis cases, or an increase in awareness of
hepatitis cases that occur at the expected rate but go undetected.
• While adenovirus is a possible hypothesis, investigations are ongoing for the causative agent.
 WHO 23 April 2022
As of 21 April 2022, at least 169 cases of acute hepatitis of unknown
origin have been reported from 11 countries (10 European region &
1 American region)
Cases are aged 1 month to 16 years; approximately 10%)

Distribution of cases of acute severe hepatitis of unknown origin by country, as of 23 April 2022

On 2 May 2022 Indonesia’s MOH, reported that

3 children died of acute hepatitis during April
2022.[19][clarification needed]

WHO
Wikipedia
WHO working case definition:

(A person who is epi-linked but also meets the confirmed or possible case definition will be recorded as a
confirmed or possible case and their epi-link noted in their record. This prevents double-counting of cases.)

World Health Organization (15 April 2022). Disease Outbreak News; Acute hepatitis of unknown
aetiology - the United Kingdom of Great Britain and Northern Ireland.
UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022
Definition: acute, severe hepatitis
• The acute symptomatic phase of (viral) hepatitis usually lasts from a few
days to several weeks
• the period of jaundice that may follow can persist from one to three weeks.
• Complications of acute viral hepatitis include fulminant hepatitis, which is a
very severe, rapidly developing form of the disease that results in:
• severe liver failure,
• impaired kidney function,
• difficulty in the clotting of blood,
• and marked changes in neurological function.
• Such patients rapidly become comatose; mortality is as high as 90 percent.
 Working hypotheses
The following hypotheses are all being actively tested by the investigations in process

Normal adenovirus infection

Novel variant adenovirus

There are increased
paediatric acute non-A- Post-infectious SARS-CoV-2 syndrome
E hepatitis
presentations due to:
drug, toxin, or environmental exposure

novel pathogen (alone or a coinfection)

new variant of SARS-CoV-2

UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022
 Associated pathogens
• Adenovirus: the most frequently detected
Working hypotheses potential pathogen.
• 163 UK cases, 126 tested for adenovirus
of which 91 (72%) adenovirus detected.
• type 41F (18 of 18 cases with an available
• The leading hypotheses remain
result)
those which involve adenovirus. • Adeno-associated Virus 2 (AAV-2).
• investigate the potential role of • uncertain significance
SARS-CoV-2 • may represent a normal reactivation of
AAV-2 during an acute viral infection (eq.
• ruling out any toxicological adenovirus) or during liver injury of
component. another cause
• SARS-CoV-2 has been detected in 24
(18%) cases of 132 with available results.

UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022

 Investigasi

Memasukkan Enhanced surveillance Pemeriksaan biopsi

KARAKTERISTIK PEJAMU

INVESTIGASI PATOGEN
EPIDEMIOLOGI

SURVEILANS

MEKANISME INJURI HATI

Usia
karakteristik penyakit for severe acute hati Mencari etiologi
infeksi di Indonesia hepatitis in children Status
yang memiliki tanda
Pemeriksaan Menyingkirkan
Not due to: patologi anatomi imunologi
& gejala mirip dengan hepatitis A-E viruses,
DD/
acute, severe Pemeriksaan Terapi
or an expected Mencari
hepatitis with presentation of imunohistologi imunosupresan
unknown origin (mis. kemungkinan
metabolic, inherited
Leptospirosis, or genetic, congenital
Pasca- koinfeksi
dengue, tifoid, dst.) or mechanical cause* transplantasi

All cases are being followed up for outcome at 28 days after presentation to health services

UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022, dengan modifikasi
Patient’s characteristic
In the first 60 case patients in England with data available, no notable
features or common exposures were observed in:
• travel,
• family structure,
• parental occupation,
• diet,
• water source
• potential exposures to toxicants
• no association with prior immunosuppression.

UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022

Possible exposures
• Relatively high numbers of dog-owning families or other dog exposures in cases (64 of 92
or 70%).
• The significance of this finding is being explored.
• Pet dog ownership is common in the UK; may include transient non-significant contact
• Approximately three-quarters mentioned paracetamol use.
• Fewer reported ibuprofen use and none reported aspirin use.
• While paracetamol is an important hepatotoxic agent in overdose, there have been no
reports of paracetamol hepatoxic presentations or histories from any of the clinical units.
• COVID-19 vaccination
• There were no COVID-19 vaccinations recorded in cases aged under 5, the age group which
makes up over 75% of hepatitis cases.
• There is no evidence of a link between COVID-19 vaccination and the acute hepatic
syndrome.

UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022

 Investigasi patogen
✓ • IgM anti HAV
✓ • HBs Ag (dengan test serologi atau rapid)
Sampel yang diambil untuk dirujuk ke
✓ • IgM anti-HBc (bila HBsAg reaktif)
laboratorium rujukan
• IgM anti HCV
• IgM anti-HDV (bila HBsAg reaktif) atau PCR HDV
RNA • Darah EDTA 3 mL (tabung tutup ungu) à sampel
• IgM anti-HEV optimal untuk adenovirus
• IgM dan IgG anti-SARS-CoV-2 • Serum 3 mL (tabung tutup merah)
• PCR SARS-CoV-2 • Feses (seperempat dari wadah feses atau 1 sendok
• IgM HSV 1 dan 2 makan)
• IgM CMV • Urin 12 mL
• Biakan darah • Rectal swab (VTM)
• Dengue (NS-1), leptospirosis (IgM anti Leptospira) • Swab nasofaring (VTM)
dan demam tifoid (anti Salmonella), disesuaikan • Cairan serebrospinal/LCS (jika ada kejang atau
penilaian klinisi. penurunan kesadaran)
• Lain-lain (termasuk PCR adenovirus 40/41, Epstein • Biopsi hati jika dilakukan
Barr Virus, dll) bila sudah ditetapkan. • Toksikologi

Protokol kewaspadaan hepatitis akut berat. Kemenkes RI 2022. 2 Mei (unpublished)

Pemeriksaan di Klinik atau FKTP
Living algorithm
Terapkan kewaspadaan standar ANAMNESIS
& isolasi pada saat memeriksa
pasien Ikterik (71,2%)
Muntah (62,7%)
Feses pucat (50,0%)
Letargi (50,0%) RIWAYAT:
- COVID-19
Gejala gastrointestinal: - Defisiensi imun
Anak usia <16 tahun dengan tanda dan gejala - Diare (44,9%) - Vaksinasi
hepatitis akut berat (acute, severe hepatitis) - Nyeri perut (41,5%)
- Mual (30,5%)
berdasar anamnesis dan pemeriksaan fisis
Demam (30,5%)
Gejala respiratori (18,6%)

PEMERIKSAAN FISIS
• Kewaspadaan standar & isolasi
kontak (cairan tubuh)
Ada tanda hepatitis akut
• Lanjutkan dengan pemeriksaan
laboratorium untuk:
- Mencari etiologi &
menyingkirkan DD/ yang
Notes: mampu laksana di FKTP
not due to: hepatitis A-E viruses, or an expected presentation of metabolic, - SGOT/SGPT
inherited or genetic, congenital or mechanical cause RUJUK RS
Pemeriksaan di RS
Living algorithm
Terapkan kewaspadaan standar ANAMNESIS
& isolasi pada saat memeriksa
pasien Ikterik (71,2%)
Muntah (62,7%)
Feses pucat (50,0%)
Letargi (50,0%)
RIWAYAT:
- COVID-19
Gejala gastrointestinal:
Anak usia <16 tahun dengan tanda dan gejala - Diare (44,9%)
- Defisiensi imun
hepatitis akut berat (acute, severe hepatitis) - Vaksinasi
- Nyeri perut (41,5%)
berdasar anamnesis dan pemeriksaan fisis - Mual (30,5%)
atau kasus rujukan Demam (30,5%)
Gejala respiratori (18,6%)
MIS-C dan DD/ lainnya

PEMERIKSAAN FISIS
Ada tanda hepatitis akut berat termasuk
penurunan kesadaran atau kejang

PEMERIKSAAN LABORATORIUM IKUTI ALUR IDAI

Notes:
not due to: hepatitis A-E viruses, or an expected SGOT atau SGPT >500 IU/L
presentation of metabolic, inherited or genetic, Bukan Hepatitis A, B, C (D, E)
congenital or mechanical cause
Setting RS:
apabila SGOT atau SGPT >500 IU/L
• Laporkan ke Dinkes
• Buat notifikasi ke Laboratorium untuk acute, severe hepatitis yang belum
diketahui sebabnya
• Notifikasi sisa sampel (seluruh specimen) untuk pemeriksaan lanjutan (termasuk
ke Lab rujukan: Labkesda, BKPK/Litbangkes)
• Laboratorium patologi klinik:
• Simpan sisa sampel untuk pemeriksaan skrining lanjutan
• Mengirim pemeriksaan untuk skrining hepatitis E ke PMI
• Mengirim sampel EDTA, VTM swab nasofaring dan rektal ke laboratorium setempat
• Dan pemeriksaan lain yang memungkinkan
• Jika pasien meninggal dalam waktu cepat lakukan swab postmortem dari
nasofaring dan rektal, serta pemeriksaan seperti di atas
Infection control
• Sampai saat ini mengikuti kewaspadaan standar dan isolasi kontak
• Berbasis penularan oro-fekal atau cairan tubuh (cairan tubuh infeksius)
• Pembuangan popok/cairan tubuh di limbah infeksius
• Perawatan tidak memerlukan ruang bertekanan
• Bukan COVID-19
• Pasien cukup dipisahkan/kohorting
• Nakes menggunakan APD sesuai (gaun, sarung tangan yang diganti antar pasien)
• Pemulasaran jenazah sesuai dengan kewaspadaan isolasi kontak
• Pedoman PPI dapat berubah sesuai dengan perkembangan pengetahuan
berbasis bukti
Masih banyak yang belum
diketahui terkait dengan
acute, severe hepatitis of
unknown origin

Kita menunggu pedoman

dari Kemenkes RI……..

Terima kasih