UKK Infeksi & Penyakit Tropis IDAI

Acute, severe hepatitis

of unknown origin in children

Anggraini Alam
 On 2 May 2022 Indonesia’s MOH, reported that
3 children died of acute hepatitis during April
WHO 2022.[19][clarification needed]
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
 Working hypotheses: acute, severe hepatitis of unknown origin in children
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
 Investigasi
Acute, severe hepatitis of unknown origin
All cases are being followed up for outcome at 28 days after presentation to health services

Possible exposure Enhanced surveillance

KARAKTERISTIK PEJAMU

INVESTIGASI PATOGEN
EPIDEMIOLOGI

SURVEILANS

MEKANISME INJURI HATI

for severe acute Usia
Mencari kasus infeksi
hepatitis in children
Pemeriksaan biopsi Mencari etiologi
yang sedang hati Status imunologi
meningkat di wilayah Not due to: Menyingkirkan
Pemeriksaan Terapi
tsb hepatitis A-E viruses,
imunosupresan DD/
or an expected patologi anatomi
Imunisasi yang telah Mencari
didapat pasien presentation of Pemeriksaan Pasca-
metabolic, inherited imunohistopatologi transplantasi kemungkinan
Pola or genetic, congenital koinfeksi
makanan/minuman or mechanical cause*
Genetik?

European CDC
UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022, dengan modifikasi
European CDC

Cases of hepatitis with known aetiology such those due to:

• Specific infectious diseases
• Drug toxicity
• Metabolic hereditary
• Autoimmune disorders

Should not be reported under this protocol

Patogen infeksi yang menyebabkan hepatitis non A - E
UKHSA publication gateway number GOV-12170. Technical briefing 2, 6 May 2022
Normal adenovirus
• Abnormal susceptibility or host response which allows adenovirus infection to progress
more frequently to hepatitis (whether direct or immunopathological), for example from
lack of exposure during the coronavirus (COVID-19) pandemic.
• An exceptionally large wave of normal adenovirus infections, causing a very rare or
under-recognised complication to present more frequently.
• Abnormal susceptibility or host response to adenovirus due to a toxin, drug or
environmental exposure.
• Abnormal susceptibility or host response to adenovirus due to priming by a prior
infection with SARS-CoV-2 (including Omicron restricted) or another infection.
• Abnormal susceptibility or host response to adenovirus due to a coinfection with SARS-
CoV-2 or another infection.
Outcome status for UK cases (n=163), 3 May 2022

11 kasus dilakukan transplantasi hati à survived

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

Alur pemeriksaan kasus
Living guideline
(masih dalam pembahasan di Komli PISP 10 Mei 2022)
European CDC

Cases of hepatitis with known aetiology such those due to:

• Specific infectious diseases
• Drug toxicity
• Metabolic hereditary
• Autoimmune disorders

Should not be reported under this protocol

Pemeriksaan di Klinik atau FKTP
Living guideline

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
Anak usia <16 tahun dengan tanda dan gejala Gejala gastrointestinal: - Defisiensi imun
- Diare (44,9%) - Vaksinasi
hepatitis akut (acute, hepatitis) berdasar - Nyeri perut (41,5%)
anamnesis dan pemeriksaan fisis - Mual (30,5%)

Demam (30,5%)
Gejala respiratori (18,6%)

PEMERIKSAAN FISIS
tanda hepatitis akut

Notes:
not due to: hepatitis A-E viruses, or an expected
presentation of metabolic, inherited or genetic,
congenital or mechanical cause
Pada saat ini WHO menggunakan batasan usia 16 tahun
karena berdasarkan temuan epidemiologi kasus

(50,0%)

(30,5%)
(62,7%)
(44,9%)
(41,5%)
(30,5%)
(71,2%)
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
Pencegahan
Take home message
• Acute, severe hepatitis of unknown origin: ???
• Definisi
• Inkubasi – onset – sampai menjadi severe
• transmisi
• Etiologi
• Tata laksana
• Tambahan masalah di Indonesia: penjaminan/pembayaran
• Pencegahan lebih baik
• Penting menjaga komunikasi ke masyarakat dan dokter agar tidak menjadi
suatu keresahan
Terima kasih