CAHAN Disease Notification: Acute Non-Viral Hepatitis Potentially Associated with an Alkaline Water Product May 27, 2021 alkaline water, California, California Department of Public Health, CDC, CDPH, Long Beach, Los Angeles, Los Angeles County, Pasadena, Real Water, Southern Nevada Health District 1507 The Southern Nevada Health District (SNHD) has identified 16 probable cases (including one death) and one suspect case of acute non-viral hepatitis in children and adults potentially linked to the consumption of an alkaline water product called “Real Water” since November 2020. The CDC issued a health advisory on the investigation of the first 5 cases in children on March 31, 2021. As of May 26, the California Department of Public Health (CDPH) has been notified of two patients in California with similar illness potentially connected to Real Water alkaline water and is investigating additional possible cases. This CDPH notification summarizes the current situation, provides recommendations for clinicians, and includes details on the clinical course of cases. Clinicians who become aware of cases similar to those described in this notification are asked to report them to the local health department. Los Angeles County DPH Acute Communicable Disease Control: Weekdays 8:30am–5pm: call 213-240-7821 OR call 888-397-3993 For urgent issues after hours: call 213-974-1234 and ask for the physician on call. Long Beach Health and Human Services: Weekdays 8am-5pm: call 562-570-4302. After hours: call the Duty Officer at 562-500-5537 Pasadena Public Health Department: Fax a CMR to 626-744-6115 or call 626-744-6089. An abridged version of the CDPH notification is below. The full CAHAN that includes a final segment with instructions for local health departments is available online. To view this and other communications or to sign-up to receive LAHANs, please visit http://publichealth.lacounty.gov/lahan Health Alert Acute Non-Viral Hepatitis of Unknown Etiology Potentially Associated with an Alkaline Water Product May 26, 2021 Key Messages Since November 2020, 16 probable cases and one suspect case of acute nonviral hepatitis of unknown etiology were reported to the Southern Nevada Health District (SNHD). One of the 16 probable cases resulted in a death. The U.S. Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), and SNHD are investigating a potential link between these illnesses and the consumption of an alkaline water product (Real Water) and other possible etiologies. The California Department of Public Health (CDPH) has been notified of two California patients with similar illness potentially connected to Real Water alkaline water. Clinicians who become aware of cases similar to those described in this alert are asked to report them to their local health department. Local health departments should report new cases or direct any inquiries to toxoutbreak@cdph.ca.gov. Current Situation As of May 20, 2021, the Southern Nevada Health District (SNHD) has identified 16 probable cases (including one death) and one suspect case of acute non-viral hepatitis potentially linked to the consumption of an alkaline water product called “Real Water.” Five cases were initially identified in children from seven months to five years of age who were hospitalized between November 23 and December 3, 2020, with signs and symptoms of acute hepatitis but negative hepatitis viral panel results. SNHD subsequently identified 12 additional cases (11 probable cases and one suspect case that meets the clinical criteria but has not been tested for viral hepatitis) in adults from 32 to 71 years of age who were hospitalized. There has been one death of a female patient in her 60s who had underlying medical conditions. Preliminary epidemiologic investigation has suggested that the only common link between the initial five cases is consumption of Real Water alkaline water. On March 24, 2021, Real Water, Inc. initiated a recall of all Real Water alkaline water. This product is available in 5-gallon, 3-gallon, 1-gallon, 1.5-liter, 1-liter, and 500-ml bottles, and as a 4-oz concentrate. Bottles and concentrate products are available for purchase online and in stores nationwide. The CDC and FDA are assisting the SNHD and other jurisdictions in investigating a potential link between these illnesses and the consumption of Real Water alkaline water or other possible etiologies, and issued a health advisory on March 31. Patients’ signs and symptoms included vomiting, poor intake, and fatigue, and laboratory testing showed elevated hepatic transaminases, hyperbilirubinemia, coagulopathy, and a negative viral hepatitis serology panel. In some cases, adults and other children living in the same household as these patients reported similar but less severe symptoms. The U.S. Food and Drug Administration (FDA) advises consumers, restaurants, and retailers not to drink, cook with, sell, or serve Real Water alkaline water until more information is known about the cause of the illnesses. Further, FDA advises that Real Water not be given to pets. As of May 26, the California Department of Public Health (CDPH) has been notified of two potential illnesses associated with consumption of Real Water alkaline water and is investigating additional potential cases. Real Water alkaline water was distributed in California. Information for Physicians and Hospitals The CDC and CDPH have identified cases of acute non-viral hepatitis of unknown etiology potentially associated with consumption of Real Water alkaline water. While information to date from the preliminary epidemiologic investigation supports that there is a strong link between these cases of acute non-viral hepatitis and consumption of Real Water alkaline water, other etiologies are being evaluated. Action Items for Physicians: Have a high index of suspicion for non-viral hepatitis in your differential diagnosis of acute hepatitis in adults and children with compatible clinical findings. Ask patients with suspected acute non-viral hepatitis about their exposure to Real Water alkaline water, as well as dietary and herbal supplements, and other possible etiologies. - Possible etiologies associated with acute non-viral hepatitis include exposure to medications, contaminated water or food, dietary and herbal supplements, traditional or home remedies, wild-growing mushrooms and plants, and chemicals such as metals, solvents, paint thinners, or pesticides. Report all suspected cases to your local health department within 24 hours. An official from your local health department may interview the patient or family members, if appropriate. Counsel your patients (or their caregivers and guardians) to stop drinking, cooking with, or using Real Water alkaline water until more is known about the cause of the illnesses per FDA recommendations. Educate your patients on the signs and symptoms of acute hepatitis due to any cause, which may include fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, light-colored stools, joint pain, and yellow skin or eyes; and the importance of seeking medical care if they develop these symptoms. Clinical Information on Acute Non-Viral Hepatitis of Unknown Etiology Potentially Associated with an Alkaline Water Product Clinical course The 17 patients identified by the SNHD (5 children aged 7 months to 5 years and 12 adults aged 32 to 71 years) presented for care with signs and symptoms of acute hepatitis. All five children and 11 adults tested negative for viral hepatitis and other infectious causes of acute hepatitis, and one adult has not been tested for viral hepatitis. One adult patient died; the other 16 patients ultimately recovered and were discharged home. All patients had been consuming Real Water alkaline water, and most continued to consume Real Water until hospitalization. Symptoms Commonly reported symptoms include: Vomiting Poor intake Fatigue Laboratory findings Elevated hepatic transaminases Hyperbilirubinemia Coagulopathy Negative viral hepatitis serology panel Diagnosis Acute Non-Viral Hepatitis of Unknown Etiology Potentially Associated with an Alkaline Water Product is a clinical diagnosis of exclusion when infectious disease, chronic hepatic injury or illness, acetaminophen toxicity, sepsis, hypotensive shock, or other processes cannot explain the hepatitis in a patient that consumed Real Water alkaline water. Treatment Guidelines for treatment of Acute Non-Viral Hepatitis of Unknown Etiology Potentially Associated with an Alkaline Water Product are not yet available. The CDC recommends clinicians obtain early consultation with and/or referral to a gastroenterologist or infectious disease specialist for medical workup and management of patients with signs and symptoms of acute hepatitis. To read the information for local health departments view the full notification posted online. To view a printable PDF of this communication and other LAHAN communications, please visit publichealth.lacounty.gov/lahan. If this message was forwarded to you, please join LAHAN here.