Revisiting the overlooked role of recycled sewage water in high-income countries in adenoviral outbreaks such as the “2022 pediatric hepatitis’ outbreak”

BACKGROUND: On the 5th of April 2022, cases of adenovirus-induced hepatitis were reported in Scotland and then reached multiple parts of the world. While adenovirus normally presents with diarrhea, vomiting, and fever, these novel cases also resulted in the development of fulminant hepatitis in non-immunocompromised cases. MAIN BODY: The responsible pathogen “Adenovirus 41” is an enterovirus. Enteroviruses are spread by the fecal-oral route and are resistant to drying. As such, they predominate in sewage water. Hepatitis is normally restricted to poorer countries, yet this new wave seems to be confined to mostly high-income countries in Europe and the USA. These countries treat and recycle a higher percentage of sewage water. We also propose that the fulminant nature of this strain could be due to either a cross-species mutation or the general decrease in trained immunity post-COVID-19 lockdown. SHORT CONCLUSION: Evidence strongly suggests that the link between these new hepatitis cases is recycled sewage water. This should warrant further investigations on the origin of this outbreak by re-visiting the role of recycled sewage water in causing such outbreak.