Investigation of Acute Non-Viral Hepatitis of Unknown Etiology Potentially Associated with an Alkaline Water Product

CDC, along with the U.S. Food and Drug Administration (FDA)external icon, the Nevada Department of Health and Human Servicesexternal icon, and the Southern Nevada Health Districtexternal icon, is investigating cases of acute non-viral hepatitis in Nevada and surrounding states with an unknown cause. Acute non-viral hepatitis is inflammation of the liver that occurs suddenly and can lead to liver failure.

Investigation Overview

On March 31, 2021 CDC issued a Health Alert Network Advisory to encourage clinicians and health departments to have a high index of suspicion for cases of acute non-viral hepatitis and to report any cases to their local health authority.

CDC and the FDA were notified of five cases of acute non-viral hepatitis of unknown etiology (unknown cause) in children by the Southern Nevada Health District (SNHD) in Nevada on March 13, 2021. CDC is assisting SNHD in investigating a potential link between acute non-viral hepatitis and the consumption of an alkaline water product called “Real Water” and other possible etiologies (causes). For the latest case count and investigation findings, please visit the SNHD websiteexternal icon.

The FDA advisesexternal icon 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. Real Water has issued a recall on their products.

Although the investigation is ongoing, information to date from the preliminary epidemiologic investigation supports that there is a strong link between these cases of acute non-viral hepatitis and Real Water alkaline water.

What is acute non-viral hepatitis?

Acute non-viral hepatitis is inflammation of the liver that occurs suddenly and can lead to liver failure. It can be caused by exposure to some medications, drugs, alcohol, and toxins. It can also be caused by autoimmune disease. Other possible causes of non-viral hepatitis include 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.

What are the symptoms of acute non-viral hepatitis?

Although hepatitis can have many causes, symptoms are often the same. Symptoms of hepatitis can include

What are the symptoms of acute non-viral hepatitis?
  • Fever
  • Abdominal pain
  • Fatigue
  • Dark urine
  • Loss of appetite
  • Light-colored stools
  • Nausea
  • Joint pain
  • Vomiting
  • Yellow skin or eyes

If you are currently experiencing these symptoms or have other symptoms that concern you, contact your healthcare provider to report your symptoms and receive care.

What is alkaline water?

The pH level is used to describe how acidic or alkaline a substance is on a scale of 0-14. Alkaline drinking water often contains additives which increase the pH. Something is defined as alkaline if it has a pH higher than 7.

Information for consumers

  • Stop drinking, cooking with, or using Real Water until more is known about the cause of the illnesses per FDA recommendationsexternal icon. FDA also advises that this water shouldn’t be given to pets.
  • Contact your healthcare provider if you are experiencing symptoms of acute non-viral hepatitis, such as fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-colored stools, joint pain, or yellow skin or eyes.

Information for clinicians

  • Counsel your patients (or their caregivers and guardians) to stop drinking, cooking with, or using Real Water until more is known about the cause of the illnesses per FDA recommendationsexternal icon.
  • Educate your patients on the signs and symptoms of acute hepatitis due to any cause, which may include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-colored stools, joint pain, or yellow skin or eyes. Also talk to your patients about the importance of seeking medical care.
  • Maintain a high index of suspicion for non-viral hepatitis in your differential diagnosis of acute hepatitis in adults and children presenting with compatible clinical findings.
  • Obtain a more detailed exposure history in patients when you suspect acute non-viral hepatitis. 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.
  • 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.
  • Contact your local health authority to report cases of acute non-viral hepatitis of unknown etiology.
  • Contact your local poison center (1-800-222-1222) for information on chemical or drug-induced liver toxicity and report any cases.

Information for public health professionals

  • Contact CDC via email (NCEHOutbreak@cdc.gov) for case classification criteria, suggested reporting guidelines, case investigation forms, and other questions. Acute non-viral hepatitis is currently not a nationally notifiable disease. Case findings may be mainly from clinicians reporting who may recognize these illnesses in their patients. The forms provided by CDC will help prepare public health agencies to receive these reports from clinicians.
  • Consider conducting case-finding activities that leverage existing data sources such as hospital discharge data, electronic syndromic surveillance systems, your local poison center, and other applicable surveillance systems. Contact CDC at NCEHOutbreak@cdc.gov for guidance on search criteria.
Page last reviewed: April 30, 2021