Instructions for Adenovirus Diagnostic Testing, Typing, and Submission

Children with Acute Hepatitis of Unknown Etiology

A standard diagnostic workup for children with acute hepatitis should be done locally per treating clinicians.

Specimen Types Involved in This Investigation

CDC recommends including adenovirus testing in children with acute hepatitis of unknown etiology.

Because the potential relationship between adenovirus and acute hepatitis is still under a national epidemiologic investigation, consider collection and submission of the following specimen types (if available) for adenovirus detection.

  • Blood specimen collected in purple top EDTA tube (whole blood, plasma) or serum; whole blood is preferred to plasma
  • Respiratory specimen (nasopharyngeal swab in VTM/UTM, sputum, or bronchioalveolar lavage [BAL])
  • Stool specimen (or rectal swab in VTM/UTM); whenever possible, a stool specimen is preferred to a rectal swab
  • If a liver biopsy has already been performed as clinically indicated, or from native liver explant or autopsy:
    • Formalin-fixed, paraffin embedded (FFPE) liver tissue
    • Fresh liver tissue, frozen on dry ice or liquid nitrogen immediately or as soon as possible, and stored at ≤ -70°C

Nucleic acid amplification testing (NAAT, e.g. PCR) is preferred for adenovirus detection. Testing whole blood by PCR may be more sensitive than testing plasma by PCR and is preferred.

Instructions for Diagnostic Adenovirus Testing of Clinical Specimens
Local/Clinical Laboratories
  • Any clinical specimens that can be tested locally, should be, to ensure the most timely results for patient care.
    • Volume permitting, prepare one aliquot for diagnostic testing and one aliquot for adenovirus typing.
      • Aliquot for the diagnostic test and store the specimens at an appropriate temperature according to the instructions in the applicable test order
      • Aliquot for adenovirus typing (minimum volume = 0.5 mL) and store frozen (use ≤ -70°C if available)
    • Any residual clinical specimens or aliquots that were positive or negative for adenovirus and collected from pediatric cases with acute hepatitis should be kept frozen (use ≤ -70°C if available) and submitted to your SPHL.
  • For any diagnostic testing needs beyond the local capacity, we recommend contacting your state public health laboratory (SPHL) to determine if direct submission to reference laboratories or the SPHL is preferred. 
  • Reference laboratory submission: Adenovirus PCR testing capacity for whole blood is less common than testing of respiratory or stool specimens and may require submission to a reference laboratory.
    • Reference Laboratories confirmed to do whole blood (in EDTA) adenovirus PCR include ARUP Laboratories and Quest Diagnostics.
      • Specimens should be packaged in compliance with IATA regulations for submission of diagnostic samples.
      • Transport and ship at 2-8°C (with frozen cold packs).
      • DO NOT freeze the whole blood for diagnostic PCR testing.
  • SPHL Submission: Any clinical specimens that need additional diagnostic testing, should be submitted to your State Public Health Laboratory. Specimens must also include two primary patient identifiers on the specimen container, in compliance with CLIA regulations, in case additional diagnostic tests are needed. Acceptable primary patient identifiers include:
    • Full patient name (First and last name)
    • Date of birth
    • A unique ID from the time of specimen collection (secondary unique identifiers do not qualify, such as a state public health lab ID)
  • After diagnostic testing has been completed, all residual clinical specimens or specimen aliquots from Persons Under Investigation (PUIs) should be frozen (use ≤ -70°C if available) and submitted to your SPHL, regardless of whether they were positive or negative for adenovirus.
State Public Health Laboratories (SPHLs)
  • Most specimens received by the SPHL should have been tested locally; diagnostic testing by the SPHL will only be required for a subset of specimens where local/reference lab testing was not available.
  • For specimens requiring testing at the SPHL, volume permitting, prepare one aliquot for diagnostic testing and one aliquot for adenovirus typing.
    • Aliquot for the diagnostic test according to the instructions in the applicable test order
    • Aliquot for adenovirus typing (minimum volume = 0.5 mL) and store frozen (use ≤ -70°C if available).
  • If a whole blood adenovirus PCR test is not available at your laboratory, please submit to a reference laboratory (instructions for ARUP Laboratories and Quest submissions are described above).
  • If your laboratory does not have an account set up for ARUP Laboratories or Quest Diagnostics or if you receive a specimen type for diagnostic testing but don’t have a test available, please notify ncirddvdgast@cdc.gov, respvirus@cdc.gov, and infectious.diseases@aphl.org to help coordinate the diagnostic testing.
  • After diagnostic testing has been completed, all residual clinical specimens or specimen aliquots from Persons Under Investigation (PUIs) should be frozen (use ≤ -70°C if available) and submitted to CDC, regardless of whether they were positive or negative for adenovirus (detailed instructions for these submissions are listed in the next section).
Instructions for Submission of all Residual Clinical Specimens from Persons Under Investigation (PUIs) for Additional Characterization

All submissions MUST be shipped through a SPHL. Adenovirus-positive specimens will undergo adenovirus typing.

Adenovirus typing is a surveillance-use only test. Results will be reported back to the SPHL only.

Local/Clinical Laboratories
  • DO NOT SUBMIT SPECIMENS DIRECTLY TO CDC. THESE MUST BE SHIPPED THROUGH THE STATE PUBLIC HEALTH LABORATORY.
  • Any residual clinical specimens or aliquots that were collected from pediatric cases with acute hepatitis, regardless of the adenovirus testing results, should be stored frozen (use ≤ -70° if available); adenovirus-positive specimens will undergo adenovirus typing.
  • Submit specimens on dry ice to your state public health laboratory, including any local test results and a notification that these specimens are associated with the “Adenovirus/Hepatitis Investigation in Children.”
State Public Health Laboratories (SPHL)
  • Clinical laboratories are being requested to send all residual clinical specimens or specimen aliquots from PUIs to SPHLs to be sent to CDC for further characterization, regardless of the adenovirus testing result.
    • Adenovirus-positive specimens will undergo adenovirus typing.
  • All specimens should be kept frozen (≤ -70°C) upon receipt.
    • The majority of adenovirus positive specimens will be identified locally; only a subset of diagnostic testing will be facilitated by the SPHL.
  • Notify your State Epidemiologist POC, state laboratory POC, and CDC (ncirddvdgast@cdc.gov and respvirus@cdc.gov) when you have specimens available from PUIs associated with this investigation.
    • CDC will provide detailed shipping instructions once notified.
    • Make sure to denote the diagnostic test results for adenovirus of each specimen, to ensure that adenovirus-positive specimens are properly identified for typing.
    • Ship to CDC on dry ice Mondays-Thursdays.
    • Once received by CDC, typing results will be reported back to the SPHL within 2 weeks for any specimens submitted as adenovirus-positive.
  • Shipments should NOT be sent until pre-approval is received from CDC.

ATTN: STAT LAB
C/O UNIT 84
RESPIRATORY VIRUSES DIAGNOSTIC LABORATORY/DVD
CENTERS FOR DISEASE CONTROL AND PREVENTION
1600 CLIFTON ROAD, NE
ATLANTA, GEORGIA, 30329

Instructions for Submission of Virus Isolates
  • If any virus isolates are received or obtained through the culturing of clinical specimens related to the pediatric hepatitis cases, please notify CDC (ncirddvdgast@cdc.gov and respvirus@cdc.gov) for submission and additional characterization.
Instructions for Submission of Fixed Tissues for Pathology Testing
Local/Clinical Laboratories

Fixed liver tissue samples (liver biopsy, explants, or autopsy) will receive routine histopathological examination and may be tested by immunohistochemistry for adenovirus and other pathogens at the clinical institution. When these samples are collected as clinically indicated, formalin-fixed, paraffin-embedded (FFPE) liver tissue can be submitted to CDC’s Infectious Diseases Pathology Branch (IDPB) for additional pathologic characterization and infectious disease testing.

Notify your state public health department and pathology@cdc.gov regarding potential submissions; all submissions will require pre-approval. Do not send specimens to CDC’s IDPB until pre-approval and submission instructions are provided by pathology@cdc.gov.

Fixed liver tissue from patients who meet the following criteria can be submitted to CDC’s IDPB:​

  • Pediatric patients with hepatitis of unknown etiology meeting the current case definition​

AND, for which​

  • Formalin-fixed, paraffin embedded liver tissue specimens are available that a) demonstrate histopathologic evidence of hepatitis AND b) have been submerged in formalin for ≤ 2 weeks prior to embedding in paraffin. ​
State Public Health Laboratories (SPHL)
  • CDC’s IDPB can receive fixed liver tissues samples for additional pathologic characterization and infectious disease testing.
  • Acceptable sample criteria: formalin-fixed, paraffin embedded liver tissue specimen that demonstrate histopathologic evidence of hepatitis and have been submerged in formalin for ≤2 weeks prior to embedding in paraffin AND from pediatric patients with hepatitis of unknown etiology meeting the current outbreak case definition.
  • Please contact CDC Pathology (pathology@cdc.gov) upon receiving tissue specimen for pre-approval and specific submission instructions. Do not send specimens until pre-approval is provided by pathology@cdc.gov.
Page last reviewed: May 24, 2022