Top 5 Takeaways

1. Cluster of Cases: Five children in Clark County, Nevada, were hospitalized with acute liver failure after consuming “Re2al Alkalized Water.”
2. Broader Impact: Eighteen probable and four suspected cases were identified in Nevada, and three probable cases in California.
3. Symptoms and Severity: Common symptoms included fatigue, vomiting, and decreased appetite. All probable cases required hospitalization, with 86% needing intensive care.
4. Product Recall: Real Water, Inc. initiated a voluntary recall of all products on March 17, 2021, and ceased operations on June 1, 2021.
5. Surveillance Challenges: The lack of an established surveillance system for hepatitis of unknown etiology (HUE) complicates case identification and reporting.

Original Article Author and Citation

Corresponding Author

Jeanne C. Ruff, qdw5@cdc.gov

Suggested Citation

Ruff JC, Zhang Y, Bui DP, et al. Notes from the Field: Acute Nonviral Hepatitis Linked to a Brand of Alkaline Bottled Water — Clark County, Nevada and California, 2020. MMWR Morb Mortal Wkly Rep 2021;70:1617–1619. DOI: http://dx.doi.org/10.15585/mmwr.mm7046a6

Summary

During November 2020, five children in Clark County, Nevada, were hospitalized with acute liver failure after consuming “Re2al Alkalized Water.” Further investigation identified 21 probable and four suspected cases of nonviral hepatitis linked to the same brand of bottled water across Nevada and California. Symptoms included fatigue, vomiting, and decreased appetite, with all probable cases requiring hospitalization. A voluntary recall of the product was initiated, and the company ceased operations in June 2021.

Methods

The investigation involved reviewing medical records, interviewing patients, and identifying cases through self-report and clinician report. Probable cases were defined by new onset hepatitis of unknown etiology with symptom onset after August 1, 2020, following Re2al Water consumption within 30 days before illness onset, negative viral hepatitis panel, and no other identified cause.

Discussion

The investigation highlighted the potential for toxic exposure from alkaline water, a product not previously associated with hepatotoxicity. The lack of a specific causative agent and an established surveillance system for HUE posed challenges. The recall and cessation of operations by Real Water, Inc. aimed to mitigate further public health risks.

Conclusion

This outbreak underscores the importance of reporting unusual illnesses to public health authorities and the need for better surveillance systems for identifying and managing cases of hepatitis of unknown etiology.

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