The Centers for Disease Control and Prevention is getting involved and investigating after 109 children have become infected with cases of severe hepatitis and five of those children died from the illness.

According to CNBC, the CDC is trying to determine a cause for the outbreak, with a primary focus on adenovirus infection after more than half of the infected children had a confirmed adenovirus infection. Of the cases, more than 90% of the children were hospitalized and 14% required liver transplants.

A nationwide health alert was issued in late April after a cluster of cases occurred among nine children in Alabama, though cases have also since surfaced in Arizona, California, Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Louisiana, Michigan, Minnesota, Missouri, North Carolina, North Dakota, Nebraska, New York, Ohio, Pennsylvania, Puerto Rico, Tennessee, Texas, Washington and Wisconsin. The World Health Organization is also monitoring the situation after cases were also identified in 11 additional countries.

No immediate cause has been determined, though COVID-19 vaccination is not linked to the outbreak, as the median age of the children was two years, meaning most were not eligible to receive their vaccines. It is also unknown if adenovirus is the actual cause as well, as it has only been confirmed in half the cases thus far and is not known to cause severe hepatitis in otherwise healthy children.

“We also don’t know yet what role other factors may play, such as environmental exposures, medications, or other infections that the children might have,’ Dr. Jay Butler, the deputy director for infectious diseases at the CDC, told CNBC.

Parents concerned about their children should look for symptoms including vomiting, dark urine, light-colored stool and yellowing of the skin.

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