Comment on “Changes in acute viral hepatitis epidemiology in the Turkish adult population: A multicenter study”

Dear Editor,

In a very interesting multicenter study conducted in Turkey, Karacaer et al. (1) reported on changes in acute viral hepatitis epidemiology in the adult population. The most commonly found microorganisms were hepatitis B virus (55.2%) and hepatitis A virus (HAV) (37.6%), and types of acute viral hepatitis significantly differed according to the age group. Out of 852 patients, majority patients were males, the median age was 31 (range, 17–89) years, and most patients were in the 21–40-year age group. In this group, HAV was more prevalent than among older patients. Potential transmission routes were as follows: consumption of suspicious food (9.3%), contact with contaminated blood and body fluids (6.3%), daily contact with an individual with chronic hepatitis (3.2%), daily contact with an individual with acute viral hepatitis (2.6%), travel history (1.2%), penetrating/perforating injuries (0.8%), suspicious sexual intercourse (0.1%), and recent surgery (0.1%) (1). We would like to highlight the minimal role of suspicious sexual contact in these data in contrast with those in other countries. At a time when the etiology of liver disease is changing in an impressive manner, with a disappearing role of viruses, we are witnessing the comeback of epidemic flares of HAV hepatitis (2). In particular, this has been mainly reported in a population of young male patients having sex with males (MSM). Similar to other European Countries, in Brescia (Northern Italy), an outbreak of hepatitis A was reported from July 2016 to July 2017. Forty-two confirmed cases were recorded: 25 (60%) were MSM and reported sexual contact at risk of sexual transmitted diseases. Compared with 2015 and the first half of 2016, when only three cases of hepatitis A were recorded, in the 12 months in question, the number of cases increased 14-fold (3). Furthermore, the same authors hypothesized that the bisexual attitude of some MSM could explain the increasing number of HAV infected heterosexual woman observed during this outbreak without a clear foodborne exposure (3). Even if it is usually a self-limiting disease and clinical improvement is observed in few weeks, acute hepatitis A could be more serious in some categories of patients, such as the co-infected ones (4). In conclusion, the role of sexual transmission of HAV among MSM and perhaps among bisexuals should be considered with great attention in cases of acute hepatitis.