Prevalence of Helicobacter pylori Infection in Asia: Remembrance of Things Past?

Prevalence of Helicobacter pylori Infection and Efficacy of Bismuth Quadruple and Levofloxacin Triple Eradication Therapies: A Retrospective Analysis

Helicobacter pylori (H. pylori) infection is a widespread global health issue and a primary cause of diseases like gastritis, gastroduodenal ulcers, and gastric cancer. This study examines the prevalence of H. pylori infection in patients undergoing upper endoscopy and assesses the efficacy of bismuth quadruple therapy (BQT) and levofloxacin triple therapy. A retrospective analysis of 507 gastroscopies was conducted, with indications including epigastric pain, heartburn, postprandial fullness, early satiation, and regurgitation. Rapid urease tests were performed, and endoscopic findings documented. Two treatment regimens were used: BQT as the first-line therapy and levofloxacin triple therapy as the second-line. Of the 507 patients, 68.8% were infected with H. pylori. Gastric ulcer patients had significantly higher H. pylori prevalence compared to those with small polyps, Barrett's esophagus, or normal endoscopy. Among the 310 patients who participated in follow-up interviews, 11.9% did not initiate therapy and 5.1% discontinued due to intolerance. The overall eradication rate was 88.6%, with BQT showing a higher eradication rate (89.4%) compared to levofloxacin triple therapy (83.8%). The study highlights the high prevalence of H. pylori among patients with gastrointestinal symptoms and the effectiveness of BQT as a first-line treatment.

Global Prevalence of Helicobacter pylori Infection and Incidence of Gastric Cancer Between 1980 and 2022

BACKGROUND & AIMS

We aimed to assess the secular trend of the global prevalence of Helicobacter pylori (H pylori) infection in adults and children/adolescents and to show its relation to that of gastric cancer incidence.

METHODS

We performed a systematic review and meta-analysis to calculate overall prevalence, adjusted by multivariate meta-regression analysis. The incidence rates of gastric cancer were derived from the Global Burden of Disease Study and Cancer Incidence in Five Continents.

RESULTS

Of the 16,976 articles screened, 1748 articles from 111 countries were eligible for analysis. The crude global prevalence of H pylori has reduced from 52.6% (95% confidence interval [CI], 49.6%-55.6%) before 1990 to 43.9% (95% CI, 42.3%-45.5%) in adults during 2015 through 2022, but was as still as high as 35.1% (95% CI, 30.5%-40.1%) in children and adolescents during 2015 through 2022. Secular trend and multivariate regression analyses showed that the global prevalence of H pylori has declined by 15.9% (95% CI, -20.5% to -11.3%) over the last 3 decades in adults, but not in children and adolescents. Significant reduction of H pylori prevalence was observed in adults in the Western Pacific, Southeast Asian, and African regions. However, H pylori prevalence was not significantly reduced in children and adolescents in any World Health Organization regions. The incidence of gastric cancer has decreased globally and in various countries where the prevalence of H pylori infection has declined.

CONCLUSIONS

The global prevalence of H pylori infection has declined during the last 3 decades in adults, but not in children and adolescents. The results raised the hypothesis that the public health drive to reduce the prevalence of H pylori as a strategy to reduce the incidence of gastric cancer in the population should be confirmed in large-scale clinical trials.

Gastric Intestinal Metaplasia: Real Culprit or Innocent Bystander as a Precancerous Condition for Gastric Cancer?

Gastric intestinal metaplasia (GIM), which denotes conversion of gastric mucosa into an intestinal phenotype, can occur in all regions of the stomach, including cardiac, fundic, and pyloric mucosa. Since the earliest description of GIM, its association with gastric cancer of the differentiated (intestinal) type has been a well-recognized concern. Many epidemiologic studies have confirmed GIM to be significantly associated with subsequent gastric cancer development. Helicobacter pylori, the principal etiologic factor for gastric cancer, plays the most important role in predisposing to GIM. Although the role of GIM in the stepwise progression model of gastric carcinogenesis (the so-called "Correa cascade") has come into question recently, we review the scientific evidence that strongly supports this long-standing model and propose a new progression model that builds on the Correa cascade. Eradication of H pylori is the most important method for preventing gastric cancer globally, but the effect of eradication on established GIM, is limited, if any. Endoscopic surveillance for GIM may, therefore, be necessary, especially when there is extensive corpus GIM. Recent advances in image-enhanced endoscopy with integrated artificial intelligence have facilitated the identification of GIM and neoplastic lesions, which will impact preventive strategies in the near future.

Gastric troubles in Iran: The role of social and economic factors in Helicobacter pylori infection

BACKGROUND

Helicobacter pylori infection is a major risk factor for gastric cancer in Iran, but the impact of socioeconomic factors on its prevalence is poorly understood. This study aimed to assess the socioeconomic inequalities and risk factors associated with H. pylori infection in Iran.

METHODS

This cross-sectional study was conducted based on the PERSIAN cohort study. A total of 20460 individuals aged 35 to 70 years in Ardabil, Iran were included in the study. H. pylori infection was determined based on stool tests and clinical records. Multilevel logistic regression models with random intercepts at household and community levels were used to identify risk factors associated with H. pylori prevalence. The concentration index (CIn) and concentration curve (CC) were employed to assess socioeconomic-related inequality.

RESULTS

In this study, 70.4% (CI 69.6-71.0) of the participants were infected with H. pylori, with a higher prevalence in women (71.2%) than men (69.6%). Age (OR: 1.37, CI: 1.17-1.61), sex (OR: 1.20, CI: 1.12-1.28), level of education (OR: 1.33, CI: 1.17-1.49), cardiac disease (OR: 1.32, CI:1.18-1.46), and BMI groups (OR: 2.49, CI: 1.11-5.58) were significantly associated with H. pylori infection based on the multivariable logistic regression. The results of the CIn and CC indicated that H. pylori were more prevalent among economically disadvantaged groups (CIn: -0.1065; [-0.1374 to -0.0755]).

CONCLUSION

The prevalence of H. pylori in Iran is higher than in other developing countries, and significant socioeconomic inequality exists between the poor and the rich. To reduce the rate of gastric cancer, socio-economic and demographic factors, especially the poor and people with low levels of education, should be considered.

Real-world outcomes associated with vonoprazan-based versus proton pump inhibitor-based therapy for Helicobacter pylori infection in Japan

Background

Japanese guidelines recommend triple therapy with vonoprazan or a proton pump inhibitor (PPI) in combination with antibiotics to treat Helicobacter pylori (H. pylori) infection. While studies have shown improved eradication rates and reduced costs with vonoprazan versus PPIs, there is little data describing healthcare resource use (HCRU) and treatment patterns.

Objectives

To compare patients treated with a vonoprazan-based or PPI-based regimen for H. pylori infection in Japan in terms of their characteristics, HCRU, healthcare costs, clinical outcomes, and treatment patterns.

Design

Retrospective matched cohort.

Methods

We used data from the Japan Medical Data Center claims database (July 2014-January 2020) to identify adult patients with H. pylori infection and a first observed use of vonoprazan or a PPI in 2015 or later (index date). Patients prescribed a vonoprazan-based or a PPI-based regimen were matched 1:1 using propensity score matching. HCRU, healthcare costs, diagnostic tests, a proxy for H. pylori eradication (i.e. no triple therapy with amoxicillin in combination with metronidazole or clarithromycin >30 days after the index date), and second-line treatment were described during the 12-month follow-up period.

Results

Among 25,389 matched pairs, vonoprazan-treated patients had fewer all-cause and H. pylori-related inpatient stays and outpatient visits than PPI-treated patients, resulting in lower all-cause healthcare costs [185,378 Japanese yen (JPY) versus 230,876 JPY, p < 0.001]. Over 80% of patients received a post-treatment test for H. pylori. Fewer vonoprazan-treated than PPI-treated patients subsequently received an additional triple regimen for H. pylori infection (7.1% versus 20.0%, p < 0.001) or a prescription for vonoprazan or a PPI as monotherapy (12.4% versus 26.4%, p < 0.001) between 31 days and 12 months after the index date.

Conclusion

Patients with H. pylori infection who were treated with vonoprazan-based therapy had lower rates of subsequent H. pylori treatment, lower overall and H. pylori-related HCRU, and lower healthcare costs than patients treated with PPI-based therapy.

Mechanism underlying Polygonum capitatum effect on Helicobacter pylori-associated gastritis based on network pharmacology

Helicobacter pylori (H. pylori) infection is a common disease that can cause H. pylori-associated gastritis (HAG), peptic ulcers, and gastric cancer. As a traditional Chinese medicine, Polygonum capitatum (PC) manifests its unique advantages in the prevention and treatment of complex diseases and chronic diseases, due to its ability to clear heat, detoxify and relieve pain, promote blood circulation, and remove blood stasis. In order to explore the molecular mechanism of PC for HAG, the study collected the predicted targets of active compounds, conducted functional analysis by the STRING database, collected HAG differential expression genes, and conducted KEGG enrichment analysis on the intersection of predicted targets and differential expression genes of gastritis by Cluego. The results show that PC works mainly by affecting phosphorylation of IκBα, NF-κB p65, p38MAPK, and ERK1/2 and nuclear transposition of NF-κB p65 and p-p38MAPK, which has been proved by in vivo and in vitro experiments. These results suggest that PC may act on HAG with multiple targets and pathways, and play a key role in the process of HAG treatment.

Global Patterns and Trends in Gastric Cancer Incidence Rates (1988-2012) and Predictions to 2030

BACKGROUND & AIMS

The long-term trend in gastric cancer rates has rarely been reported from a global perspective. We aimed to explore the past temporal trends (1988-2012) in gastric cancer incidence rates in 43 countries and to predict future trends (2012-2030).

METHODS

Data on yearly gastric cancer incidence by age group and sex were drawn from 108 cancer registries in 43 countries in the Cancer Incidence in Five Continents Time Trends (CI5plus) database. Age-standardized incidence rates per 100,000 persons were computed from 1988-2012. The number of new cases and incidence rates were predicted to 2030 using the Bayesian age-period-cohort model.

RESULTS

Persistent decreasing trends in gastric cancer incidence rates were observed from 1988-2012 worldwide, with an overall average annual percentage change of -2.1% (95% confidence interval, -2.5--1.7). The trends will continue or remain stable until 2030 in most of the selected countries except for Ecuador and Lithuania, whose gastric cancer incidence rates will experience substantially increasing trends in the next several decades.

CONCLUSION

The incidence rates of gastric cancer are expected to decrease through 2030 in most countries except Ecuador and Lithuania. Reductions in smoking and Helicobacter pylori prevalence and improvement in diet probably contributed to the decrease. Gastric cancer still represents a major cancer burden worldwide, and the large number of gastric cancer cases worldwide may still call for lifestyle interventions in terms of smoking and diet and massive efforts for H pylori screening and treatment, especially in countries with predicted increasing incidence rates of gastric cancer.

Cost Analysis in Helicobacter pylori Eradication Therapy Based on a Database of Health Insurance Claims in Japan

Objective

Cost-benefit is an important consideration for Helicobacter pylori (H. pylori) eradication in Japan, where 1.5 million patients were reported to receive first-line eradication annually. This study aimed to identify the optimal cost-saving triple therapy regimen for H. pylori eradication in Japan.

Materials and Methods

This retrospective observational study used data from a large-scale, nationwide health insurance claims database (2015‒2018). Using success rates of first-line eradication, mean total costs of first-line and second-line eradications per patient were compared between regimens including a potassium-competitive acid blocker (P-CAB) or a proton pump inhibitor (PPI), and between two clarithromycin (CAM) doses (400 and 800 mg/day). Subgroup analyses by smoking habit or body mass index (BMI) were performed.

Results

Among propensity score (age, gender, CAM dose, disease name)-matched patients (P-CAB regimen, n=22,002; PPI regimen, n=22,002), total costs were lower with the P-CAB than the PPI regimen (Japanese yen [JPY] 12,952 vs 13,146) owing to significantly higher first-line eradication rates with the P-CAB regimen (93.6% vs 79.7%; p<0.001). For both regimens, even among current smokers or patients with BMI ≥25 kg/m², eradication rates did not differ by CAM dose, and total costs were approximately JPY1000 lower with CAM 400 mg/day than with CAM 800 mg/day.

Conclusion

High success rate of first-line eradication contributes to saving in total eradication costs by reducing costs of subsequent therapy, irrespective of patients' smoking status or BMI class. The combination of more potent acid-inhibitory medicine and low-dose CAM may be the optimal regimen in terms of efficacy and cost-benefit in Japan.

Endoscopy for Gastric Cancer Screening Is Cost Effective for Asian Americans in the United States

BACKGROUND & AIMS

Endoscopic screening for gastric cancer is routine in some countries with high incidence and is associated with reduced gastric cancer-related mortality. Immigrants from countries of high incidence to low incidence of gastric cancer retain their elevated risk, but no screening recommendations have been made for these groups in the United States. We aimed to determine the cost effectiveness of different endoscopic screening strategies for noncardia gastric cancer, compared with no screening, among Chinese, Filipino, Southeast Asian, Vietnamese, Korean, and Japanese Americans.

METHODS

We generated a decision-analytic Markov model to simulate a cohort of asymptomatic 50-year-old Asian Americans. The cost effectiveness of 2 distinct strategies for endoscopic gastric cancer screening was compared with no screening for each group, stratified by sex. Outcome measures were reported in incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). Extensive sensitivity analyses were performed.

RESULTS

Compared with performing no endoscopic gastric cancer screening, performing a 1-time upper endoscopy with biopsies, with continued endoscopic surveillance if gastric intestinal metaplasia was identified, was cost effective, whereas performing ongoing biennial endoscopies, even for patients with normal findings from endoscopy and histopathology, was not. The lowest ICERs were observed for Chinese, Japanese, and Korean Americans (all <$73,748/QALY).

CONCLUSIONS

Endoscopic screening for gastric cancer with ongoing surveillance of gastric preneoplasia is cost effective for Asian Americans ages 50 years or older in the United States. The lowest ICERs were for Chinese, Japanese, and Korean Americans (all <$73,748/QALY).

Sequential Helicobacter pylori eradication therapy in Myanmar; a randomized clinical trial of efficacy and tolerability

BACKGROUND AND AIM

There is little published research to examine the best approach to the management of Helicobacter pylori in Myanmar. This study aimed to determine the relative efficacy and tolerability of sequential eradication therapy compared to Myanmar's current recommendation of a concomitant four drug regimen.

METHODS

Patients were screened for H. pylori using monoclonal Stool Antigen Testing (SAT). Those testing positive were randomized 1:1 to receive receive Myanmar's first-line regimen of 14 days of concomitant rabeprazole, clarithromycin, amoxycillin and tinidazole (140 pills, cost US$23) or 10 days of sequential rabeprazole, clarithromycin, amoxycillin and tinidazole (60 pills, cost US$10). Adherence and adverse effects were recorded, and the efficacy of the regimens assessed with repeat SAT.

RESULTS

Of the 1011 patients screened for H. pylori infection, 313 (31%) tested positive. There was no statistical difference in the cure rates of the two regimens in either intention-to-treat: 128/157 (82%; 95% confidence interval (CI): 75-87%) receiving sequential therapy versus 123/156 (79%; 95% CI: 72-85%) receiving concomitant therapy (P = 0.55) or per-protocol analysis: 125/131 (95%; 95% CI: 90-98) receiving sequential therapy versus 121/130 (93%; 95% CI: 87-96) receiving concomitant therapy (P = 0.42). Side effects of therapy were reported in 54/157 (47%) patients taking sequential therapy compared with 62/156 (53%) taking concomitant therapy, but this difference did not reach statistical significance (P = 0.33).

CONCLUSIONS

In this high-burden, resource-poor setting, less expensive sequential therapy was as effective and as well tolerated as the currently recommended concomitant four drug regimen for eradication of H. pylori.

Rapidly declining trend of signet ring cell cancer of the stomach may parallel the infection rate of Helicobacter pylori

Background

Studies indicate that gastric cancer (GC) incidence has decreased, whereas signet ring cell carcinoma (SRC) incidence has increased. However, recent trends in GC incidence are unclear. We used our hospital cancer registry to evaluate the changes in the incidence of GC, SRC, and non-SRC (NSRC) over time in comparison to changes in the H. pylori infection rates over time.

Methods

We identified 2532 patients with GC enrolled in our registry between January 2007 and December 2018 and statistically analyzed SRC and NSRC incidence. The H. pylori infection rate in patients with SRC was determined by serum anti-H. pylori antibody testing, urea breath test, biopsy specimen culture, and immunohistochemical analysis (IHC) of gastric tissue. Additionally, genomic detection of H. pylori was performed in SRCs by extracting DNA from formalin-fixed paraffin-embedded gastric tissue and targeting 16S ribosomal RNA of H. pylori.

Results

Overall, 211 patients had SRC (8.3%). Compared with patients with NSRC, those with SRC were younger (P <  0.001) and more likely to be female (P <  0.001). Time series analysis using an autoregressive integrated moving average model revealed a significant decrease in SRC (P <  0.001) incidence; NSRC incidence showed no decline. There was no difference in H. pylori infection prevalence between the SRC and NSRC groups. IHC and genomic methods detected H. pylori in 30 of 37 (81.1%) SRCs.

Conclusions

Reduction in H. pylori infection prevalence may be associated with the decrease in the incidence of SRC, which was higher than that of NSRC.

Burden of disease from Helicobacter pylori infection in western Canadian Arctic communities

Background

Indigenous communities across the circumpolar north have elevated H. pylori (Hp) prevalence and stomach cancer incidence. We aimed to describe the Hp-associated disease burden among western Canadian Arctic participants in community-driven projects that address concerns about health risks from Hp infection.

Methods

During 2008–2013, participants underwent Hp screening by urea breath test and gastroscopy with gastric biopsies. We estimated Hp prevalence and prevalence by Hp status of endoscopic and histopathologic diagnoses.

Results

Among 878 participants with Hp status data, Hp prevalence was: 62% overall; 66% in 740 Indigenous participants; 22% in 77 non-Indigenous participants (61 participants did not disclose ethnicity); 45% at 0–14 years old, 69% at 15–34 years old, and 61% at 35–96 years old. Among 309 participants examined endoscopically, visible mucosal lesions were more frequent in the stomach than the duodenum: the gastric to duodenal ratio was 2 for inflammation, 8 for erosions, and 3 for ulcers. Pathological examination in 308 participants with gastric biopsies revealed normal gastric mucosa in 1 of 224 Hp-positive participants and 77% (65/84) of Hp-negative participants with sharp contrasts in the prevalence of abnormalities between Hp-positive and Hp-negative participants, respectively: moderate-severe active gastritis in 50 and 0%; moderate-severe chronic gastritis in 91 and 1%; atrophic gastritis in 43 and 0%; intestinal metaplasia in 17 and 5%.

Conclusions

The observed pattern of disease is consistent with increased risk of stomach cancer and reflects substantial inequity in the Hp-associated disease burden in western Arctic Canadian hamlets relative to most North American settings. This research adds to evidence that demonstrates the need for interventions aimed at reducing health risks from Hp infection in Indigenous Arctic communities.

Prevention of gastric cancer by Helicobacter pylori eradication: A review from Japan

Japan introduced a Helicobacter pylori eradication therapy strategy in 2013, with the aim of decreasing the number of gastric cancer‐related death, the number of new cases of gastric cancer, and associated medical costs. Five years have passed since then, but no reduction in the annual number of gastric cancer has been observed. In addition, it was suggested that the number of deaths due to gastric cancer could be reduced to 30,000 a year by 2020, but the annual death toll in 2017 remained at more than 45,000. Based on the above evidence, it was examined whether it was possible to reach the target value based on the data from the last 5 years. The number of deaths per year in 2020 is predicted to be more than 40,000, which is clearly different from the target value. Logically, the effect of the strategy might appear by 2023. However, there is a possibility that the risk of gastric cancer may increase in some populations due to the influence of proton pump inhibitors and dysbiosis in the gastric microbiome. To solve these problems, combined therapy with PPIs and aspirin for patients after H pylori eradication should be considered.

Epidemiology of Helicobacter pylori infection

This review provides the most recent data concerning the epidemiology of Helicobacter pylori infection. Overall, the trend of declining prevalence of H. pylori infection is continuing, with major evidence available from studies in Europe. However, in some parts of the world, for example, in some countries in the Middle East, the prevalence has remained relatively stable. A number of systematic reviews and meta-analyses have been published during the past year indicating the lowest prevalence rates of the infection in Oceania (24.4%), the highest in Africa (79.1%), and the global annual recurrence rate of H. pylori (4.3%). The recurrence rates were found to be directly related to the human development index and prevalence of infection. Several studies have addressed the correlation between H. pylori infection and sociodemographic conditions, source of drinking water and dietary factors. A hypothesis on the role of insects and yeasts in transmitting H. pylori has been suggested and addressed. Helicobacter sp. have been found in flow flies in Brazil. So far there is no evidence available that H. pylori may survive and persist on the outer body of the fly.