Helicobacter pylori test-and-treat strategy for second-year junior high school students aimed at the prevention of gastric cancer in Takatsuki City

Parental Knowledge and Attitudes Towards Helicobacter Pylori Screening in Adolescents: A School-Based Questionnaire Study Among Guardians of Junior High School Students in Yokosuka City, Japan

PURPOSE

Helicobacter pylori (HP) infection, a risk factor for gastric cancer, is prevalent in Japan. Consequently, some municipalities across Japan are implementing HP screening and treatment programs for adolescents. However, little is known about parents' attitudes and awareness regarding HP screening for their children. This study aimed to elucidate parental perspectives on HP screening for their children and identify the factors influencing these attitudes.

METHODS

This study focused on the parents of first-year junior high school students in Yokosuka City, Kanagawa Prefecture, where an HP screening and treatment program had been implemented for adolescents. The survey questionnaire was distributed among parents in all 23 public junior high schools in Yokosuka City.

RESULTS

Among the 618 respondents, 86.4% supported HP screening for their children. Regression analysis identified sufficient knowledge about HP (adjusted odds ratio (aOR) = 5.80; 95% confidence interval (CI), 2.10-16.03) and being in their 40s (aOR = 2.25; 95% CI, 1.35-3.77) as significant factors influencing supportive attitudes. For parents favoring the screening, common reasons included perceiving it as a promising opportunity (53.2%) and considering the test necessary (44.0%). In contrast, those who opposed screening frequently cited it as unnecessary (66.7%) or believed that their children did not have HP.

CONCLUSIONS

A significant proportion of parents in Yokosuka City, Japan, demonstrated a good understanding of HP and expressed a high level of interest in HP screening for their children. Further investigation of parents' attitudes is essential for the effective implementation of adolescent HP screening programs.

Effectiveness of vonoprazan-based regimens compared with proton pump inhibitor-based regimens as first-line Helicobacter pylori agents

In this study, we compared the success rate of eradicating Helicobacter pylori (H. pylori) in adults and children using vonoprazan (VPZ)-based H. pylori regimens to that of proton pump inhibitors (PPIs). In Japan, the success rate of a VPZ-based regimen as first-line therapy was lower in children than in adults. Compared with adults, children around puberty have higher CYP2C19 and CYP3A4 enzymatic activity to metabolize PPIs and VPZ. Further, children generally have shorter intestinal transit times than adults and may absorb antibiotics to a lesser extent. When comparing success rates of pediatric and adult eradication therapy using VPZ, it is very important to maintain a higher intragastric pH with sufficient gastric acid suppression to maintain H. pylori in a replicating state and amoxicillin and clarithromycin in the intestinal tract for as long as possible by reducing diarrhea as a side effect. Based on the above, it is reasonable that VPZ, which can suppress stomach acids more strongly than PPI, is a more relevant H. pylori eradication therapy.

Efficacy and safety of vonoprazan-based regimen for Helicobacter pylori eradication therapy in Japanese adolescents: a prospective multicenter study

BACKGROUND

Vonoprazan (VPZ)-based regimen for Helicobacter pylori (H. pylori) is safe and more efficacious than the proton pump inhibitor-based regimen mainly in adults. This study aimed to evaluate the efficacy and safety of a VPZ-based regimen for H. pylori eradication therapy in adolescents.

METHODS

An H. pylori screening and treatment longitudinal project for third-year junior high school students in Saga Prefecture began in 2016. Students who tested positive for both urine and stool tests received a VPZ-based regimen. On the checklist, students were asked for diarrhea, fever, abdominal pain, nausea, vomiting, urticaria, dysgeusia, or bloody stool occurrence during the therapy.

RESULTS

The longitudinal project for H. pylori screening and treatment among third-grade students in Saga Prefecture targeted 41,115 students from 2017 to 2021 and 836 as positive. Of the 645 students, 542 (84.0% in per protocol [PP] analysis and 73.6% in intention-to-treat [ITT] analysis) were successful in primary eradication therapy. The secondary eradication therapy was successful in 79 (96.3% in PP analysis and 76.7% in ITT analysis) of 82 students. In the primary eradication therapy, abdominal pain occurred in 164 (27.9%), diarrhea in 217 (36.9%), nausea or vomiting in 7 (1.2%), and urticaria in 13 (2.2%) students. In the secondary eradication therapy, abdominal pain occurred in 12 (19.4%) and diarrhea in 17 (27.4%) students. The eradication therapy of 5 students was interrupted due to adverse events only by primary eradication therapy.

CONCLUSIONS

VPZ-based regimen for H. pylori was efficacious and safe for adolescents, as in adults, for both primary and secondary eradication therapies.

Is Helicobacter pylori Anyway Pathogen in Children?

Helicobacter pylori (H. pylori) infection is a continuous challenge for both gastroenterologists and pediatricians. The international guidelines regarding diagnostic and treatment pathways differ between adults and children. The pediatric guidelines are more restrictive because children are rarely affected by serious consequences, particularly in Western countries. Therefore, infected children should be treated only after a careful case-by-case evaluation by a pediatric gastroenterologist. In any case, recent studies are confirming an increasingly all-around pathological role of H. pylori even in asymptomatic children. For these reasons, following the current evidence, we feel that H. pylori-infected children could be treated starting in pre-adolescence, particularly in Eastern countries, because their stomachs have already begun to develop the biomarkers of gastric damage. Therefore, we believe that H. pylori is anyway pathogen in children. Nevertheless, the possible beneficial role of H. pylori in humans has not yet been conclusively disproved.

Smart Gene™ as an effective non-invasive point-of-care test to detect Helicobacter pylori clarithromycin-resistant mutation

BACKGROUND AND AIM

Smart Gene™ was developed based on the concept of point-of-care genetic testing. We evaluated the detection performance of a reagent for Helicobacter pylori (H. pylori) clarithromycin (CAM)-resistant mutation assessment and determined the association between the results of Smart Gene™ and those of eradication therapy for H. pylori.

METHODS

In 2020, the present study was conducted on participants of the H. pylori test and treat project in Saga Prefecture. The submitted stool samples were measured for H. pylori gene and CAM-resistant mutation by Smart Gene™, and the results were compared with real-time polymerase chain reaction (PCR) and sequencing analysis. Finally, the results of the eradication therapy were examined for each result of Smart Gene™.

RESULTS

Stool samples were obtained from 139 patients who were tested positive by stool antigen test and were analyzed. The H. pylori detection rate was 95.7% by Smart Gene™, 92.8% by real-time PCR (P < 0.01), and 89.2% by sequencing analysis (P = 0.06). The overall concordance rate for CAM-resistant mutation between Smart Gene™ and sequencing analysis was 96.7%. Moreover, 35 of 48 students with CAM-resistant mutation and 33 of the 35 students with a mutation without CAM resistance succeeded in CAM-containing triple therapy, and the success rate was significantly higher for the mutation without CAM resistance (P = 0.012).

CONCLUSIONS

The detection performance of Smart Gene™ was comparable with that of real-time PCR and sequencing analysis. It is expected that the success rate of eradication would be further improved by using the reagent.

Clinical Evaluation of a Novel Stool Antigen Test Using Bioluminescent Enzyme Immunoassay for Detecting Helicobacter pylori

BACKGROUND

BLEIA ™ "EIKEN" Helicobacter pylori antigen (B[EIA]) is based on the bioluminescent enzyme immunoassay (BLEIA) method that was newly developed with high sensitivity in detecting Helicobacter pylori (H. pylori) antigen in feces.

METHODS

In the project for H. pylori screening and treatment in Saga Prefecture in 2019, 141 students received the stool H. pylori antigen test as a secondary test. For 141 students, a comparative test was conducted between B (EIA) and extracorporeal diagnostic agents that were marketed in Japan as of 2019. The detection performance of H. pylori ATCC43504 standard strain and H. pylori antigen in commercial human fecal specimens were conducted.

RESULTS

The comparison of B (EIA) with Quick Chaser ^TM H. pylori (Q [IC]) revealed positive and negative concordance ratios of B (EIA) to Q (IC) of 100.0% (110/110) and 71.0% (22/31), respectively. A comparative test was conducted between B (EIA) and extracorporeal diagnostic agents that were marketed in Japan as of 2019, and B (EIA) was most sensitive on "detecting H. pylori antigen of ATCC43504 standard strain" and "detecting H. pylori antigen in commercial human fecal specimens," compared with other kits. Nine dissociated specimens that were negative for Q (IC) and positive for B (EIA) were confirmed. The measured value of B (EIA) in the dissociation samples were 1.3-87.4 cutoff index in the range that can be evaluated as negative by other fecal H. pylori antigen test kits, all the dissociation samples were H. pylori antigen-positive cases, and finally the cause of result divergence was presumed as false negative due to insufficient sensitivity of Q (IC).

CONCLUSION

B (EIA) that is based on the BLEIA method, which applies firefly luciferase luminescence, is more sensitive than stool antigen test kits that are currently marketed in Japan and is very useful in diagnosing H. pylori infection, especially in situations where noninvasive tests are preferred, such as in children.

Serum pepsinogen cut-off values in Helicobacter pylori-infected children

BACKGROUND

The aim of this study was to evaluate the standard values for gender- and age-stratified serum pepsinogen (sPG) in Helicobacter pylori (H. pylori) non-infected children and to determine the optimal cut-off values of sPG for predicting H. pylori-infected gastritis in children.

METHODS

A prospective study for determination of sPG levels was performed in children with epigastric pain who underwent esophagogastroduodenoscopy over the past 16 years. After excluding subjects diagnosed with inflammatory bowel diseases, eosinophilic gastrointestinal disorders, or immunoglobulin A vasculitis, the diagnosis of H. pylori infection was defined by positive tissue culture or concordant-positive results for histology and the rapid urease test.

RESULTS

A total of 405 subjects were diagnosed as being H. pylori-infected (79) or non-infected (326). In the H. pylori non-infected group, there were no significant differences in sPG levels among age groups; males had higher sPG I and sPG II levels than females. In the H. pylori-infected group, sPG I and sPG II levels were significantly higher and the sPG I/II ratio was lower than those in the non-infected group. In receiver operating characteristics analyses in diagnosing H. pylori infection, the areas under the curves for sPG I, sPG II and sPG I/II ratio were 0.896, 0.980, and 0.946, respectively. The optimal cut-off value of sPG II of ≥9.0 ng/mL was considered positive for H. pylori infection (sensitivity: 92.4%, specificity: 93.9%).

CONCLUSIONS

The optimal cut-off value of sPG II of ≥9.0 ng/mL may be a good predictor of H. pylori-infected gastritis in children.

The role of the occupational physician in controlling gastric cancer attributable to Helicobacter pylori infection: A review

This review aimed to describe the potential role of occupational physician in the implementation of a screening program for Helicobacter pylori (Hp) infection for gastric cancer prevention. We reviewed the epidemiological background of gastric cancer and its association with Hp, exploring the hypothesis of a "test-and-treat" protocol among working population. Clinical trials and model-based studies were collected to provided empirical evidence of the feasibility of eradication on large scale. In particular, previous studies conducted in occupational settings were discussed. Hp prevalence ranges between about 20 and 90%, with higher rates in Asia and Latin America and lower rates in Europe and North America. Large-scale trials on screening and treatment of infection have been conducted especially in East Asia, lacking elsewhere. Only few studies investigated Hp prevalence among workers. The benefit of eradication at occupational level has not yet been adequately studied. The design of a workplace-based Hp screening program appears to be innovative and could contribute to controlling gastric cancer. The benefit would involve not only high-risk subjects, but also their families, since the route of transmission is principally within the household. An occupational setting for a Hp screening would have positive consequences in terms of individual and public health.

Gastrointestinal adverse reactions reduce the success rate of Helicobacter pylori eradication therapy: A multicenter prospective cohort study

BACKGROUND

The screening and treatment of Helicobacter pylori infection for all junior high students in Saga Prefecture, Japan, were started in 2016. The present study aims to evaluate the influence of adverse reactions on the success of the eradication therapy.

METHODS

From 2017 to 2019, 25,006 third-grade junior high school students were tested for urinary anti-H. pylori antibodies. Positive cases were confirmed by H. pylori stool antigen tests. Of the 531 students who were found to be H. pylori-positive, 390 (358 in first-line and 32 in second-line therapy) underwent eradication therapy, and 274 (242 in first-line and 32 in second-line) students actually completed a self-reported form to rate stool consistency (based on the Bristol Stool Scale), the maximum number of bowel movements, and abdominal symptoms during the 7 days of treatment.

RESULTS

Among the 274 students, the total of primary and secondary eradication success rates was 87% (95% confidential interval: 82.9-90.1) in intention-to-treat analysis. On days 4, 5, and 6, stool consistency was looser in the primary eradication failure group than in the success group (p < .05). Looser stool consistencies were observed in male students with abdominal pain compared to those who did not experience pain (p < .05). Abdominal pain and diarrhea were detected in 28.5% and 42.7% of the subjects, respectively. The overall incidence of other adverse events was low (n = 8/274, 2.9%), and only two students discontinued treatment because of adverse events.

CONCLUSIONS

Softening of the stool was related to the eradication failure in the junior high school students, especially in males with abdominal pain. Adverse effects did not induce discontinuation of the eradication treatment.

Gut microbiota changes related to Helicobacter pylori eradication with vonoprazan containing triple therapy among adolescents: a prospective multicenter study

Currently, it is unclear whether treating Helicobacter pylori (H. pylori) infection is safe among adolescents. This study aimed to evaluate the safety of H. pylori eradication therapy by examining gut microbiota changes in adolescents 3 months after the therapy. H. pylori-infected adolescents were enrolled in this study. Their stool samples were collected at the following three time points: before treatment, 1-2 days after completion of treatment, and time of eradication successful judgment. We assessed the relative abundance, alpha-diversity, and beta-diversity of the gut microbiota and adverse events. The number of isolated Actinobacteria decreased immediately after eradication therapy in the 16 students included in the study, and it returned to pretreatment condition at the eradication judgment point. There was no change in the relative abundance at genus level. The alpha-diversity was lost immediately after eradication therapy; however, it recovered at the time of eradication judgment, and it was restored to pretreatment condition. Meanwhile, none of the participants experienced serious adverse events. H. pylori eradication therapy is safe for adolescents with respect to gut microbiota changes associated with H. pylori eradication therapy. Therefore, further long-term evaluations of gut microbiota changes following eradication therapy are warranted.

Clinical impact of vonoprazan-based dual therapy with amoxicillin for H. pylori infection in a treatment-naïve cohort of junior high school students in Japan

BACKGROUND

Although 7-day triple therapy, consisting of vonoprazan, amoxicillin (AMO), and clarithromycin (CLA), is recommended for Helicobacter pylori (H. pylori) eradication in adults. However, the importance of reducing antibiotic use in pediatric patients is well recognized. Therefore, our aim was to compare the effectiveness and safety of vonoprazan and AMO (VA) dual therapy to vonoprazan-based (VAC) triple therapy for H. pylori eradication in a cohort of treatment-naïve junior high school students in Japan.

METHODS

This was a prospective observational study of second-year junior high-school students in Yurihonjo and Nikaho Cities, Japan. Between 2015 and 2017, 161 students were treated with VAC-triple therapy (20 mg vonoprazan, 750 mg AMO, and 200 mg CLA, twice a day for 7 days), while 60 students were treated with VA-dual therapy (20 mg vonoprazan and 750 mg AMO, twice a day for 7 days) since 2018. The success rate of H. pylori eradication and drug-related adverse events were compared between the two therapy groups. Intention-to-treat (ITT) and per-protocol (PP) analyses were performed.

RESULTS

Groups were comparable at baseline. The ITT and PP eradication rates were 85.0% (95% confidence interval [CI] 75.8-94.2%) and 86.4% (95% CI 77.4-95.5%), respectively, with VA-dual therapy and 82.0% (95% CI 76.0%-87.9%) and 84.1% (95% CI 78.3-89.8%), respectively, with VAC-triple therapy. VA-dual therapy was non-inferior to VAC-triple therapy (ITT, p = 0.018; PP, p = 0.020). The adverse event rate was 10.0% with VA-dual therapy and 19.8% with VAC-triple therapy (p = 0.108).

CONCLUSIONS

The effectiveness of VA-dual therapy was comparable to that of VAC-triple therapy in H. pylori treatment-naïve junior high school students, while reducing the use of antibiotics.

The association of recurrent abdominal pain and Helicobacter pylori infection in correlation with esophagogastroduodenoscopy findings

Abstract: Aim: The aim of this research was to determine the association of recurrent abdominal pain and Helicobacter pylori (H. pylori) infection in childhood, in correlation with the finding of an upper endoscopy. Introduction: Recurrent abdominal pain (RAP) was defined according to Apley and Naish's criteria from the year 1959 as at least three or more episodes of abdominal pain lasting longer than three months in children older than 3 years, and severe enough to prevent normal activities in child. The association of RAP and H. pylori has been analyzed in several different researches, and there are conflicting results about their interconnection. However, the etiological association of the presence of H. pylori with the onset and development of acute and chronic active gastritis and duodenal ulcer is known. Material and method: The research protocol included a total of 77/183 (42.07%) children divided by age into three subgroups: preschool age (3 to 6.9 years), school-age (7 to 10.9 years) and adolescent age (11 to 15 years) in whom the diagnosis of RAB was determined by meeting the criteria according to Apley and Naish (1959), and the American Academy of Pediatrics (2005). H. pylori infection was confirmed by enzyme-linked immunosorbent assay (ELISA), while esophagogastroduodenoscopy was performed by the device for upper endoscopy type Olimpus GIF Type Q156, in the endoscopic cabinet of the Clinic for Internal Medicine, University Clinical Center Tuzla. Results: Of the total number of examined children (77), the analyse of Helicobacter pylori infection presence showed the biggest number of positive findings in school age 91.3%, in adolescent age 78.0%, while the smallest number was in preschool age (25.0%). The most common findings of upper endoscopy and microscopic findings were described as: antritis acuta in 16%, gastritis chronica activa et erosiva in 32%, and duodenitis acuta (12%). Conclusion: A significant association of H. pylori infection and RAP are confirmed by positive finding of esophagogastroduodenoscopy, leading to conclusion that immunological testing for the presence of this bacteria is justified. After obtaining a positive finding with confirmed infecion, it is necessary to start with the treatment.