Where are we today with Helicobacter pylori infection among healthy children in Saudi Arabia?

Epidemiology, pathogenicity, risk factors, and management of Helicobacter pylori infection in Saudi Arabia

Helicobacter pylori (H. pylori) is a gastric microbial pathogen that infects approximately half of the global population. This bacterium significantly contributes to various gastroduodenal diseases, including chronic active gastritis, peptic ulcerations, and malignant transformations. This review focuses on epidemiology, pathogenicity, virulence genes, risk factors, and management of H. pylori infection, specifically within the context of Saudi Arabia. The results presented here are grounded in studies conducted in Saudi Arabia, contrasting with mere bibliographic reviews of findings from other countries. H. pylori infection has been observed in Saudi Arabia, with substantial differences in the prevalence, ranging between 10-96% among various studied populations. Several risk factors for H. pylori infection have been identified, encompassing socioeconomic status, medical history, personal hygiene, and behavioral practices. Among the virulence genes harbored by H. pylori, cytotoxin-associated gene A (cagA) and vacuolating cytotoxin (vacA) are most common, with their presence correlating with the pathogenicity and clinical manifestations of the associated diseases. A range of invasive and non-invasive diagnostic assays have been utilized to identify H. pylori infection, with their employment being influenced by factors like availability, cost, patient age, gastric symptoms, and the specifics of clinical information sought. While detection methods like the H. pylori stool antigen test and the urea breath test offer more accuracy and speed, culturing remains indispensable for determining the antimicrobial susceptibility profile. The emergence of resistant strains across varying regional settings poses a significant challenge to treatment endeavors, necessitating an assessment of local antimicrobial resistance rates prior to formulating treatment strategies. The findings of this review highlight the importance of continuous implementation of screening, control, and prevention of H. pylori infection to combat the spreading infection and other related complications.

Awareness and Practice of Patients with Helicobacter pylori Infection Toward their Disease in the Riyadh Region, Saudi Arabia

Objective

This study aimed to study the awareness and practice of patients with Helicobacter pylori (H. pylori) toward their disease in the Riyadh region, Saudi Arabia.

Material and Methods

This is a descriptive cross-sectional community-based study, in the central region of the kingdom. The target population of this study was adult patients with H. pylori infection, and a sample of 808 Saudi and non-Saudi male and female individuals were randomly selected using an online questionnaire. A consent form was obtained from all participants. Ethical approval was obtained from the university ethics committee.

Results

There were a total of 808 responses. Most participants were female (89.4%) (n = 722) and between the ages of 35 and 60 years (60.8%), and most participants had a bachelor's degree (62.4%). 53.47% of the participants have good knowledge regarding their disease. Most of the participants knew it could cause gastric and duodenal ulcers (82.5%), but they did not know the infection might cause gastric cancer (48.6%).

Conclusion

The study concluded that the majority of patients with H. pylori infection (53.47%) have good knowledge regarding their disease. Additionally, many participants were aware of the symptoms associated with H. pylori. Furthermore, many participants complained about their treatment.

The Effectiveness of an Educational Intervention on Helicobacter pylori for University Students: A Quasi-Experimental Study

Introduction

Helicobacter pylori infection is widespread and harmful, rendering its eradication a serious public health problem. Undergraduate students' general understanding of H. pylori infection is relatively poor. This was a second-phase research study to evaluate the efficacy of an educational intervention in raising awareness among university students.

Methods

A quasi-experimental approach was employed, with 108 undergraduate students at King Saud University as participants. First, during the October 2021 academic year, data were gathered using a validated survey. The survey was divided into sociodemographic characteristics and H. pylori knowledge. Second, we assessed the effectiveness of an educational intervention to increase university students' awareness of the topic.

Results

Before the intervention, the percentage of students that had good (9.3%), fair (28.7%) and poor (62%) knowledge of H. pylori infection changed to 55.6%, 41.7%, and 2.8% respectively. There was a significant increase in overall and domain-wise mean knowledge score after the educational intervention (p = 0.001). The pretest knowledge was independent of all socio-demographic variables except "whether or not they had heard about H. pylori infection" (χ²= 8.666, p = 0.013).

Conclusion

Educational intervention may help increase students' awareness of H. pylori infections.

Molecular characterization of Helicobacter pylori clinical isolates from Eastern Saudi Arabia

OBJECTIVES

To describe the frequency of cytotoxin-associated gene A (CagA) and vacuolating cytotoxin A (VacA) virulence genes and clarithromycin resistance-associated mutations among Helicobacter pylori (H. pylori) clinical isolates from Eastern Saudi Arabia.

METHODS

A cross-sectional study was carried out between July 2020 and June 2021 in a tertiary hospital in AL-Khobar, Saudi Arabia. A total of 34 H. pylori isolates were obtained from gastric biopsies of patients with dyspepsia. The existence of the virulence genes was studied by polymerase chain reaction and the gene fragment of the 23s ribosomal subunit (23s rRNA) gene was sequenced.

RESULTS

All isolates harbored the CagA gene. Approximately 97.1% (33/34) isolates were positive using the VacA M primer and 91.2% (31/34) isolates were positive using the VacA S primer. The most frequent allelic combination was S2/M2/cag (60%), followed by S1/M2/cag (26.7%), S1/M1/cag (10%), and S2/M1/cag (3.3%). Approximately 6.5% isolates harbored the A2142G mutation and 29% isolates harbored the A2143G mutation. One isolate contained the mutation T2182C. The phylogenetic analysis showed that 58% isolates clustered with the regional and global isolates while the remaining 42% isolates seemed to be specifically circulating in Saudi Arabia. Most of the patients (73.5%) had already underwent a previous H. pylori eradication therapy.

CONCLUSION

We showed that there is a regional variation in the frequency of the virulence genes among H. pylori isolates. Additionally, we showed the frequency of 23s rRNA mutations related to clarithromycin resistance in Saudi Arabia.

Worldwide Prevalence and Risk Factors of Helicobacter pylori Infection in Children

Helicobacter pylori is usually acquired during childhood. The reports from the last two decades pointed out a decrease in H. pylori prevalence across geographical areas worldwide compared to previously reported data. Most of the studies performed in America found an overall H. pylori infection prevalence of approximately 50%. The most important risk factors in America include being male, poor adherence or difficult access to treatment, and the lack of in-home water service. Despite the descending trend in prevalence worldwide, the overall prevalence in Africa remains very high (70%). Nevertheless, the prevalence of H. pylori in children without gastrointestinal who underwent screening was reported to be only 14.2%. The main risk factors in Africa are having a traditional pit or no toilet, poverty, birth order, source of drinking water, or being a farmer. Asia seems to have the widest variations in terms of H. pylori prevalence. Several risk factors were reported in Asia to be associated with this infection, such as lower income and educational level, house crowding, rural residence, ethnicity, the use of tanks as water supplies, alcohol drinking, active smoking, eating spicy food or raw uncooked vegetables, poor living conditions and sanitation. The overall prevalence of H. pylori infection in European children is almost 25%. Portugal has the highest prevalence of all European countries at 66.2% in children 13 years of age. The risk factors in European individuals consist of living in rural areas, eating unwashed fruits and vegetables, not washing hands after school, low parental education and unemployment, and short education duration. Further studies are required to identify the precise mechanisms involved in the discrepancies of H. pylori prevalence worldwide.

Vitamin D and iron deficiencies among Saudi children and adolescents: A persistent problem in the 21st century

BACKGROUND

Although several studies have reported on the prevalence of micronutrients in Saudi Arabia, most frequently vitamin D and iron, they are either old or hospital- or primary health care center-based. The objectives of our study were to provide more updated data on the prevalence rate of micronutrients deficiency among the Saudi general pediatric population and to determine if there is an association between micronutrients deficiency and undernutrition.

METHODS

The present study is part of a cross-sectional mass screening study, "Exploring the Iceberg of Celiacs in Saudi Arabia" conducted among school-aged children (6-16 years) in 2014-2015. A sample of 7,931 children aged 6-16 years was randomly selected. We identified thin children [body mass index (BMI) z-score <-2 SD, for age and gender], using the WHO reference 2007. A case-control study was performed, where the sera of 182 thin children (cases) and 393 normal BMI children (controls) were tested for levels of iron, ferritin, vitamin D, zinc, selenium, and copper.

RESULTS

The prevalence of thinness was 3.5%. The two most common micronutrients deficient among Saudi children with normal BMI were iron (20%) and vitamin D (78%). Vitamin D levels were significantly higher among boys as compared to girls (39.6 nmol/L vs. 31.15 nmol/L; P < 0.001). Deficiency of copper, zinc, and selenium occurred in 0.25%, 1%, and 7.4% of the children with normal BMI. Comparisons between the cases and controls did not show statistically significant differences.

CONCLUSION

Vitamin D and iron deficiencies are still common forms of malnutrition in the Saudi community, that have remained unchanged over the past 20-30 years, while the intake of trace elements (zinc, copper, and selenium) is adequate as evident by normal serum levels in the vast majority of the investigated children. We could not observe a correlation between undernutrition and micronutrient deficiencies.

Time trends of causes of upper gastrointestinal bleeding and endoscopic findings

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a frequent cause for emergency endoscopy and, in a proportion, requires the application of endotherapy. We aim to evaluate the proportion of variceal and nonvariceal upper gastrointestinal bleeding (NVUGIB), the endoscopic findings that were detected, as well as the temporal trends of endoscopic findings over a period of 13 years.

METHODS

This is a retrospective study of patients who underwent an esophagogastroduodenoscopy with an indication of UGIB or presented with hematemesis, melena, or both, as well as those who had hematochezia, from January 2004 to December 2016 (13 years).

RESULTS

A total of 2075 patients were included with a mean age of 56.8 years (range 18-113) and males constituted 67.9%, while 65.9% had at least one comorbidity. Symptoms on presentation included hematemesis (52.5%), melena (31.2%), both hematemesis & melena (15.1%), and hematochezia (1.2%). The majority of UGIB were from a NVUGIB source (80.5%) and a variceal source was found in 13.1%, while no endoscopic findings were found in 6.4% of cases. The most common endoscopic diagnosis was gastroduodenal erosions (23.8%), duodenal ulcers (23.5%), reflux esophagitis (16.0%), esophageal varices (12.1%), and gastric ulcers (10.8%). There was no change in the endoscopic findings over the time period of the study. A third of duodenal ulcers (33.3%) as well as 21.9% of gastric ulcers were actively bleeding at the time of endoscopy, while 3.3% of duodenal ulcers had an adherent clot.

CONCLUSIONS

NVUGIB composed the majority of cases presenting with UGIB and variceal bleeding was lower than that described in prior studies, but there were no clear trends in the proportion of causes of UGIB during the study duration.

Upper gastrointestinal bleeding: Causes and patient outcomes

BACKGROUND

Upper gastrointestinal bleeding (UGIB) remains a healthcare burden and is associated with considerable morbidity and mortality. We aim to describe the presentation, clinical, and laboratory characteristics of patients presenting with UGIB as well as important patient outcomes.

METHODS

This is a retrospective study performed at a tertiary care university hospital in Riyadh. Electronic endoscopic reports of patients undergoing gastroscopies for the indication of UGIB from January 2006 to January 2015 were included. Demographic data, past medical conditions, medications used, symptoms on presentation, as well as the patients' hemodynamic status, laboratory investigations on presentations, the need for blood products, the need for admission to an intensive care unit, rebleeding, and in-hospital mortality rates were retrieved from medical records.

RESULTS

Two hundred fifty-nine patients were included with a mean age of 57.1 years and males constituted 66.8% of the study cohort. At least one comorbidity was present in 88.2%, while 20.7% had a history of prior UGIB, 12.6% had a history of peptic ulcer disease, and 9.2% had known esophageal varices. A nonvariceal source represented 80.1% of the causes (95% CI: 75.4 to 85.3%), 15.5% required admission to the intensive care unit (ICU), the rebleeding rate was 8.9% (95% CI; 5.7% to 12.2%) while the in-hospital mortality was 4.4% (95% CI; 2.4% to 6.9%). The mean pre-endoscopic Rockall score was 2.6 (range: 0 to 5), while the total Rockall score was 4.4 (range: 1 to 9). There was no association between the pre-endoscopic Rockall score and rebleeding (3.0 vs. 2.5, P = 0.27) or need for ICU admission (3.2 vs. 2.4, P = 0.08), the total Rockall score and rebleeding (5.0 vs. 4.4, P = 0.58) or need for ICU admission (5.0 vs. 4.3, P = 0.36).

CONCLUSION

Causes of UGIB in this patient population were predominantly nonvariceal and the rebleeding and mortality rates resembled those of other studies.

Review: Helicobacter pylori infection in children

Helicobacter pylori infection in children and adolescents differs in comparison to adults with respect to epidemiology, host responses, and disease manifestations. Furthermore, treatment options are limited in this population and antibiotic resistance rates continue to increase. Therefore, ongoing research is vital to understand disease pathogenesis and provide optimal management of children with infection. This review summarizes relevant publications from April 2019 to March 2020. Similar to adults, recent studies show a decreasing prevalence of infection in the pediatric population. Studies of pathogenesis investigated serum immune responses and the potential inverse association of infection and allergy. Several studies investigated the effect of H pylori and related inflammation on the gut microbiome. The recommendation of endoscopy-based testing to identify the cause of symptoms and not just H pylori, reserving noninvasive UBT or stool antigen tests for post-eradication follow-up, was supported by the current literature.

Association of Helicobacter pylori Infection with Vitamin D Deficiency in Infants and Toddlers

Helicobacter pylori (H. pylori), a gram-negative pathogen, has been shown to colonize multiple organs and cause various forms of extra-gastrointestinal diseases. The association of H. pylori infection with vitamin D status in apparently healthy children remained unclear; therefore, we investigated the relationship between vitamin D and H. pylori infection among apparently healthy infants and toddlers. In this large cross-sectional study, the examination data of children were collected from January 2013 to September 2017 in the Center for Children's Health Care. Among these children, 6,896 infants and toddlers were screened for our study. Helicobacter pylori infection and vitamin D status were the main indicators, and micronutrients (zinc, iron, copper, magnesium), and growth parameters (height, weight, and weight for age Z score [WAZ], height for age Z score [HAZ]) were also analyzed in this study. Among the 6,896 infants and toddlers, the detection rate of H. pylori seropositivity was 30.6%. The prevalence of vitamin D deficiency in H. pylori seropositive and seronegative groups was 20.7% and 12.1%, respectively (P < 0.001). The logistic regression analysis suggested children with H. pylori-positive antibody were 2.06 times more likely to be vitamin D deficient compared with children who had negative H. pylori antibody (odds ratio: 2.06; 95% CI: 1.77, 2.38) after controlling for confounding factors. These data suggested that there was a significant association between H. pylori seropositivity and vitamin D deficiency in children aged 6-36 months, which would make a contribution to the treatment and monitoring of vitamin D deficiency and H. pylori infection.

Global whole family based-Helicobacter pylori eradication strategy to prevent its related diseases and gastric cancer

Helicobacter pylori (H. pylori) infects approximately 50% of the world population. The multiple gastrointestinal and extra-gastrointestinal diseases caused by H. pylori infection pose a major healthcare threat to families and societies; it is also a heavy economic and healthcare burden for countries that having high infection rates. Eradication of H. pylori is recommended for all infected individuals. Traditionally, “test and treat” and "screen and treat" strategies are available for various infected populations. However, clinical practice has noticed that these strategies have some shortfalls and may need refinement, mostly due to the fact that they are not easily manageable, and are affected by patient compliance, selection of treatment population and cost-benefit estimations. Furthermore, it is difficult to control infections from the source, therefore, development of additional, compensative strategies are encouraged to solve the above problems and facilitate bacteria eradication. H. pylori infection is a family-based disease, but few studies have been performed in a whole family-based approach to curb its intra-familial transmission and the development of related diseases. In this work, a third, novel whole family-based H. pylori eradication strategy is introduced. This approach screens, identifies, treats and follows up on all H. pylori-infected individuals in entire families to control H. pylori infection among family members, and reduce its long-term complications. This strategy is high-risk population-oriented, and able to reduce H. pylori spread among family members. It also has good patient-family compliance and, importantly, is practical for both high and low H. pylori-infected communities. Future efforts in these areas will be critical to initiate and establish healthcare policies and management strategies to reduce H. pylori-induced disease burden for society.