INTRODUCTION
Helicobacter pylori (H. pylori) is a Gram-negative, spiral-shaped, microaerophilic bacterium that is widely distributed all over the world (1). This bacterium is an important pathogen associated with diseases such as peptic ulcers, chronic gastritis, gastric MALT lymphoma, and gastric cancer. For treating diseases caused by H. pylori, long-term and intensive use of antibiotics is necessary. Colonization formed by the bacteria is mostly asymptomatic, but these people are in the risk group rega rding gastric diseases (2). Approximately 1% of people infected with H. pylori develop gastric cancer (3). Although it remains unclear how the infection is transmitted, it is thought that it can be transmitted in different ways such as fecal-oral, oral-oral, or gastro-oral (4).
Age, race, rural life, population density, socioeconomic status, poor health conditions, low education level, malnutrition, and insufficient water resources are important risk factors for the transmission of H. pylori (4,5). In consideration of all these factors, it can be stated that the disease is more common in developing countries. In developed countries, adequate socioeconomic conditions, effective hygiene and sanitation, and elimination of disease carriers with antimicrobial therapy reduce the prevalence of H. pylori (4,5).
Invasive and non-invasive techniques can be used for the diagnosis of H. pylori infection. Invasive methods such as immunohistochemistry tests, rapid urease tests, culture methods, and polymerase chain reaction require endoscopy, and these tests are known as biopsy method-based tests. Non-invasive methods include the gaita-antigen test, urea breath test, and ELISA H. pylori-IgG antibody tests. The sensitivity, specificity, and the cost of the test and clinical conditions are among the main factors affecting test selection (4,6,7).
H. pylori antigen search tests in feces have been widely used recently. It is stated that these tests using monoclonal anti-H. pylori antibodies have high sensitivity and specificity. It has been reported that these tests are useful for planning appropriate treatment methods because they are an alternative to invasive methods, cost-effective, and give rapid results (8).
This study retrospectively analyzed the presence of H. pylori antigen in the fecal samples of patients who applied to Sivas Cumhuriyet University Medical Faculty Practice and Research Hospital between January 2018-May 2022 with gastroduodenal complaints.
METHODS
This study, carried out at Sivas Cumhuriyet University Medical Faculty Hospital, was planned retrospectively to cover January 2018-May 2022 dates. The laboratory test results of patients who had gastroduodenal complaints and whose H. pylori-antigen rapid test cassette kit were studied from fresh feces samples in the medical microbiology laboratory within the specified time were included in the study.
Fresh feces samples from patients were analyzed using H. pylori-Antigen Rapid Test Cassette (Acro Biotech Inc, USA) kits, a qualitative chromatographic immunoassay test. According to the producer company bulletin, the sensitivity of the test kits using monoclonal anti-H. pylori antibodies is 99.9% and the specificity is 98.4%.
All tests were studied based on the guides of the producer company. The fecal samples were transferred to sample collection tubes containing the extraction buffer and homogenized. Two drops of this mixture were taken and dropped into the sample well in the test cassette. After waiting for 10 minutes, the formed bands were evaluated according to company guide. The formation of a colored line in the control (C) region of the test strips indicates that the test was performed following the guideline and the test result is valid. Only the formation of a colored line in the C region is interpreted as a negative result. A colored line in both the C region and the test (T) region is interpreted as a positive result.
Statistical Analysis
The statistical analysis of the research was made with IBM-SPSS 25.0 (IBM Co., USA). The numerical variables are given as frequencies (percentages). Chi-square test was used to evaluate the data. A value of p<0.05 was considered significant statistically.
This study was conducted with the approval of the Sivas Cumhuriyet University Faculty of Medicine Non-Invasive Clinical Research Ethics Committee (decision no: 2022-06/14, date: 22.06.2022).
RESULTS
The 5,718 patients [3,285 patients were females (57.5%) and 2,433 were males (42.5%)] with gastroduodenal complaints were included in the study. The ages of the patients ranged from 0 to 96. The 791 patients (13.8%) were in the child age group and 4,927 patients (86.2%) were in the adult age group. When the ranges of laboratory tests by years were examined, it was determined that the maximum number of laboratory tests was made in 2021 (33.4%). The ranges of the patients according to age, gender and laboratory test dates are given in Table 1.
H. pylori antigen positivity was determined in fecal samples of 1,429 patients (25%) included in the study. The antigen positivity rate was determined as 26.6% in women and 22.9% in men. This difference between men and women was considered statistically significant (p<0.05) (Table 1).
Antigen positivity in feces was detected in 80 persons (10.1%) of the pediatric patients (0-18 age) included in the study. Antigen positivity in feces was detected in 1,349 persons (27.4%) of the adult patients (≥19) included in the study (Figure 1).
The H. pylori antigen positivity rate was found to be statistically significantly higher compared to the adult age group and the pediatric age group (p<0.01).
In this study, the range of H. pylori antigen positivity rates in age groups was also examined. It was determined that the fecal H. pylori antigen test was mostly performed in patients aged 19-29 years and 40-49 years old (Table 1). It has been determined that patients in the 30-39 age group have a higher H. pylori antigen positivity rate compared to patients in other age groups (Figure 2).
DISCUSSION
H. pylori continues to be a significant public health problem because it causes diseases such as peptic ulcers, chronic gastritis, and gastric cancer (9,10). It is thought that more than 50% of people worldwide are infected with H. pylori. However, the prevalence of H. pylori varies due to regional differences worldwide. While the prevalence of H. pylori is 25-40% in industrialized and developed countries, it is reported to be 60-85% in developing countries (9,10).
There are data in the literature indicating that the prevalence of H. pylori tends to decrease in different regions of the world compared to the past (9-11). It has been stated that the prevalence of H. pylori is low, especially in children and young people in developed countries (10,12). However, it is argued that for developing countries, a similar assessment is not yet possible. In addition, the uncontrolled population growth and immigrant problem caused by socioeconomic reasons may negatively affect regional prevalence data (9,12).
Regional prevalence data can be informative about the development levels of countries in socioeconomic issues such as urbanization, infrastructure services, and access to clean water compared to the past. In addition, these data may offer implications for the future prevalence of H. pylori-related diseases, such as peptic ulcers, especially gastric cancer, and chronic gastritis (9).
A meta-analysis was recently published, presenting data from 412 studies in China (13). In this study, the prevalence of Chinese H. pylori was determined to be 44.2%. However, the authors noted that the prevalence of H. pylori in China, which has wide geography, shows regional variations. In this study, it was reported that a higher prevalence of H. pylori was observed in adults (46.1%) compared with children (28%). In addition, the prevalence level in women (42%) was lower than in men (44.9%). In this study, in which the data of the last 40 years of the country were examined, it was determined that there was a significant decrease in the prevalence of H. pylori, especially in the last 10 years. The researchers stated that this is related to their country’s socioeconomic developments such as infrastructure services, health services, and an increase in quality of life.
Alsulaimany et al. (14) published a review aiming to determine the prevalence of H. pylori in the Middle East and North African countries in 2020. In this study, high prevalence rates of 7-50% in children and 40-90% in adults were reported in countries such as Egypt, Iran, Israel, Lebanon, Libya, Saudi Arabia and Tunisia. The researchers reported that they did not detect a significant difference in terms of the gender variant in the prevalence of H. pylori, except a few studies (14). Lower prevalence rates have been reported in regions with advanced infrastructure and high socioeconomic status, such as Oceania (24%), Western Europe (34%), and North America (37%) (9).
In recent studies in Türkiye, the prevalence of H. pylori was found to be between 11 and 65% (15-21). It was determined that the prevalence range in these studies varied in terms of the age group variable. Lower prevalence rates have been reported in children and individuals over the age of 65. It has also been reported that there has been a recent decrease in H. pylori prevalence rates compared with previous years in Türkiye. In our study, similar to other studies conducted in Türkiye, H. pylori antigen test positivity in feces was found to be 25%. This rate was determined as 10.1% for children and 27.4% for adults (p<0.01).
In many studies conducted in our country, it has been determined that the prevalence of H. pylori does not make a significant difference in terms of gender (16-21). However, Maçin et al. (15) found a higher rate of antigen positivity in women compared to men in their study. Similarly, Alim et al. (22) reported a higher prevalence rate in women in their study in our province. In our study, similar to the results of this study, a higher H. pylori antigen positivity was found in female patients (26.6%) than in male patients (22.9%) (p<0.05).
A prevalence study was conducted in our province in 2004 involving 620 adult patients aged 28-69 years. In this study, the presence of H. pylori IgG-antibody in serum samples of patients was investigated by the ELISA method. The antibody test was positive in 70.1% of the patients (22). When these results are compared with the results of our study in which we present the data of our region, we can be stated that the prevalence of H. pylori has decreased compared with previous years. This situation can be evaluated as an indicator of socioeconomic developments such as the improvement of infrastructure services in our province, access to clean water, access to qualified health services, increase in education level, and increase in quality of life. Another reason for determination of positivity rates at different amounts can be said to be the difference in the methods used. A rapid cassette test based on the chromatographic immunoassay method was used in this study. Antigen search tests in feces, which have become more common recently, are among the non-invasive techniques that can be used in the diagnosis of H. pylori infection. These tests, which are an alternative to invasive methods, are advantageous because of their cost-effectiveness and rapid results. On the other hand, the feces antigen test and 13C-urea breath tests have higher sensitivity and specificity compared to the H. pylori IgG antibody test (23,24). It is also reported in the literature that the feces-antigen tests are useful for epidemiological studies and screening, are affordable in terms of cost and equipment, and give reliable results, which were used methodologically in this study too (24). In addition, there is currently no technique accepted as the gold standard for the diagnosis of H. pylori.
CONCLUSION
Regional prevalence data provide information on socioeconomic issues such as the city’s infrastructure services, access to clean water, health services, education level of people, and quality of life. Regular testing and presentation of the prevalence of H. pylori in Türkiye will contribute to the development of screening and diagnostic approaches for H. pylori. We think that this study, in which the data of our region is shared, is significant at this point.
ETHICS
Ethics Committee Approval: This study was conducted with the approval of the Sivas Cumhuriyet University Faculty of Medicine Non-Invasive Clinical Research Ethics Committee (decision no: 2022-06/14, date: 22.06.2022).
Informed Consent: Retrospective study.
Authorship Contributions
Concept: F.Ç., M.H., Design: F.Ç., A.H.T.K., M.H., C.Ç., Data Collection or Processing: F.Ç., A.H.T.K., M.H., C.Ç., Analysis or Interpretation: F.Ç., A.H.T.K., Literature Search: F.Ç., A.H.T.K., R.A., Writing: F.Ç., A.H.T.K., R.A.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declare that this study received no financial support.