H Pylori: common in US veterans

 A recent large analysis of veterans confirmed that H. pylori infection is quite common in the US, in a preprint, pre-peer-reviewed article (see See h pylori US veterans ClinGastroHepat2023 in dropbox or doi.org/10.1016/j.cgh.2023.05.016 ) 

 

Details: 

-- 913,328 individuals were evaluated who had had H. pylori testing while receiving routine care through the VA system, in a nationwide retrospective analysis of veterans between 1999 and 2018   

-- mean age 58; 90.2% male; 7% Hispanic, 17% non-Hispanic Black, 6% non-Hispanic other, 64% non-Hispanic white 

-- all of these individuals in the study had been tested for H. pylori, which included either serologic testing for antibody or non-serologic testing with fecal H. pylori antigen, urea breath test or gastric biopsies done during an endoscopy 

-- the highest prevalence of H. pylori infection detected was in the South (especially Texas, Alabama, Mississippi, Kentucky, and Georgia), and California and New York (20 to 40% range, the highest were in Los Angeles at 36% and in the Bronx at 40%) 

    -- in non-Hispanic white patients, H. pylori positivity was most notable in the Northeast states, Michigan, Minnesota, North Dakota, some Western states, and South Florida 

 

Results: 

-- the numbers below reflect the number of positive H. pylori tests (serologic or non-serologic) in veterans who had been tested for H. pylori; i.e., the denominator is not the overall number of veterans seen, but only those who had been tested

-- H. pylori positivity rate overall was 25.8% 

-- positivity rates by race/ethnicity: 

    -- non-Hispanic Black: 40.2% (40.0%-40.5%) 

    -- Hispanic: 36.7% (36.4%-37.1%) 

    -- non-Hispanic white: 20.1% (20.0%-20.2%) 

        -- 4.7% of the variation in H. pylori positivity was explained by demographics; 3.5% of the attributable variation was for race and ethnicity 

-- H. pylori positivity was more common in men than women, irrespective of geography 

 

-- H. pylori positivity declined over the 20 year time period of the study, from 35.9% in 1999-2006 to 18.4% in 2013-2018 

 

Commentary: 

-- H. pylori is the most common chronic bacterial infection worldwide: 4.4 billion people are infected 

-- H. pylori is a documented human carcinogen, associated with 80 to 90% of gastric cancers globally 

    -- H. pylori is now considered a carcinogen per the NIH: http://gmodestmedblogs.blogspot.com/2022/03/carcinogen-update-now-including-h-pylori.html  

-- H. pylori eradication reduces the risk of gastric cancer even in those asymptomatic, as well as the complications of peptic ulcer disease 

-- H. pylori infections are largely asymptomatic or minimally symptomatic, suggesting that routine testing needs to be done to eliminate the burden of H. pylori infections 

-- a meta-analysis covering the years 1970-2016 found the highest pooled rate of H. pylori positivity was in Africa (79%), with lower rates being in North America (37%), Western Europe (34%), and Oceania (24%). A more recent meta-analysis found that these numbers largely persisted, with North America having 36% positivity

    -- it should be noted that the quality and rigor of epidemiologic studies in resource limited  countries is likely more limited 

-- one large US study with 16,144 people in 4 Hispanic/Latino communities found a seroprevalence of 57% for H pylori 

-- an NHANES study of 7465 people from 1988-1991 in the US found a 32.5% seropositivity (see https://academic.oup.com/jid/article/181/4/1359/856832 ) 

-- a prior US veterans study confirmed a high rate of H. pylori infections in the US and increased incidence of gastric cancer, but a 76% decreased rate of gastric cancer with adequate H. pylori therapy, over a seven year follow-up: http://gmodestmedblogs.blogspot.com/2019/12/h-pylori-in-us-veterans.html . this blog cites several prior ones, including details of some specific H Pylori variants of concern: (Cag-A  and VacA are more carcinogenic, the latter being associated with colon cancer) 

-- strikingly enough, for the most common bacterial infection in the world (infecting 50% of the global population), the epidemiology is still quite unclear. In resource limited countries, the majority of children are infected before age 10 and the prevalence in adults is up to 90% before age 50; in the US and other resource rich countries, the incidence is low in young children and increases from age 18 to 30, with a prevalence of up to 50% in those older than 60yo

    -- The mode of transmission of H. pylori, not well understood, may rely on person-to-person transmission through fecal/oral or oral/oral exposures (seems likely, but not known for sure)

    -- this study above did analyze several demographic factors associated with H. pylori in the US, finding that race and ethnicity were very important 

    -- race/ethnicity in general reflect systematic racism, leading to significant differences in stress levels (and the associated immunological and other effects of stress hormones), as well as financial, housing, food insecurity, and the quality of living situations (quality of housing, quality of water, crowding) that might affect H. pylori transmission 

        -- for example, the risk of acquiring H. pylori infections in youth is related to social economic status, education, and living conditions early in life.  

 

Limitations: 

-- this was a study done in the VA hospital system, which was predominantly male, and might limit generalizability to the general population. It should be noted that the absolute number of women in the study was still sizable at 89,449 

-- there were several concerns about the testing done: 

    -- we do not know why the tests were done. Were patients symptomatic? Was this routine testing by clinicians? We do know that the majority of people infected with H. pylori are asymptomatic. So it is hard to know how generalizable these findings are… 

   -- there may well be a discordant relationship between serologic and non-serologic H. pylori testing. When someone is infected, their antibody test remains positive for life. Yet some of these patients may have had disease resolution, perhaps by having taken antibiotics for other reasons (it is well-known that some people who have positive antibodies in their blood have negative tests for ongoing infection, and that is certainly my experience). So, the group “with H pylori infection” determined by serology likely includes people without actual active infection.

-- we also do not have information as to where these VA patients were born, whether they had international exposures during their lifetimes (including during their time in the Armed Forces), also limiting the generalizability to the general population; and no information  on occupational exposures, social economic status, or other socioeconomic variables (including income, housing situation, etc as above) that might influence the rate of HP positivity

 

So, this study adds to prior studies indicating that H. pylori is a significant disease in the United States, though is largely asymptomatic.

 

I personally have been checking patients regularly in the past few decades after a few of my patients died from gastric cancer. Since then, I have found patients with severe ITP, chronic pruritus, and urticaria with complete resolution after successful H Pylori treatment. And I have found many patients with H pylori who were asymptomatic and have never been outside of the US. This study, despite its limitations, does support this broad screening approach. And the numbers of people in the US with H pylori infection is quite large and is at least in line with many of our other preventive medicine tests.

 

Prior blogs on H. pylori: 

-- for the many prior blogs, see http://gmodestmedblogs.blogspot.com/search?q=H+pylori

-- for a blog of studies showing that H. pylori eradication decreased gastric cancer, see http://gmodestmedblogs.blogspot.com/2019/06/h-pylori-eradication-and-decreased.html , which reviews several studies including those done in asymptomatic patients, as well as some less typical presentations for H. pylori, including ITP, an array of dermatologic manifestations including chronic pruritus/chronic urticaria, and association with colon cancer

-- there are also many blogs on different therapies for H. pylori, as well as some insight into drug resistance patterns in the US: http://gmodestmedblogs.blogspot.com/2023/01/h-pylori-antimicrobial-resistance-in.html

 

 

geoff

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