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Seroepidemiological Investigation of Antigen and Antibody for the Detection of Helicobacter Pylori Infection in a Rural Area of Nepal

Article Information

Suresh Jaiswal1,3*, Bishnu Raj Tiwari1, Ashok Kumar Sah2, Dinesh C Sharma3

1School of Health & Allied Sciences, Pokhara University, Pokhara, Nepal

2Amity Medical School, Amity University, Haryana, Gurugram, India

3School of Life and Allied Health Science, Glocal University, Saharanpur, UP, India

*Corresponding Author: Suresh Jaiswal, Ph.D. Research Scholar, School of Life and Allied Health Sciences, Glocal University, Saharanpur, UP, India

Received: 29 April 2020; Accepted: 11 May 2020; Published: 15 May 2020

Abstract

Abstract

Objective: Helicobacter pylori (H. pylori) is now recognized as a worldwide problem. The objective of the study was to investigate the seroprevalence of H. pylori infection and factors associated in a rural area of Nepal.

Methods: A community based cross-sectional study was carried out on 120 individuals based on cluster sampling of residential location in Province 2, Nepal. H. pylori infection status was determined by serology test on stool and blood samples for antigen and antibody. A questionnaire was filled out and written consent was taken. Data were analyzed using chi- square test and P- value (≤ 0.05) were considered statistically significant.

Results: Out of 120 participants 57(47.5%) and 63(52.5%) were female and male respectively. Similarly 5.8% were less than 20 years of age 49.2% were 20 to 40 age and 45% were more than 40 years age. Significant association was seen with occupation P=0.023 with antigen and P=0.042 with antibody result, consumption of water P=0.04 with antigen and P=0.005 with antibody, with onion and garlic P=0.032, consumption fried food P=0.024 and consumption and spicy food consumption P=0.050 with antigen, with onion and garlic P=0.027, consumption of fried food P=0.024 and consumption of spicy food P=0.050 with antibody positive result showed significant association.

Conclusions: The result of our research suggests the periodic screening and checkup of the patients in order to detect the infecting agent among the rural areas patient and effective treatment is required.

Keywords

Gastritis; Retrosternal- burn; Helicobacter pylori; Antigen; Antibody

Article Details

Introduction

Helicobacter pylori is associated with gastro-duodenal infections in human [1] H. pylori has been found strongly related to chronic gastritis, duodenal ulcer, gastric carcinoma, and mucosa-associated lymphoid malignancies. Gastric cancer is the most common disease related cancer globally [2,3,4].

The infection is widespread throughout the world, and is present in about 50% of the global human population; with 80% in developing countries and 20 - 50% in industrialized countries. It is the major cause of gastritis, which plays a key role in the etiology of peptic ulcer and is a risk factor for gastric carcinoma [5].

Sero-epidemiological investigations represent the most rapid and convenient way of obtaining a picture of the prevalence of H. pylori infection in a population, but the assays used need to be validated in the population studied [6, 7, 8]. Serologic investigations are usually performed to detect specific antibodies against H. pylori. They are commercially and easily available, less expensive and easy to perform. However this diagnosis of H. pylori cannot differentiate between active and asymptomatic colonization, past and current infection [9]. Stool antigen Immunochromatography Rapid Detection Test (RDT) is used to detect H. pylori antigens in the feces. However this is a reliable and accurate diagnostic technique for H. pylori infection and verification of its cure after treatment. It is convenient for the patients and can be easily performed even in small laboratories [10,11]. However its accuracy in different clinical settings and controlled studies is a problem for discussion [12,13].

The present study was therefore designed for comparative evaluation of stool antigen test and blood antibody test methods detection by a commercially available kit for diagnosis of H.pylori infection in rural areas of Nepal.

Methodology

1. Study design, period and setting

This was a cross-sectional, community based study conducted in the Aurahi village, Mahottari district, Nepal. The study took place over a 1 year period from February 2019 till January 2020. About 120 participants were enrolled in the study.

2. Study population

All participants were from this village. The suspicious patient for H. pylori with symptoms such as abdominal pain, recurrent vomiting, and upper gastrointestinal bleeding were recruited. A total of 120 participants were enrolled for the study.

3. Study tools and data collection

Demographic details and clinical features

  1. a) A pre-test structured questionnaire was used to collect information from the participants regarding possible risk factors for infection including the following: (i) socio- demographic characteristics including age, gender, residence, education, family members (number of people living in the household), and availability of potable water; and (ii) dietary practices, such as daily eating food habits. Questions used in this section were adopted from the various literature by the researchers and were revised by experts from Microbiology.

4. Ethical Consideration

An ethical permission was obtained from Institutional Review Committee, Pokhara University for ethical clearance (Ref no.97/076/077). The permission was obtained from the Aurahi, ward office, Mahottari District, Nepal. Participants were verbally informed about the study and written consents were taken from the eligible participants.

5. Laboratory tests

  1. Helicobacter pylori antigen testing
  2. pylori was diagnosed using a stool antigen test which is rapid, non-invasive, reliable and easy to perform and can be used to detect an existing infection. Participants were given clean, leak proof containers to provide fresh stool samples within 2 hours. All stool specimens were transported to the laboratory maintaining at −4°C. The specimen that took more than 2 hours before processing were kept at −20°C. A lateral flow Immunochromatography assay for detection of H. pylori antigen in stool was used with a sensitivity of 96% and specificity of 83% by CTK diagnostic kit. Based on the intensity of the color band developed, results were reported as H. pylori antigen not detected or detected.

b. Helicobacter pylori antibody testing

Blood samples were collected which were labeled with unique code number and centrifuged to get serum and the samples were processed for H. pylori antibody by rapid kit method by CTK diagnostic kit with a sensitivity of 96% and specificity of 83%.

6. Statistical analysis

Recorded data was entered on the computer using the MS Excel and statistical analysis was done by Statistical Package of Social Science Software Program (SPSS), version 16. Data was presented using mean, median, range, and frequency and percentages for qualitative ones. Comparison between groups was performed using chi-square test for qualitative ones. P-value (≤ 0.05) was considered statistically significant.

Results

A community based cross-sectional study was carried out in a rural area, Aurahi, Mahottari district, Nepal. All together 120 participants were involved in the study. 57(47.5%) and 63(52.5%) were female and male participant respectively. 95% were Hindu and 5% were Muslim. Similarly 5.8% were less than 20 years of age 49.2% were 20 to 40 age and 45% were more than 40 years age as shown in table 1.

Table 1: Socio-demographic characteristics of participants

Variables

Frequency(n)

Percentages (%)

Age category (yrs.)

Less than 20

7

5.8

20-40

59

49.2

More than 40

54

45.0

Sex

Female

57

47.5

Male

63

52.5

Marital status

Divorced

1

.8

Married

114

95.0

Unmarried

5

4.2

Religion

Hindu

114

95.0

Muslim

6

5.0

Total

120

100.0

Family status of the participants show that 55% were less than 5 family numbers 42.5% were less than 10 and more than 5, 2.5% were more than 10 in their family. Similarly 15% were businessman, 21.7% were employee, 17.5 were farmer, 43.3% were housewife and 2.5% were student respectively. Similarly 44.2% were illiterate, 25% had primary education, 21.7% had secondary education and 9.2% were university graduates. 50% were those who had income less than1 lakh per year as in table 2.

Table 2: Family status of participants

Variables

Frequency(n)

Percentages (%)

Family member

Less than 10 and more than 5

51

42.5

Less than 5

66

55.0

more than 10

3

2.5

Occupation

Business

18

15.0

Employee

26

21.7

Farmer

21

17.5

Housewife

52

43.3

Student

3

2.5

Education

Illiterate

53

44.2

Primary school

30

25.0

Secondary school

26

21.7

University

11

9.2

Total income

1lakh to 2.5 lakh

40

33.3

2.5 to 5 lakh

12

10.0

Less than 1 lakh

60

50.0

More than 5 lakh

8

6.7

Total

120

100.0

Table 3: Food habits of participants

Variables

Frequency(n)

Percentages (%)

Frequency of vegetables

Everyday

110

91.7

Never

1

.8

Some times a week

9

7.5

Fruits

Everyday

30

25.0

Never

9

7.5

Sometimes a week

81

67.5

Milk, Meat products

Everyday

60

50.0

Never

8

6.7

Sometimes a week

52

43.3

Onion & garlic

Everyday

116

96.7

Never

1

.8

Sometimes a week

3

2.5

Fried foods

Everyday

50

41.7

Never

2

1.7

Sometimes a week

68

56.7

Spicy foods

Everyday

73

60.8

Never

8

6.7

Sometimes a week

39

32.5

Total

120

100.0

Table 4: Alcohol consumption and smoking habits of participants 25.8% were alcohol consumer while 14.2% were smokers.

Variables

Frequency(n)

Percentages (%)

Alcohol

No

89

74.2

Yes

31

25.8

Smoking

No

103

85.8

Yes

17

14.2

Total

120

100.0

Table 5: Hygiene practices

Variables

Frequency(n)

Percentages (%)

Using finger to eat

Always

120

100.0

Hand washing before meal

Always

116

96.7

Less frequent

4

3.3

Toilet facility

No

9

7.5

Yes

111

92.5

Hand washing after toilet

Always

117

97.5

Less frequent

3

2.5

Consumption of drinking water

Hand pump

108

90.0

Public

8

6.7

Well

4

3.3

Total

120

100.0

Table 6: H. pylori antigen and antibody detection 41.7% (50) were positive for H. pylori antibody while 43.3% (52) were positive H. pylori antigen test as shown in table.

Variables

Frequency(n)

Percentages (%)

Results (Ab)

Negative

70

58.3

Positive

50

41.7

Results (Ag)

Negative

68

56.7

Positive

52

43.3

Total

120

100.0

Table 7: Association of socio demography with H. pylori antigen antibody positive test.

H. pylori Antigen

H. pylori Antibody

(n = 120)

(n = 120)

Variable

No.

No. (%)

p-value

No. (%)

p-value

Category

positive

positive

Age (years)

Less than 20

7

2(3.8%)

0.358

2(4.0%)

0.564

20-40

59

23(44.2%)

23(46.0%)

More than 40

54

27(51.9%)

25(50.0%)

Sex

Female

57

28(53.8%)

0.223

26(52.0%)

0.460

Male

63

24(46.2%)

24(48.0%)

Marital status

Divorced

1

1(1.9%)

0.513

1(2.0%)

0.493

Married

114

49(94.2%)

47(94.0%)

Unmarried

5

2(3.8%)

2(4.0%)

Total

120

52(100.0%)

50(100.0%)

No significant association was seen with sociodemographic study.

Table 8: Association of family status with H. pylori antigen antibody positive test.

H. pylori Antigen

H. pylori Antibody

(n = 120)

(n = 120)

Variable

No.

No. (%)

p-value

No. (%)

p-value

Category

positive

positive

Family members

Less than 10 and

more than 5

51

25(48.1%)

0.546

23(46.0%)

0.465

Less than 5

66

26(50.0%)

26(52.0%)

More than 10

3

1(1.9%)

1(2.0%)

Occupation

Business

18

7(13.5%)

0.023*

7(14.0%)

0.042*

Employee

26

5(9.6%)

5(10.0%)

Farmer

21

13(25.0%)

13(26.0%)

Housewife

52

25(48.1%)

23(46.0%)

Student

3

2(3.8%)

2(4.0%)

Education

Illiterate

53

27(51.9%)

0.237

26(52.0%)

0.185

Primary school

30

9(17.3%)

8(16.0%)

Secondary school

26

10(19.2%)

10(20.0%)

University

11

6(11.5%)

6(12.0%)

Total income

1lakh to 2.5 lakh

40

17(32.7%)

0.498

16(32.0%)

0.498

2.5 to 5 lakh

12

3(5.8%)

3(6.0%)

Less than 1 lakh

60

29(55.8%)

28(56.0%)

More than 5 lakh

8

3(5.8%)

3(6.0%)

Total

120

52(100.0%)

50(100.0%)

*Significant association

Significant association was seen with occupation P-value (0.023) with antigen and P-value (0.042) with antibody positivity result.

Table 9: Association of Hygiene practice with H. pylori antigen antibody positive test.

H. pylori Antigen

H. pylori Antibody

(n = 120)

(n = 120)

Variable

No.

No. (%)

p-value

No. (%)

p-value

Category

positive

positive

Hand washing before meal

Always

116

48(92.3%)

0.334

47(94.0%)

0.307

Less frequent

4

4(7.7%)

3(6.0%)

Toilet facility

No

9

4(7.7%)

0.569

4(8.0%)

0.507

yes

111

48(92.3%)

46(92.0%)

Hand washing after toilet

Always

117

50(96.2%)

0.578

49(98.0%)

0.658

Less frequent

3

2(3.8%)

1(2.0%)

Consumption of drinking water

Hand pump

108

48(92.3%)

0.04*

46(92.0%)

0.005**

Public

8

4(7.7%)

4(8.0%)

Well

4

0(0.0%)

0(0.0%)

Total

120

52(100.0%)

50(100.0%)

*Significant ** highly significant

Significant association was seen with consumption of water P-value (0.04) with antigen and P-value (0.005) with antibody positivity result.

Table 10: Association of eating habits with H. pylori antigen antibody positive test.

H. pylori Antigen

H. pylori Antibody

(n = 120)

(n = 120)

Variable

No.

No. (%)

p-value

No. (%)

p-value

Category

positive

positive

Frequency of eating vegetables

Everyday

110

46(88.5%)

0.239

44(88.0%)

0.207

Never

1

0(0.0%)

0(0.0%)

Some times a week

9

6(11.5%)

6(12.0%)

Consumption of fruits

Everyday

30

16(30.8%)

0.405

15(30.0%)

0.452

Never

9

3(5.8%)

3(6.0%)

Sometimes a week

81

33(63.4%)

32(64.0%)

Milk and meat products

Everyday

60

23(44.2%)

0.372

23(46.0%)

0.425

Never

8

5(9.6%)

5(10.0%)

Sometimes a week

52

24(46.2%)

22(44.0%)

Onion and Garlic

Everyday

116

48(92.3%)

0.032*

46(92.0%)

0.027*

Never

1

1(1.9%)

1(2.0%)

Sometimes a week

3

3(5.8%)

3(6.0%)

Fried Foods

Everyday

50

27(51.9%)

0.024*

26(52.0%)

0.024*

Never

2

2(3.8%)

2(4.0%)

Sometimes a week

68

23(44.2%)

22(44.0%)

Spicy foods

Everyday

73

33(63.5%)

0.050*

32(64.0%)

0.05*

Never

8

6(11.5%)

6(12.0%)

Sometimes a week

39

13(25.0%)

12(24.0%)

Total

120

52(100.0%)

50(100.0%)

*Significant

Significant association was seen with onion and garlic P-value (0.032), consumption of fried food P-value (0.024) and consumption of spicy food P-value (0.050) with antigen while significant association was seen with onion and garlic P- value (0.027), consumption fried food P-value (0.024) and consumption and spicy food consumption P-value (0.050) with antibody positive result.

Table 11: Association of Alcohol and smoking habits with H. pylori antigen antibody positive test.

H. pylori Antigen

H. pylori Antibody

(n = 120)

(n = 120)

Variable

No.

No. (%)

p-value

No. (%)

p-value

Category

positive

positive

Alcohol consumption

No

89

41(78.8%)

0.401

39(78.0%)

0.276

Yes

31

11(21.2%)

11(22.0%)

Smoking habits

No

103

43(82.7%)

0.412

42(84.0%)

0.409

Yes

17

9(17.3%)

8(16.0%)

Total

120

52(100.0%)

50(100.0%)

No significant association was seen with alcohol consumption and smoking habits.

Discussion

This study was a community based cross sectional study choosing individual with gastritis as a research participants. The study was carried out in a rural areas in a village called Aurahi, Mahottari district, Nepal. In our study, the total number of 120 research participants were included whose stool was collected for IRD antigen test and blood sample for serum IRD antibody test.

The prevalence of H. pylori was 43.3% by stool antigen test and 41.7% serum antibody by Immunochromatography Rapid Test. This prevalence was low compared to other studies done elsewhere in the developing world [14,15]. The difference in results is probably due to the variations in the study population, and the age and health conditions of the patients. In addition, differences in the geographic regions, the type of test specimens (stool and blood), the analytical methods used, and the target molecules, that is, antigen versus antibodies, are likely to have influenced the differences in the study findings.

The current study population was mainly above 14 years of age, hence a lower prevalence than that reported in other developing countries. This is supported by the findings of studies by Newton et al. [16], Jackman et al. [17], Brandi et al. [18], and Hestvik et al. [19]. A study by Triantafyllopoulou et al. [20] revealed that most adults infected with H. pylori organism are asymptomatic and may therefore test negative by the antibody-detection tests and positive by the antigen- detection tests. Hence, the stool antigen tests can aid in detection of actively infected or carrier individuals.

More female patients tested positive (53.8% by stool antigen and 52.0% by serum antibody); however, this was not significantly different (p=0.460) to that of the male participants (46.2.8% by stool antigen and 48.0% by serum antibody). However, Moayyedi et al. [21] reported that males, living with a partner, and poor adult socio-economic conditions are associated with increased risk of H. pylori infection. Our study also examined possible predisposing factors to infection. It was found that cigarette smoking, poor sanitation, and lack of formal education were the predisposing factors to H. pylori infection.

  1. pylori Seropositivity decreased linearly with cigarette consumption because Khalifa et al. [22] proved that there is no significant association between cigarette smoking with H. pylori infection, the most likely risk factor in the current study was poor living conditions, which is in agreement with findings from similar studies in other countries [23- 26]. Triantafyllopoulou et al. [20] reported that the acquisition of H. pylori could result from environmental and professional exposure issues, and poor public water supply.

The current study aimed at establishing the Seroepidemiological prevalence of H. pylori and the risk factors in rural parts of Nepal. The prevalence is less than what has previously been reported in other developing countries as well as in urban areas and rural areas.

Conclusion and Recommendation

Even though people were using gastritis drugs, still the prevalence of H. pylori in these individuals is found higher. H. pylori was more among female than male and was higher in age group more than 40 years. The result of our research suggests the periodic screening and checkup of the patients in order to detect the infecting agent among the rural areas patient. Only the use of gastritis drugs is not enough to complete treatment anti H. pylori drugs are required for treating of infective gastritis for complete treatment.

Various public awareness and health education programs should be conducted to aware people about gastritis and its consequences like having ulcers. Awareness campaigns should be focused in remote areas where education is not primary.

Acknowledgement

The authors like to acknowledge the Research Centre, Pokhara University and ward office Aurahi for giving the permission to undertake the study. The authors like to thank all the participant and those directly and indirectly who supported to shape up of this research.

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    Editor In Chief

    Jean-Marie Exbrayat

  • General Biology-Reproduction and Comparative Development,
    Lyon Catholic University (UCLy),
    Ecole Pratique des Hautes Etudes,
    Lyon, France

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