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The Prevalence of Helicobacter Pylori seropositivity in Children with

Chronic Diseases

Soad M Jaber

Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah,

Saudi Arabia

Running title: H. pylori among chronic diseased children.

Correspondence author

Dr. Soad M Jaber, MD

Pediatrics Consultant

Department of Pediatrics

King Abdulaziz University Hospital

P.O. box 17818, Jeddah 21494

Kingdom of Saudi Arabia

Telephone # +966505620044

Fax # 96626444673

Email: [email protected]

1 Abstract

Helicobacter pylori seroprevalence among asympatomatic and chronically diseased children in Jeddah, Saudi Arabia was determined to gain insight into its prevalence.

Serum samples obtained from 1432 children; 543 asymptomatic and 889 chronically diseased children (diabetes, chronic asthma, chronic hemolytic anemia, neurological impairment and Down’s syndrome); were tested by ELIZA for H. pylori IgG antibodies. Dermatographic data obtained including nationality, gender, age and disease status. One hundred and twenty eight (23.6%) of 543 asympatomatic children were seropositive with no significant difference in seroprevalence of infection between Saudi and non-Saudi (p<0.09) and between boys and girls (p<0.67), but significant rise was notice by increasing age (p<0.001). An increase in risk of H. pylori was significantly increased in chronic anemia and neurological impairment

(p<0.01 and p<0.05) compared to controls. The prevalence did not differ according to nationality and gender but significantly increased with age in chronic asthma, chronic anemia and neurological impairment (p<0.01 for all) and also increased significantly with duration of illness, number of blood transfusions, number of hospital admission and mode of feeding. In conclusion, infection with H. pylori seems to occur early in life and its prevalence increased with age in Jeddah, Saudi Arabia. The risk of H. pylori infection was significantly increased within children suffers from chronic hemolytic anemia; neurological impairment compared to controls and was significantly related to severity of the chronic disease.

Key words: Helicobacter pylori, seroprevalence, diabetes, chronic asthma, chronic anemia, neurological impairment.

2 Introduction

Since the discovery of Helicobacter pylori by Warren and Marshall(1) two decades ago, evidence has been accumulating to indicate that it plays a significant role in the development of chronic gastritis, peptic ulcer diseases, mucosa-associated lymphoid tissue lymphoma, and gastric cancer.(2) Factors such as age, socio-economic level and living conditions, especially during childhood, have been postulated as important determinants in the acquisition of the microorganism. (3) Seroepidemiologic investigations have indicated that infection with H. pylori is very common throughout the world(4) and most infections are acquired during childhood. (5) The prevalence of

H. pylori infection in children in developing countries is higher, and begins at a younger age, than in developed countries. (6)

It is well known that H. pylori colonization of the gastric mucosa stimulates the release of various proinflammatory substances, such as cytokines, eicosanoids and proteins of the acute phase. (7) Moreover, a cross mimicry between bacterial and host antigens exist in H. pylori infected patients. (8) Therefore, a pathogenetic link between

H. pylori infection and diseases characterized by activation of inflammatory mediators and/or induction of autoimmunity might exist. (9) The association between

H. pylori infection and some of the chronic diseases such as diabetes, allergy, anemia, neurological impairment, and Down’s syndrome in children had previously been reported.(10, 11, 12)

Seroanthropological investigations have been useful adjuncts in improving our understanding of the co-evolution of humans and infecting microorganisms.

Microbiological and histological methods, as well as polymerase chain reaction and urea breath test, have been used to assess H. pylori infection; however, it has been

3 stressed that, in children, the specific immunoglobulin G (IgG) test may provide a useful tool in the diagnostic work-up of H. pylori infection.(13)

The aim of the current study was to determine the prevalence of H. pylori infection in Jeddah, Saudi Arabia, with a well-established ELIZA technique among asymptomatic children as well as in chronically diseased children (diabetes, chronic asthma, chronic anemia, neurological impairment and Down’s syndrome). The seroprevalence of H. pylori was evaluated according to nationality, age, sex and severity of the disease.

4 Patients and Methods

Serum samples were collected over a 2-years period between October 2001 and October 2003 from a total of 1432 children attending to outpatient clinics at King

Abdulaziz University and Maternity & Children's Hospitals, Jeddah Saudi Arabia.

The participants comprised of 543 asymptomatic children served as controls and 889 children suffer form chronic disease [diabetes (n=61); chronic asthma (n=220); chronic hemolytic anemia (n=347); neurological impairment (n=237); Down’s syndrome (n=24)]. Study participation was voluntary, and written informed consent was obtained from parents and from the older children. The Medical Ethics

Committee of King Abdulaziz University approved the study. All participated patients did not complain of any specific symptoms that might be attributable to infection with

H. pylori, such as gastrointestinal bleeding and abdominal pain. Children taking antimicrobial drugs during the 2 months prior to the study, those taking immunosuppressive or chemotherapeutic drugs, and those with primary or secondary immunodeficiency diseases were excluded from the study. Serum samples were stored at -20ºC until use. The sera were tested for H. pylori IgG with a commercially available enzyme linked immunosorbent assay kit (HM-CAP; Enteric Products

Incorporation, Westbury, NY). Using control sera, specimens were tested in duplicate according to the manufacturer's specifications,(14) which categorize results as negative, indeterminate, or positive if absorbance values (for sera diluted 1:100 at 450 nm) are

<1.8, 1.8 to 2.2, or >2.2 units, respectively. Consistent results (both positive and negative) were classified accordingly; discordant or indeterminate results were repeated and if they remained indeterminate, the patients were excluded from additional analyses. The sensitivity and specificity of the kits were 98% and 94%, respectively.(15)

5 Statistical analysis

Data were recorded and analyzed using Epi Info (version, 6.04; CDC).16 Odds ratio is used to determine the strength of association between the study outcome (H. pylori infection) and any factor believed to influence its risk. Further, the 95% confidence bounds are determined to test whether the strength of association is statistically significant. Mantel-Haenszel Chi-squared tests were used for statistical analysis. Values of P <0.05 were accepted as significant. Seroprevalence rates were compared by nationality, sex, age and severity of illness.

6 Results

Five hundred and forty-three asymptomatic children were enrolled in the study, 286 Saudi (52.7%) and 257 non-Saudi (47.3%) and 335 boys (61.7%) and 208 girls (38.3 %). Of the 543-asympatomatic children studied, positive titers for H. pylori were found in 128 children (23.6%). There was no significant difference in the prevalence of infection between non-Saudi to Saudi (12.7% versus 10.9%, p<0.09) and in boys to girls (14.9% versus 8.7%, p<0.67). However, the prevalence of H. pylori infection significantly increased with age, ranging from 12.9% in the 1- 5 years age, to 22.2% in the 6-9 years age and to 33.8% in the 10 years age, (p<0.001). This increase in prevalence with age was found among all the asympatomatic subgroups, in

Saudi (p<0.01), non-Saudi (p<0.01), males (p<0.001) and females (p<0.05; Table 2).

Patients with type I diabetic did not differ significantly in the prevalence of H. pylori infection compared with control (34.4% versus 23.6%, p<0.06), with odds ratio

1.71 and confidence limits (CI: 0.94-3.11; Table 3). There was no-significant difference in the H. pylori prevalence related to nationality, gender and increase age

(p<0.76, p<0.93, p<0.68, respectively) (Tables 4, 5) but significant difference related to the duration of illness (p<0.01; Table 6).

In chronic asthmatic patients, the prevalence of H. pylori infection was not significantly differs from control (20.4% versus 23.6%, p<0.36), with odds ratio

(0.84) and confidence limits (CI: 0.56-1.25; Table 3). There were no significant difference related to nationality and gender (p<0.42, p<0.96, respectively) among patients (Table 4). However, there were significant differences in H. pylori seroprevalence related to age (p<0.01). Increase in the prevalence with age was more apparent among Saudi and male patients (p<0.05, p<0.05 respectively) but not among non-Saudi and female patients (p<0.17, p<0.12 respectively; Table 5). No-significant

7 differences related to the duration of illness, number of hospital admission and number of ER visiting (p<0.13, p<0.55, p<0.44, respectively) were reported (Table 6).

Chronic hemolytic anemia patients showed increase in the prevalence of H. pylori infection versus control (31.7% versus 23.6%, p<0.01), with odds ratio (1.15) and confidence limits (CI: 1.11-2.07; Table 3). There were no significant difference related to nationality and gender (p<0.40, p<0.79, respectively; Tables 4). However, significant differences in H. pylori seroprevalence related to increasing age (p<0.01) was reported. The increase in the prevalence with increase age was significantly among Saudi and male patients (p<0.05, p<0.05 respectively) but not among non-

Saudi and females patients (p<0.06, p<0.25 respectively; Tables 5). There were significant association between H. pylori seroprevalence with duration of illness and number of blood transfusions (p<0.001, p<0.05, respectively; Table 6).

In patients suffer from neurological impairment, the prevalence of H. pylori infection was significantly differs from control (32.1% versus 23.6%, p<0.05), with odds ratio (1.54) and confidence limits (CI: 1.08-2.18; Table 3). There were no significant differences related to nationality and gender (p<0.91, p<0.80, respectively;

Tables 4) but a significant difference related to increasing age (p<0.01). Increase in the prevalence with age was more apparent among male patients (p<0.05) but among non-Saudi, Saudi and females patients (p<0.07, p<0.09, p<0.69 respectively; Tables

5). Significant differences in H. pylori seroprevalence related to duration of illness, number of hospital admissions and mode of feeding (p<0.001, p<0.05, p<0.01, respectively), but not with mobilization (p<0.56; Table 6) were reported.

In patients with Down’s syndrome, the prevalence of H. pylori infection was not significantly differs from control (29.2% versus 23.6%, p<0.52), with odds ratio

8 (1.34) and confidence limits (CI: 0.49-3.53; table 3). There were no significant difference related to nationality and gender (p<0.19, p<0.21, respectively; Table 4).

9 Discussion

Although H. pylori have been isolated worldwide, it is more frequently recovered from patients in developing countries.(6) This cross-sectional population based serosurvey demonstrates the prevalence of H. pylori infection among asympatomatic children in Jeddah, Saudi Arabia was 23.6%, which was not related to nationality and gender. In consistent with others(17, 18, 19) a significant increase in the seroprevalence of H. pylori infection among asympatomatic children by age was found. It has been reported that the difference in seroprevalence of H. pylori for each age group increased by approximately 1% per year.(20) A previous study in Riyadh,17

Saudi Arabia reported rapid increase in the prevalence of H. pylori infection with age from 40% at 5-10 years old to 70% at 20 years old.

Metabolic derangements that occur in diabetes may impair a number of host defenses both humoral and cellular immunity.(21) It has been speculated that alterations in the glucose metabolism may promote H. pylori colonization,(22) which could be due to the reduced gastric motility(23) or by chemical changes in gastric mucosa due to non-enzymatic glycosylation of mucins or increased sialic acid(24) which may be involved as a receptor for H. pylori on the cell surface(25) by promoting adhesion of H. pylori to gastric mucosa cells.

The current study revealed increased risk of H. pylori infection among type I diabetic children compared to controls but the difference did not reach the significant level. The increased risk was not related to nationality, gender and age; on the other hand it was associated significantly with increase duration of illness. In this concept, some investigators did not found any association between H. pylori infection and diabetes mellitus,(26) meanwhile others showed a lower seroprevalence of H. pylori in type I diabetic patients compares with controls.(27, 28) Some authors have suggested an

10 increasing prevalence of H pylori among diabetic patients,(29) however the validity of those findings has been severely criticized.(30) The great heterogeneity of results reported in the different studies could be due to methodological differences. Many studies have not reported the method used for selecting cases and control subjects or used a small sample size. It had been reported that, children with type I diabetes and

H pylori infection had an increased daily insulin requirement compared with the requirement of their uninfected peers and eradication of H. pylori infection associate with better control of glycemia.(31)

In consistence with some authors(32, 9) and in contrast with others,(33) the result of this study did not reveal increased risk of H. pylori infection in chronic asthmatic patients compared to asymptomatic children. A significant association between seroprevalence of H. pylori and increasing age was reported, on the other hand there were not related to nationality, gender, duration of illness, number of hospital admission and number of ER visiting. A novel epidemiological data from a cross- sectional survey showed that in active H. pylori infection patients, the prevalence of asthma, eczema, and allergic rhinitis is lower than in H. pylori-negative subjects.(12)

H. pylori infection is usually associated with chronic diseases; one of them is chronic anemia. In consistence with others,(34, 35, 11) the results of the present study showed a significant increase in the prevalence of H. pylori infection in chronic anemic patients compared to asymptomatic children. This study reported significant association between prevalence of H. pylori in studied chronic hemolytic anemic children with increase age, duration of illness and number of blood transfusions, meanwhile no association with nationality and gender were reported. Association between H. pylori infection and recurrent abdominal pain in children with sickle cell

11 anemia(36, 37) and iron deficiency anemia(10) in school-age children had been reported previously.

Those participants suffer from neurological impairment as reported in other studies,(38,39) showed a significant increased in the prevalence of H. pylori seropositivity compared to asymptomatic children. The prevalence of infection was significantly related to increase age, duration of illness, number of hospital admissions and mode of feeding suggesting that H. pylori seropositivity frequently develops at our institution. An increased prevalence of H. pylori seropositivity in institutionalized patients with neurological impairment had been suggested by other authors.(40, 41, 39) The factors responsible for a higher prevalence of H. pylori seropositivity in institutionalized patients with neurological impairment have not been elucidated but may include domestic crowding and other conditions, such as length of stay and age of the residents.(40) In agree with other reports,(39) this study shows that H. pylori seropositivity in institutionalized patients with neurological impairment is not associated with specific symptoms.

Mentally disabled children may be at higher risk of infections because of different feeding abilities, toileting needs, living and sanitary arrangements. No significant difference was reported in this study between risks of H. pylori infection within children suffer from Down’s syndrome compared to asymptomatic children.

The prevalence also was not related to nationality and gender. On the other hand, It had been reported by Bohmer et al.(38) that intellectually disabled persons and employees with close physical contact to them for a considerable period are at high risk of developing H. pylori infection.

12 In conclusion, the serosurvey described here found a high prevalence of H. pylori-specific IgG among asympatomatic and chronic diseased children in Jeddah,

Saudi Arabia. The prevalence of H. pylori seropositivity in children suffer from chronic disease (chronic anemia, neurological impairment) have higher risk of infection than asymptomatic children. The rate of seropositivity increased with increasing age in asympatomatic and children suffer from chronic asthma, chronic anemia and neurological impairment children. Also, there was an association between the prevalence of H. pylori seropositivity and duration of illness, number of hospital admissions, number of blood transfusions and mode of feeding in the studied chronic diseased children.

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18 Table (1): Prevalence of Helicobacter Pylori among asympatomatic children with nationality and gender variable.

Variable Seropositive Total Significance Number (%) Number (%) Saudi (%) 59 (10.9%) 286 (52.7%)

Non-Saudi (%) 69 (12.7%) 257 (47.3%) p>0.05

Male (%) 81 (14.9%) 335 (61.7%)

Female (%) 47 (8.7%) 208 (38.3%) p>0.05

Total (%) 128 (23.6%) 543 (100%)

Significance Saudi versus non-Saudi, male versus female.

Table (2): the frequency of risk of Helicobacter pylori infection in relation to age, nationality, gender within asympatomatic children.

Variable Age (years) 1-5 years 6-9 years ≥10 years Significance Seropositive % Seropositive % Seropositive % ((total ((total ((total Saudi 8 (81) 4.9% 19 (98) 10.3% 32 (102) 16.4% P<0.01

Non-Saudi 13 (82) 8.0% 22 (87) 11.9% 34 (93) 17.4% P<0.01

Male 15 (109) 9.2% 26 (112) 14.1% 40 (114) 20.5% P<0.001

Female 6 (54) 3.7% 15 (73) 8.1% 26 (81) 13.3% P<0.05

Total 21 (163) 12.9% 41 (185) 22.1% 66 (195) 33.8% P<0.001

Significance between different ages in the same group.

19 Table (3): The difference of risk of Helicobacter pylori infection in chronically diseased children compared with controls.

Prevalence Odds ratio Chi-square [Confidence limits (CI)] P value Control 23.6%

Diabetic 34.3% 1.71 (0.94-3.11) >0.05

Chronic asthma 20.4% 0.84 (0.56-1.25) >0.05

Chronic anemia 31.7% 1.15 (1.11-2.07) <0.01

Neurological 32.1% 1.54 (1.08-2.18) <0.05 impairment

Down’s syndrome 29.2% 1.34 (0.49-3.53) >0.05

Significance versus control group.

20 Table (4): Association of Helicobacter Pylori seropositivity with nationality and gender variable within various groups of chronically diseased children.

Variable Seropositive Total Significance Number (% to group) Number (% to group) Diabetic Saudi 5 (8.2%) 16 (26.2%) Non-Saudi 16 (26.2%) 45 (73.8%) p>0.05 Male 17 (27.9%) 49 (80.3%) Female 4 (6.6%) 12 (19.7%) p>0.05 Total of the group 21 (34.3%) 61 (100%)

Chronic asthma Saudi 28 (12.7%) 148 (67.3%) Non-Saudi 17 (7.7%) 72 (32.7%) p>0.05 Male 30 (13.6%) 146 (66.4%) Female 15 (6.8%) 74 (33.6%) p>0.05 Total of the group 45 (20.4%) 220 (100%)

Chronic haemolytic anaemia Saudi 49 (14.1%) 166 (47.8%) Non Saudi 61 (17.6%) 181 (52.2%) p>0.05 Male 74 (21.3%) 230 (66.3%) Female 36 (10.4%) 117 (33.7%) p>0.05 Total of the group 110 (31.7%) 347 (100%)

Neurological impairment Saudi 41 (17.3%) 129 (54.5%) Non-Saudi 35 (14.8%) 108 (45.6%) p>0.05 Male 49 (20.7%) 150 (63.3%) Female 27 (11.4%) 87 (36.7%) p>0.05 Total of the group 76 (32.1%) 237 (100%)

Down’s syndrome Saudi 3 (12.5%) 12 (50.0%) Non-Saudi 4 (16.7%) 12 (50.0%) p>0.05 Male 6 (25.0%) 16 (66.7%) Female 1 (4.2%) 8 (33.3%) p>0.05 Total of the group 7 (29.2%) 24 (100%)

Significance Saudi versus non-Saudi, male versus female.

21 Table (5): the frequency of risk of Helicobacter pylori infection in relation to age, nationality, gender within chronically diseased children.

Age (years) 1-5 years 6-9 years ≥10 years Significance Seropositive % Seropositive % Seropositive % ((total ((total ((total Diabetes Saudi - - 2 (8) 8.0% 3 (8) 9.7% p>0.05 Non Saudi 1 (5) 20.0% 6 (17) 24.0% 9 (23) 29.0% p>0.05 Male 1 (5) 20.0% 7 (21) 28.0% 9 (23) 29.0% p>0.05 Female - - 1 (4) 4.0% 3 (8) 9.7% p>0.05 Total 1 (5) 20.0% 8 (25) 32.0% 12 (31) 38.7% p>0.05

Chronic asthma Saudi 8 (72) 7.7% 7 (36) 13.3% 13 (39) 20.6% P<0.05 Non Saudi 4 (32) 3.8% 4 (17) 7.5% 8 (24) 12.7% p>0.05 Male 9 (70) 8.7% 7 (33) 13.3% 14 (43) 22.2% P<0.05 Female 4 (34) 3.8% 4 (20) 7.5% 7 (20) 11.1% p>0.05 Total 13 (104) 12.5% 11 (53) 20.8% 21 (63) 33.3% P<0.01

Chronic haemolytic anaemia Saudi 4 (32) 7.4% 14 (59) 12.0% 31 (84) 17.6% P<0.05 Non Saudi 6 (30) 11.1% 17 (59) 14.5% 38 (92) 21.6% p>0.05 Male 7 (37) 13.0% 22 (81) 18.8% 45 (109) 25.6% P<0.05 Female 3 (17) 5.5% 9 (36) 7.7% 24 (67) 13.6% p>0.05 Total 10 (54) 18.5% 31 (117) 26.5% 69 (176) 39.2% P<0.01

Neurological impairment Saudi 10 (46) 11.6% 13 (43) 16.5% 18 (40) 25.0% p>0.05 Non Saudi 9 (40) 10.5% 11 (36) 13.9% 15 (32) 20.8% p>0.05 Male 12 (54) 14.0% 16 (51) 20.3% 21 (45) 29.2% P<0.05 Female 7 (32) 8.1% 8 (28) 10.1% 12 (27) 16.6% p>0.05 Total 19 (86) 22.1% 24 (79) 30.4% 33 (72) 45.8% P<0.01

Significance between different ages in the same group.

22 Table (6): the frequency of risk of Helicobacter pylori infection in relation to different categories within chronically diseased children. Category Seropositive (%) Total number of patients Significance Diabetes Duration of illness 0-4 5 (10.0%) 30 5-7 5 (38.5%) 13 ≥8 11 (61.1%) 18 P<0.01 Chronic asthmatic Duration of illness 0-4 27 (17.6%) 153 5-7 9 (22.5%) 40 ≥8 9 (34.6%) 26 p>0.05 Number of hospital admissions 0-1 35 (19.1%) 183 2-3 4 (26.7%) 15 >3 6 (27.3%) 22 p>0.05 Number of ER visiting 0-12 35 (19.0%) 184 13-23 5 (25.0%) 20 >23 5 (31.3%) 16 p>0.05 Chronic haemolytic anaemia Duration of illness 0-4 9 (10.3%) 87 5-7 36 (32.1%) 112 ≥8 65 (43.9%) 148 P<0.001 Number of blood transfusions 0-9 64 (27.5%) 233 10-14 38 (38.4%) 99 >14 8 (53.3%) 15 P<0.05 Neurological impairment Duration of illness 0-4 25 (24.5%) 102 5-7 33 (30.6%) 108 ≥8 17 (63.0%) 27 P<0.001 Number of hospital admissions 0-9 41 (26.1%) 157 10-14 15 (39.5%) 38 >14 20 (47.6%) 42 P<0.05 Mobilization Free mobilization 33 (35.9%) 92 Bed ridden 11 (32.3%) 34 Wheel chair 32 (28.8%) 111 p>0.05 Mode of feeding Oral 62 (32.5%) 191 N.G 10 (58.8%) 17 Others 3 (10.7%) 28 P<0.01

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