|Year : 2022 | Volume
| Issue : 1 | Page : 4
Helicobacter pylori infection in a multi-ethnic population in east coast of Borneo, Malaysia: The effects of ethnicity
Ooi-Cheng Lee, Chung-Ket Lai
Duchess of Kent Hospital, Sandakan, Sabah, Malaysia
|Date of Submission||16-Mar-2020|
|Date of Decision||17-Feb-2022|
|Date of Acceptance||02-May-2022|
|Date of Web Publication||25-May-2022|
Duchess of Kent Hospital, Sandakan, Sabah
Source of Support: None, Conflict of Interest: None
Objective: To determine the prevalence of Helicobacter (H.) pylori infection among the population of east coast of Borneo and explore the relationship between demographic factors, ethnicity and risk of H. pylori infection.
Methods: This cross-sectional study enrolled 211 patients who underwent elective oesophagogastroduodenoscopy in 2017. Demographic data, endoscopic indications as well as the results of the mucosal biopsy were obtained and analysed from the endoscopy unit registry.
Results: A total of 211 patients from 14 ethnic groups were enrolled in the study, most of were Chinese (28.4%), followed by Dusun (14.7%) and Songgai (13.7%). Overall, the period prevalence for 2017 was 44.5%. Multivariate logistic regression analysis showed an association between ethnicity and H. pylori. Bajau (adjusted odds ratio=5.612, P=0.005) and Dusun ethnic groups (adjusted odds ratio=7.359, P=0.001) were at a significantly higher risk of H. pylori infection compared to Chinese. However, the regression model only explained 11.6% (Cox & Snell Pseudo R2) of the prevalence of H. pylori infection.
Conclusions: The period prevalence for 2017 was 44.5%, with certain indigenous ethnic groups having a higher risk than others. Clinicians should consider obtaining further history regarding the ethnic’s culture and dietary practice prior to starting H. pylori eradication therapy.
Keywords: Helicobacter pylori; Prevalence; Borneo; Ethnicity
|How to cite this article:|
Lee OC, Lai CK. Helicobacter pylori infection in a multi-ethnic population in east coast of Borneo, Malaysia: The effects of ethnicity. One Health Bull 2022;2:4
|How to cite this URL:|
Lee OC, Lai CK. Helicobacter pylori infection in a multi-ethnic population in east coast of Borneo, Malaysia: The effects of ethnicity. One Health Bull [serial online] 2022 [cited 2022 Dec 2];2:4. Available from: http://www.johb.info/text.asp?2022/2/1/4/345316
| Introduction|| |
Dyspepsia is defined as pain or discomfort centered on the upper abdomen. It is an extremely common but not yet fully understood clinical problem. One common etiology of dyspepsia is Helicobacter (H.) pylori infection. About 50% or more of the world population is infected with H. pylori, making it one of the most widespread infections across the globe. H. pylori is known to be more prevalent in developing countries and it can result in ulcers and complications such as bleeding or perforation if left untreated. It thus poses heavy morbidity and economic impact towards the healthcare system.
In Malaysia, H. pylori infection rates have been reported between 19%-38.2%. Studies in Peninsular Malaysia demonstrated that Indian and Chinese communities have higher proportion of H. pylori infection compared to Malay population,,. However, only small number of studies on H. pylori infection have been conducted in Sabah and Sarawak (east Malaysia). A single centre study by Chai et al. concluded that the indigenous group have higher incidence of H. pylori infection compared to the Chinese ethnic group. Previously, Goh KL conducted sero-epidemiology of H. pylori among different ethnic groups and found that H. pylori prevalence was 55% in Sabah and indigenous group had higher odds to be infected compared to the other ethnic groups. In both studies, the risk factors of H. pylori infection amongst indigenous population of Borneo were not fully explored.
Sabah is part of Borneo and consists of 42 indigenous groups with various cultural practices and socio-economic backgrounds. However, knowledge of H. pylori infection is limited among many ethnic and indigenous population in Sabah. Hence, this study was to explore the risk of H. pylori infection among different ethnic groups in Sabah. The main objectives were to determine the prevalence of H. pylori infection among the population of east coast of Borneo and explore the relationship between demographic factors, ethnicity and the risk of H. pylori infection.
| Materials and methods|| |
2.1. Ethical Approval
This study obtained ethical approval from the Medical Research and Ethics Committee (MREC) of Malaysia. [email protected];No.NMRR-18-3073-44823]
This was a cross-sectional study conducted in a district hospital as well as being the only hospital that exclusively provides endoscopic services, covering the area of 28 000 square kilometre. This study included all consented patients who underwent selective oesophagogastroduodenoscopy (OGDS) from January 1 to December 31, 2017, either with indication of organic or non- organic dyspepsia, or the others who had indications of screening or postoperative surveillance for malignancy.
Mucosal samples were biopsied and performed using Rapid Urease Test (Pronto Dry; Pentland Medical) for individual patients. A positive Rapid Urease test indicates the presence of H. pylori infection. Demographic data, endoscopic indications as well as the results of the mucosal biopsy were obtained from the endoscopy unit registry. Emergency cases were excluded as the cases were all due to upper gastro-intestinal bleed. As blood decreases the sensitivity of Rapid Urease Test due to the presence of albumin, those cases were excluded to prevent over-reporting.
After data collection, the analysis was done using R-studio software (R-studio; Public Benefit Corporation). Findings were presented descriptively using mean (SD) and median (IQR) for normally and non-normally distributed continuous variables, respectively, while results of categorical variables were presented as frequencies (n) and percentages (%). Linear regression was used to assess independent association between the outcome variable. Multivariate logistic regression analysis was used to select variables by stepwise methods, analyse the clinical indications of H. pylori infection and associated demographic factors (including age, gender, ethnicity, marital status), check for multicollinearity and no factors were removed from the generalized linear model. Interactions between predictor variables were examined and model fitness was assessed using Hosmer-Lemeshow goodness-of-fit test as well as Receiver Operator Characteristic curve analysis. A value of P<0.05 was considered statistically significant.
| Results|| |
A total of 211 consecutive patients were enrolled in the study, aged from 13 to 88 , comprising 111 males and 100 females. Overall there were 14 ethnic groups, majority being Chinese (28.4%), followed by Dusun (14.7%) and Sungai (13.7%).
The prevalence of H. pylori among patients who had OGDS was 44.5% (94/211). [Table 1] shows the demographic distribution of the patients with presence of H. pylori infection. For ethnicity, major ethnic groups were included for analysis, while 6 minor ethnic groups such as Kegayan, Bisaya and Murut ethnics were categorized into others.
|Table 1: Demographic and ethnic data of patients with Helicobacter pylori.|
Click here to view
[Table 2] shows the results of the univariate and multivariate logistic regression of patients’ demography with H. pylori infection. Age, gender, marital status and indication for OGDS were not statistical significant. On the other hand, ethnicity was identified as a risk for H. pylori infection (P=0.002), of which the Bajau and Dusun ethnic groups had 5.6 times higher odds (P=0.005) and 7.4 times higher odds (P=0.001) respectively of being infected with H. pylori compared to those of Chinese ethnicity. However, in this study, dyspepsia was not considered a significant risk of having H. pylori infection (P≥0.95 ).
|Table 2: Univariate & multivariate logistic regression analysis for factors associated with Helicobacter pylori infection.|
Click here to view
| Discussion|| |
In this study, the period prevalence for H. pylori infection was about 44.5% and this was comparable to the findings by Goh KL who reported a prevalence of 55% among indigenous population. Nevertheless, the H. pylori prevalence in our sample was comparatively higher than the globally reported Malaysian ranges of 19%-38.2%, as the true prevalence of H. pylori in Sabah may be lower due to the method of sampling used (convenience sampling). Furthermore, being the referral centre for OGDS which covers 28 000 square kilometre, subjects’ medical records were taken from an endoscopy unit, and thus increases the proportion of those diagnosed with H. pylori.
Reviews demonstrated that H. pylori infection was significantly higher among those with dyspepsia compared to those who were asymptomatic,, as well as H. pylori eradication therapy improveed the symptoms of dyspepsia. Our data showed 83.4% of the subjects underwent OGDS because of dyspepsia. However, our
Data for this study was collected in 2017 and analyzed in 2020, and re-analyzed on similar dataset in Feburary 2022 with similar results. The analysis of all variables showed the regression model had an acceptable fit by Hosmer-Lemeshow goodness of fit test [X2 (df) =2.1924(8), P=0.9745] as well as with Receiver Operator Characteristic curve analysis with Area Under the Curve with an acceptable level of 70.1%. However the model only explained 11.6% (Cox & Snell Pseudo R2) of the prevalence of H. pylori infection of this study.
study concluded that there were no statistical association between dyspepsia and H. pylori infection. This might be due to other causes of dyspepsia such as functional dyspepsia, alcohol consumption, and drugs such as non-steroidal anti-inflammatory drugs, but details regarding drug history or history of alcohol consumption were unavailable within the medical records, which is a limitation for this study.
Multiple studies have shown that the difference in prevalence among the major ethnic groups of Malaysia which consist of Malay, Chinese and Indian,. Nonetheless, the strength of our study was the ability to demonstrate that specific ethnic group in Borneo were at risk to be infected by H. pylori, which no other studies have discovered. Our study used the Chinese ethnic group as the reference group for statistical analysis due to the recent study in Borneo reported the Chinese having lower risk of H. pylori infection compared to indigenous population. We reported that few indigenous groups were at higher odds of being infected due to the different cultural and dietary practice of food consumption which use more preserved and salted food, and regular consumption of salted food increases the risk of H. pylori infection,. Malaysian indigenous population were generally from low socio-economic background, consequently, families lived in an overcrowded houses with non-optimal sanitation and water filtration, which increased the risk of being infected by H. pylori. However, as part of the limitation of this study, details of patients’ socio-economic background as well as individual ethnic dietary practice were not within the medical records, therefore this lack of information serves as a platform for future researches to explore on different dietary practice and sanitation among each ethnic group with the risk of H. pylori infection or large-scale studies that compare every ethnic groups both in Borneo and Peninsular of Malaysia.
In Asia, there may be some genetic variations among different population. The variable genetic expression of the person may increase or decrease the risk of being infected by H. pylori. So far in Malaysia, a few studies have demonstrated that there is an association between the genetic constitution of individual ethnicity and H. pylori infection,, however they did not have information regarding indigenous population of Peninsular or Borneo. But the risk of being infected may also be due to the virulence of the bacteria. In Vietnam, some ethnic groups were statistically more at risk of being infected by H. pylori, as well as significant difference in histological scores and genotypes between each group. Similarly, in Thailand, there were different distributions of H. pylori strains among independent ethnic groups. In Malaysia, it was reported that the Chinese ethnic group was more prone to be infected with metronidazole-sensitive H. pylori strains, whereas Malay and Indian population were more likely to be infected with the antibiotic- resistant strains, . This is due to the difference in genomic sequence of H. pylori present in each ethnic group of Malaysia. However, there is no available study to discuss the antibiotics- resistance and virulence of H. pylori in Borneo. There is also gaps of knowledge regarding genetic predisposition of the indigenous population of Borneo. Hence more research indicated for genetic exploration about the host as well as the pathogen, as it may alter the treatment of H. pylori eradication in terms of choice of antibiotics.
In conclusion, the period prevalence for this study was 44.5%, with certain indigenous ethnic groups had higher risk than the other. Clinicians should consider obtaining further history regarding the ethnic’s culture and dietary practice prior to starting H. pylori eradication therapy, specifically in certain ethnic groups with dyspepsia in a primary care setting or centres with limited resources. However patients must be individually assessed before initiation of eradication therapy to ensure the maximal benefit for them.
Conflict of interest statement
The authors claim they have no conflict of interest.
The study received no extramural funding.
Dr Ooi was responsible for literature collection, writing the draft of the article, methodology planning, local ethical application, data collection, data management, and data analysis. As the corresponding author, Dr Ooi controlled the content of the whole review. Dr Lai serves as the content matter expert and supervisor for the entire study.
| References|| |
Chua ASB. Reassessment of functional dyspepsia: A topic review. World J Gastroenterol
Mahadeva S, Yadav H, Everett SM, Goh KL. Economic impact of dyspepsia in rural and urban Malaysia: A population-based study. J Neurogastroenterol Motil
Hooi JKY, Lai WY, Ng WK, Suen MMY, Underwood FE, Tanyingoh D, et al. Global prevalence of Helicobacter pylori
infection: Systematic review and meta-analysis. Gastroenterology
Boey CC, Goh KL, Lee WS, Parasakthi N. Seroprevalence of Helicobacter pylori
infection in Malaysian children: Evidence for ethnic differences in childhood. J Paediatr Child Health
Goh KL. Epidemiology of Helicobacter pylori
infection in Malaysia- Observations in a multiracial Asian population. Med J Malaysia
Nafeeza MI, Isa MR, Kudva MV, Ishak MS, Mazlam MZ, Haron A, et al. Helicobacter pylori
related functional dyspepsia in a defined malaysian population. Malays J Med Sci
Chai FY, Chong HC, Tan YE, Heng SSL, Asilah SMD, Ridwan H. Helicobacter pylori
infection rates in patients undergoing endoscopy in the interior of Borneo. Helicobacter
Goh KL, Parasakthi N. The racial cohort phenomenon: Seroepidemiology of Helicobacter pylori
infection in a multiracial South-East Asian country. Eur J Gastroenterol Hepatol
Lee HG. Borneo survey: Autonomy, identity, Islam and language/ education in Sabah. ISEAS Perspective
Leung WK, Sung JJ, Siu KL, Chan FK, Ling TK, Cheng AF. False- negative biopsy urease test in bleeding ulcers caused by the buffering effects of blood. Am J Gastroenterol
Veldhuyzen van Zanten SJ, Sherman PM. Helicobacter pylori
infection as a cause of gastritis, duodenal ulcer, gastric cancer and nonulcer dyspepsia: A systematic overview. CMAJ
Bazzoli F, De Luca L, Pozzato P, Zagari R., Fossi S, Ricciardiello L, et al. Helicobacter pylori
and functional dyspepsia: Review of previous studies and commentary on new data. Gut
(Suppl 4): iv33-iv5.
Halder SL, Locke GR 3rd, Schleck CD, Zinsmeister AR, Talley NJ. Influence of alcohol consumption on IBS and dyspepsia. Neurogastroenterol Motil
Enck P, Azpiroz F, Boeckxstaens G, Elsenbruch S, Feinle-Bisset C, Holtmann G, et al. Functional dyspepsia. Nat Rev Dis Primers
17081. doi: 10.1038/nrdp.2017.81.
Kaur G, Naing NN. Prevalence and ethnic distribution of Helicobacter pylori
infection among endoscoped patients in North Eastern Peninsular Malaysia. Malays J Med Sci
Sasidharan S, Lachumy SJT, Ravichandran M, Latha LY, Gegu SRS. Epidemiology of Helicobacter pylori
among multiracial community in Northern Peninsular, Malaysia: Effect of age across race and gender. Asian Pac J Trop Med
Khasag O, Boldbaatar G, Tegshee T, Duger D, Dashdorj A, Uchida T, et al. The prevalence of Helicobacter pylori
infection and other risk factors among Mongolian dyspeptic patients who have a high incidence and mortality rate of gastric cancer. Gut Pathogens
14. doi: 10.1186/s13099-018-0240-2. eCollection 2018.
Shu L, Zheng PF, Zhang XY, Feng YL. Dietary patterns and Helicobacter pylori
infection in a group of Chinese adults ages between 45 and 59 years old: An observational study. Medicine
Kari FB, Masud MM, Yahaya SRB, Saifullah MK. Poverty within watershed and environmentally protected areas: The case of the indigenous community in Peninsular Malaysia. Environ Monit
Assess 2016; 188
Ahmed KS, Khan AA, Ahmed I, Tiwari SK, Habeeb A, Ahi JD, et al. Impact of household hygiene and water source on the prevalence and transmission of Helicobacter pylori:
A South Indian perspective. Singapore Med J
Boonyanugomol W, Rukseree K, Kongkasame W, Palittapongarnpim P, Baik SC, Manwong M. Genetic polymorphisms of CXCL8
(-251) are associated with the susceptibility of Helicobacter pylori
infection increased the risk of inflammation and gastric cancer in Thai gastroduodenal patients. Iran J of Allergy Asthma Immunol
Jiang J, Jia ZF, Cao DH, Jin MS, Kong F, Suo J, et al. Polymorphisms of the DNA methyltransferase 1 associated with reduced risks of Helicobacter pylori
infection and increased risks of gastric atrophy. PLoS One
Schmidt HM, Ha DM, Taylor EF, Kovach Z, Goh KL, Fock KM, et al. Variation in human genetic polymorphisms, their association with Helicobacter pylori
acquisition and gastric cancer in a multi-ethnic country. J Gastroenterol Hepatol
Maran S, Lee YY, Xu SH, Raj MS, Majid NA, Choo KE, et al. Towards understanding the low prevalence of Helicobacter pylori
in Malays: Genetic variants among Helicobacter pylori
-negative ethnic Malays in the north-eastern region of Peninsular Malaysia and Han Chinese and South Indians. J Dig Dis
Binh TT, Tuan VP, Dung HDQ, Tung PH, Tri TD, Thuan NPM, et al. Molecular epidemiology of Helicobacter pylori
infection in a minor ethnic group of Vietnam: A multiethnic, population-based study. Int J Mol Sci
Subsomwong P, Miftahussurur M, Vilaichone RK, Ratanachu EKT, Suzuki R, Akada J, et al. Helicobacter pylori
virulence genes of minor ethnic groups in North Thailand. Gut pathog
56. doi: 10.1186/ s13099-017-0205-x. eCollection 2017.
Alfizah H, Rukman AH, Norazah A, Hamizah R, Ramelah M. Ethnicity association of Helicobacter pylori
virulence genotype and metronidazole susceptibility. World J Gastroenterol
Rehvathy V, Tan MH, Gunaletchumy SP, Teh X, Wang S, Baybayan P, et al. Multiple genome sequences of Helicobacter pylori
strains of diverse disease and antibiotic resistance backgrounds from Malaysia. Genome Announc
[Table 1], [Table 2]