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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 8  |  Page : 1188-1193

Prevalence and risk factors for helicobacter pylori infection among children in Owerri, Nigeria


1 Department of Paediatrics, Federal Medical Centre, Owerri, Nigeria
2 Department of Paediatrics, College of Medicine, University of Nigeria/Teaching Hospital, Ituku - Ozalla, Enugu State, Nigeria

Date of Submission18-Sep-2020
Date of Acceptance08-May-2021
Date of Web Publication14-Aug-2021

Correspondence Address:
Dr. A N Ikefuna
Department of Paediatrics, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital, Ituku – Ozalla, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_687_20

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   Abstract 


Background: Helicobacter pylori (H. pylori) is a gram-negative ubiquitous bacterium affecting over half of the world's population. Most infections are acquired in early childhood with highest prevalence in Africa and Asia. Infected individuals develop antibodies against H. pylori which persist up to 6 months after eradication. Low socioeconomic status, poor sanitation, poor personal hygiene, and absence of potable household water supply are prevalent in our environment and also linked with increased frequency of the disease with attendant health consequences. Aims: The aim of the study was to determine the seroprevalence of H. pylori infection and potential sociodemographic factors among children in Owerri. Methods: One hundred and twenty children aged 6 months to 15 years were studied from March to June 2016. Sociodemographic data was documented in a pretested structured questionnaire while rapid test kit that detects antibody to H. pylori by chromatographic flow was used to identify subjects with infection. Data were analyzed using SPSS version 20.0 with level of statistical significance at P < 0.05. Results: H. pylori infection prevalence was 20.0%, increased with age and highest in the 10–15 years age group (P = 0.001). Increasing age and low socioeconomic class (SEC) were found to be significant risk factors of H. pylori seropositivity among study subjects. Conclusion: Prevalence of H. pylori infection was high, increased with age and lower SEC as well as highest among children aged 10 years and older. Efforts should be made to exclude H. pylori infection in children with suspected symptoms considering the high burden of the disease in our setting.

Keywords: Children, Helicobacter pylori infection, prevalence, risk factors


How to cite this article:
Emerenini F C, Nwolisa E C, Iregbu F U, Eke C B, Ikefuna A N. Prevalence and risk factors for helicobacter pylori infection among children in Owerri, Nigeria. Niger J Clin Pract 2021;24:1188-93

How to cite this URL:
Emerenini F C, Nwolisa E C, Iregbu F U, Eke C B, Ikefuna A N. Prevalence and risk factors for helicobacter pylori infection among children in Owerri, Nigeria. Niger J Clin Pract [serial online] 2021 [cited 2022 May 23];24:1188-93. Available from: https://www.njcponline.com/text.asp?2021/24/8/1188/323868




   Introduction Top


Helicobacter pylori (H. pylori) is a ubiquitous gram-negative bacterium that selectively colonizes the gastric epithelium and infects over half of the global population.[1],[2] Its prevalence varies between countries and among racial groups resident within the same country. It presents with non-specific dyspeptic symptoms with a varying range of severity.[2] In general, children and adults in developing countries are more infected than developed countries.[3],[4],[5],[6] This may be because of factors such as poor sanitation and lack of potable water supply in developing countries.

There is evidence that H. pylori infection is primarily acquired early in life and once established, persists in the individual into adulthood.[2],[5] The exact route of transmission is not clear though human-to-human transmission either through feco-oral or oro-oral routes has been documented.[7] Familial clustering is common with increased prevalence in institutions.[8]

The outcome of H. pylori infection is diverse though persistent infection results in antral gastritis. Disease manifestation in childhood is commonly asymptomatic and usually apparent on upper gastrointestinal endoscopy.[8]

H. pylori infection is causally related to peptic ulcer disease,[2],[9],[10],[11] and should be eradicated when detected in such setting. Possible causal links have also been made with iron deficiency anaemia (low serum ferritin and haemoglobin levels), short stature, atopy, and idiopathic thrombocytopenia (ITP) among others.[12],[13]

Evidence also suggests that H. pylori can suppress the gastric acid barrier, allowing ingested entero-pathogens in weaning foods to gain access into the small intestine.[14] This predisposes to childhood diarrhoea, malabsorption of essential nutrients such as vitamins B12 and C as well as growth failure.[15],[16]

H. pylori is also a carcinogen with increased risk of gastric mucosal-associated lymphoid tissue (MALT) lymphoma and adenocarcinoma.[12]

Studies have shown wide variability in the prevalence of H. pylori infection between countries and among racial groups within the same countries.[5],[6] Despite the high prevalence of infection in developing countries including sub-Saharan Africa and the potential to cause serious disease, only few studies have been carried out on the topic and still fewer in children. This study sought to determine the epidemiology of H. pylori infection in children aged 6 months to 15 years seen in Federal Medical Centre Owerri, Southeast Nigeria.


   Subjects and Methods Top


This was a descriptive cross-sectional study conducted at the Pediatric Department of Federal Medical Centre, Owerri from March to June 2016. The study was carried out among children that visited the Emergency Paediatric Unit (EPU) and Children outpatients (CHOP) Unit during the period.

Ethical Approval for the study was obtained from the health Research Ethics Committee of Federal Medical Centre Owerri (FMC/OW/HREC/2015/17). Written informed consent was obtained from the parents/guardians of the subjects before they were recruited into the study while child's assent was obtained where required.

The sample size for the study was determined using the formula for proportions.[17]

where p is the best estimate of population prevalence rate for H. pylori in Nigerian children of 92%.[18]

A sample size of 103 was obtained which was adjusted for populations less than 10,000 and an added assumed attrition of 10% giving a final sample size of 114 subjects.

Children aged 6 months to 15 years who attended the hospital for either follow-up clinical visit, or new consults at CHOP and EPU were recruited consecutively from March to June 2016.

Excluded were very ill children (defined as a child that needed other forms of emergency care) as well as icteric children because bilirubin interferes with sensitivity of the Test Kits.

Information about demographics, breastfeeding practices, socioeconomic, and environmental characteristics of the family were obtained and documented in the proforma. The social classes of the families were ascertained using the method employed by Ogunlesi et al.[19] which was a modification of the Oyedeji's[20] social classification scheme and grouped as upper, middle and lower classes, respectively.

Under aseptic procedure, venipuncture was done and about 2 ml of blood collected into an EDTA bottle. The test was done using a chromatographic lateral flow immunoassay which detects IgG antibodies specific to H. pylori. Specifically. Instant- View © H. Pylori Rapid Test Kit manufactured in the United States with an expiry date of March 2017, sensitivity of 95.1% and a specificity of 94.1% was used according to the manufacturer's guide.[21] The test kit was placed on a flat surface, the provided dropper was used to collect blood to fill the dropper up to the first line from its tip end. The whole content of the dropper was dispensed into the sample well on the test kit and allowed for 30 s, then three drops of buffer was added and results read in 5 min. and interpreted according to the manufacturer's guide. A stopwatch with alarm set to ring at 5 min. was used to ensure that time requirement which was within 7 min. was adhered to.

Data were analyzed by descriptive and inferential statistics using Statistical Package for Social sciences (SPSS), IBM SPSS Statistics for windows, Version 20.0, Armonk, NY: IBM Corp. Means and standard deviations (SD) were calculated for continuous variables like age and weight while proportions were calculated for categorical variables. Categorical variables were compared using the Pearson Chi-squared (χ2) test. A multivariate logistic regression analysis was done to determine factors independently associated with H. pylori with P value less than 0.05, to confirm the variable as risk factors of H. pylori seropositivity.

Level of significance was set at P value of less than 0.05 or 95% confidence interval (CI).


   Results Top


One hundred and twenty children were studied and majority were males, 68 (56.7%) aged from 6 months to 15 years with a mean age of 59 (±52) months [Table 1]. One hundred and ten (91.7%) of the households used water cistern as mode of sewage disposal while 10 (8.3%) made use of pit latrine. No household reported non-availability of sewage disposal facilities. The major source of household water supply for all families was borehole, no household was found to use well or stream [Table 1].
Table 1: Socio-demographic characteristics of the subjects

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The height/length ranged from 67.0 cm to 162.0 cm with a mean of 104.5 (±32.0) cm and the weight ranged from 5.4 kg to 65.0 kg with a mean of 20.7 (±14.0) kg.

Twenty-four of the study subjects were positive for H. pylori antibodies giving a prevalence of 20% as shown in [Table 2].
Table 2: Prevalence of H. pylori in children studied

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Prevalence was higher in males 16 (23.5%) than females 8 (15.4%), but this difference was not statistically significant (P = 0.230) [Table 3].
Table 3: Risk factors for H. pylori infection in the study population

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However, the prevalence of H. pylori infection increased with increasing age. The highest prevalence was observed in the age group 120--180 months with a prevalence of (50%), while lowest prevalence of infection was found in the age group 6--59 months (under 5 years old), and the difference was statistically significant on multivariate analysis (P = 0.001) [Table 4].
Table 4: Multivariate logistic regression analysis of risk factors of H. pylori infection in the study population

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H. pylori seropositivity was also found to be significantly associated with social status using multivariate analysis (P = 0.035) as shown in [Table 4]. Prevalence was highest among the lower social class 6/12 (50%) decreased to 10/42 (19.20%) among middle class and lowest among the upper class. See [Table 3].

Number of persons living in a household irrespective of the nature of the building was found to be significantly associated with H. pylori infection. Prevalence was higher among households with more than 4 persons 20/78 (25.64%) compared to 4/56 (9.52%) among households with less than 4 persons with a statistical significance on bivariate analysis (χ2 = 4.43; P = 0.040), though did not show any association on multivariate analysis (P = 0.614).

There was no significant association between prevalence of H. pylori and birth orders 1st to 4th; 1st 13.04%, 2nd 23.07%, 3rd 33.33%, and 4th 20.00% (P = 0.340) [Table 3] and [Table 4], respectively].

Similarly, sharing of bed and type of sewage disposal did not reveal any significant statistical relationship with H. pylori infection, (P = 0.650) and (P = 1.000), respectively [Table 3].


   Discussion Top


The prevalence of H. pylori infection in children aged 6 months to 15 years in the present study was 20%. This is close to 30.9% prevalence found by Ikpeme et al.[22] in Uyo, south-south Nigeria but lower than values of 63.6% and 82% documented by Senbanjo et al.[23] and Holcombe et al.[18] in Lagos and Maiduguri, respectively. All the cited studies were hospital based applying anti-H. pylori IgG antibodies in serum.

The variation in H. pylori infection prevalence noticed in Nigerian studies is in keeping with the reported regional and inter-racial variation in prevalence.[24],[25],[26] Variation of H. pylori infection prevalence between races, regions, and nations have been attributed to differences in diet.[3],[4],[5],[6],[23],[27],[28] though not explored in this study. Uyo[22] and Owerri (current study site) which are closest in terms of geographical characteristics have very similar prevalence of H. pylori which is different from the result found in Lagos (South West)[23] and Maiduguri (North East).[18] It has been postulated that consumption of food of plant origin may affect prevalence of H. pylori. Some of the edible vegetable considered to be protective against H. pylori infection include Carica papaya, Ocsimum gratissimum, and Allium.[23],[27] These products are readily consumed more in the South-East and South-South than the north.[27] Another possible explanation for this variation may be improvement in standard of living especially water supply over time. There is reported increase in the proportion of Nigerian household access to improved water supply over the last 3 decades. National Demographic and Health Survey (NDHS) reported an improved access to water supply among Nigerian households from 56% in 2008 to 61% (76% urban) in 2013.[29] Sources of household water identified in earlier studies were borehole, well, stream and pipe borne water while in this study the source of household water was borehole alone.[23],[24] It can, therefore, be postulated that the seroprevalence of H. pylori infection in Nigeria is decreasing though a multiregional and multicentre study needs to be carried out to affirm this.

H. pylori infection prevalence was found to be higher in males than females (23.5% vs. 15.4%) though not statistically significant and is similar to findings of other researchers.[22],[23]

Highest and lowest prevalence were in age groups 120--180 months (10--15 years) and 6–59 months, respectively, indicating an increase with age. Similar findings were documented in a Vietnamese study,[30] and by Senbanjo et al.,[23] in Lagos Nigeria, who also found an increased prevalence with age with the highest prevalence of 85% in the 6--10 years group.

Therefore, increasing age is a positive risk factor for H. pylori infection though this cannot be explained. However, researchers suggest that environmental influences especially sanitation, standard of living and clean water supply play a significant role as it has been noted in studies from western counties that the intensity of H. pylori infection decreased with improved sanitation and standard of living.[31] It may, therefore, imply that the more exposed an individual to the risk factors, the greater the risk of infection.

In this study, H. pylori infection prevalence in children was 14.3% and 50% in upper and lower social classes, respectively. Children from lower social class were more likely to be infected with H. pylori than those in upper class as SEC showed a significant statistical relationship (P = 0.001) with H. pylori seropositivity. Some studies identified socioeconomic factors as risk factors for H. pylori infection,[32],[33] but the variables considered in its determination were rural dwelling, source of drinking water, and environmental sanitary conditions. In the Vietnamese study[30] where parental occupation and education were considered independently, it was found that neither of them significantly influenced H. pylori infection prevalence. These differed from our use of parental occupation and educational level for social class classification as proposed by Ogunlesi.[19] However, lower social class is associated with poor sanitation, overcrowding, and lack of portable water supply. These factors were independently found to be associated with high H. pylori seroprevalence as transmission might not be affected if there is provision of adequate portable water, optimal environmental sanitation, good housing and income.

There was increasing prevalence of H. pylori infection with birth order. Among first birth order children prevalence was 13% and increased to 33.3% at the third child with a later decrease to 20% at the fourth child and beyond though not significant (P value = 0.340). Goodman and Correa[34] reported a similar effect of birth order on H. pylori infection using urea breath test. The actual reason for this trend is not fully known. However, presence of older persons in the household has been shown to negatively affect seropositivity,[34] while the exact reason for this finding has not been fully identified.

Household size did not influence H. pylori infection prevalence using multivariate analysis although higher prevalence of infection was found among children from household with more than 4 persons. Findings from studies in Nigeria[20] and Vietnam,[28] corroborate with this result. This may be because of overcrowding which is a risk factor for infection. Goodman[32] found an increasing odd of infection with increase in number of children aged between 2 and 9 years supporting the view of person-to -person, especially older sibling to younger sibling, transmission of H. pylori.

It was observed that bed sharing did not significantly influence H. pylori seropositivity in the present study. Nguyen et al.[28] identified that number of persons per bed and sharing bed with siblings was not significantly associated with H. pylori infection while the occurrence and duration of sharing bed with parents was significantly associated with H. pylori infection. It was reported that the odd of H. pylori infection is twice in those who shared bed with parents when compared with those who did not share bed with parents.[28] Similar odds were also found when the children share bed with parents for more than 24 months. However, there is dearth of data on which of the parents, mother, or father that possess the greater risk.


   Conclusions Top


The prevalence of H. pylori infection was 20%, increased with lower SEC and age and highest among children aged 10 years and older. In view of the high prevalence of H. pylori infection among study population, routine screening for H. pylori is recommended for older children of lower socioeconomic background considering its high burden in our setting.

Ethical approval and Consent

Ethical Approval and Consent to Participate: Ethical approval was sought and obtained from the Human Ethics and research Committee of Federal Medical Centre, Owerri, Nigeria (FMC/OW/HREC/2015/17). Written informed consents was obtained from the parents/guardians of the subjects before they were recruited into the study while child's assent was obtained where required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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