Journal of Pediatric Gastroenterology & Nutrition:
Familial and Community Environmental Risk Factors for Helicobacter pylori Infection in Children and Adolescents
Wizla-Derambure, Nathalie*; Michaud, Laurent*; Ategbo, Simon*; Vincent, Pascal†; Ganga-Zandzou, Serge*; Turck, Dominique*; Gottrand, Frédéric*
*Clinique de Pédiatrie, Hôpital Jeanne de Flandre, Centre Hospitalier et Universitaire, and †Service de Bactériologie A, Faculté de Médecine, Pôle Recherche, Lille, France
Received May 11, 2000; accepted March 26, 2001.
Address correspondence and reprint requests to Frédéric Gottrand, Clinique de Pédiatrie, Hôpital Jeanne de Flandre, Centre Hospitalier et Universitaire, 59037 Lille, France (e-mail: email@example.com).
Background: The aim of the study was to identify familial and community environmental risk factors associated with Helicobacter pylori infection in a pediatric population.
Methods: Children requiring diagnostic upper endoscopy were included in the study during a 2-year period. During endoscopy, five gastric biopsies were performed for the histologic or bacteriologic diagnosis, or both, of H. pylori infection. Epidemiologic data collected by a questionnaire were analyzed using the chi-square test or Fisher test and stepwise logistic regression.
Results: The authors included 436 patients (242 boys), aged 2 days to 17.9 years (median, 2.7 years). H. pylori prevalence was 7.3%. Univariate analysis found H. pylori was more common in older patients (P < 0.00001), in children who had at least one parent born in a developing country (P < 0.02) or with a low socioeconomic status (P < 0.02), and in those living in crowded conditions (P < 0.02). Children whose mother worked at home were more frequently infected than children whose mother worked outside the home (P < 0.02). Attendance at nursery or school before the age of 6 years was not associated with infection. Logistic regression showed a strong association with H. pylori only for age and number of persons at home.
Conclusions: The source of H. pylori is intrafamilial rather than from a community, such as nursery and school attended at a young age. The number of persons in the home influences the infection status of children but not by the presence of the mother in home. These data suggest that H. pylori infection transmission occurs from siblings or the father rather than from mother.
Helicobacter pylori is one of the most common chronic infections in the world. Colonizing the human stomach, it causes chronic gastritis (1–3), is associated with recurrence of peptic ulcer disease (4–6), and is a risk factor for the development of gastric carcinoma (7,8). The mechanisms by which H. pylori is transmitted is unknown. Seroepidemiologic studies have shown that the prevalence of H. pylori increases with age and is high in developing countries (9–12). It has been suggested that infection is mainly acquired during childhood (13–15). Most of risk factors for H. pylori infection are closely related to poor living conditions in childhood both in developing and developed countries: low socioeconomic level (16–18), poor hygiene conditions and absence of running hot water (19,20), sharing a bed (21), and overcrowding (10,19,22). The prevalence of infection is also high among persons living in closed environments such as orphans (23), submarine crew members (24), and institutionalized patients (25,26), supporting the hypothesis of a person-to-person transmission (27,28).
Most of these epidemiologic studies have been carried out in adults more often than in children. However, pediatric studies directly address the likely main period of acquisition of H. pylori and could thereby more accurately identify epidemiologic risk factors for infection. To identify risk factors associated with H. pylori, we compared living conditions of infected and noninfected children and adolescents and studied the role of the presence of the mother at home and the contact of children with a community (school and nursery) in the epidemiologic characteristics of H. pylori infection.
PATIENTS AND METHODS
During a 2-year period (August 1993–November 1995), all children and adolescents requiring diagnostic or therapeutic upper endoscopy, at the determination of their treating gastroenterologist, were included in the study. Inclusion criteria were the following: age less than 18 years, no history of treated H. pylori infection or past inclusion in this study, no known trouble with hemostasis. Informed consent of parents and of patients, when applicable, was obtained before inclusion in the study.
To avoid an eventual bias related to particular living conditions of neurologically impaired patients (high prevalence of institutionalization), we decided to separate for data analysis patients with neurologic impairment including mental retardation from those free of neurologic impairment. Seventy-seven patients aged 4 months to 16 years (median age, 6 years) were recognized as having a neurologic impairment. Fifty-two of these 77 patients (67.5%) were so impaired that they could neither eat nor move independently. Forty-two of the 77 patients (54.5%) were institutionalized. The other patients lived exclusively in the family home.
We only present here the results of nonneurologically impaired patients.
Esophagogastroduodenoscopy (Upper Endoscopy) and Gastric Biopsies
During upper endoscopy, three gastric antral biopsies (two samples for histologic study and one for bacteriologic study) and two fundic biopsies (one for histologic study and one for bacteriologic study) were taken.
Biopsy specimens were fixed in 10% formalin, embedded in paraffin, and cut at 6 μm. Sections were stained with hematoxylin–eosin–saffron and modified Giemsa technique for light microscopy. All the sections were observed by the same pathologist, who noted the presence or absence of H. pylori.
Biopsy specimens were immediately placed in a transport media (25% cysteinated Ringer) at 4°C and transported within 2 hours to the laboratory. Biopsies were quantitatively plated onto H. pylori specific media: Colombia agar (Pasteur Institut Production, Marnes la Coquette, France) supplemented with 10% horse blood (Eurobio, Paris, France). Plates were incubated at 37°C for 4 to 7 days under microaerobic conditions (10% CO 2 , 5% O 2 ) in a gas regulated incubator (Forma Scientific, Marietta, OH).
Helicobacter pylori Infection
Patients were considered to be infected when H. pylori was present in at least one gastric biopsy specimen, in the histologic analysis, in culture, or a combination thereof. They were considered not infected if both histologic analysis and culture were negative for the five biopsies.
An epidemiologic questionnaire was filled out by the pediatric endoscopist before performing endoscopy. Questions related to the individual's history were as follows: age; gender; patient's and parents' birthplace (developed or developing country); type of housing (house, apartment); number of persons living in housing; number of rooms in housing excluding bathroom and kitchen; father's educational level (I < high school, II ≥ high school); father's occupation according to the INSEE classification (French National Institute for Statistics and Economic Status) and classified as nonworker, manual worker, or nonmanual worker; mother's occupation (at home or worker); and past or present contact with a community (nursery, school, or other). Household density was defined as the number of persons per room (excluding kitchen and bathroom). The cut-off point used in this study to classify homes as overcrowded was one person.
To determine the association between H. pylori infection and epidemiologic factors, data were analyzed using the chi-square test or the Fisher test (depending on the size of the sample; EPI Info software, version 5, CDC, Atlanta, GA). P values less than 0.05 were required for significance. A stepwise logistic regression (SAS Software, Cary, NC) was then performed with variables associated with H. pylori infection in the univariate statistical analysis.
The study was approved by the Research Ethics Committee of the University Hospital of Lille.
Four hundred thirty-six children and adolescents (194 girls, 242 boys), aged 2 days to 17.9 years (median, 2.7 years) were included in the study. On the basis of our diagnostic criteria, 7.3% of the patients (32/436) were infected with H. pylori (28 patients were positive for H. pylori by both histologic analysis and culture, 3 patients were positive only by histologic analysis, and 1 patient was positive only by culture).
Endoscopy was indicated for suspicion of esogastric disorder (71.3%), performing small bowel biopsy (15.8%), suspicion of Crohn's disease, portal hypertension or caustic ingestion (6.9%), follow-up of various gastrointestinal disorders (4.2%), or in a therapeutic aim such as esophageal dilation or perendoscopic gastrostomy (1.8%). The most frequent indication was a suspicion of esophagitis (60.4%) in children fewer than 3 years of age and a suspicion of gastric disorder (38.6%) in children older than 10 years.
Most of the children undergoing endoscopy reported symptoms at the time of inclusion in the study: abdominal pain (n = 193), vomiting (n = 158), digestive hemorrhage (n = 34), other (i.e., anemia, hypotrophy, weight loss, etc.; n = 87). A same child could have more than one symptom at presentation. Thirty-five patients (8%) were asymptomatic at the time of inclusion in the study. However, they all had a medical reason to undergo an endoscopy: suspicion of caustic ingestion (n = 14), follow-up of various gastrointestinal disorders such as coeliac disease or esophagitis (n = 11), follow-up of hepatic disease with portal hypertension (n = 7), and therapeutic aim such as esophageal varices sclerosing (n = 3).
The response rate to each question of the questionnaire varied from 82% to 100%. Results of the univariate analysis are shown in Table 1. Attendance a nursery before the legal age of schooling in France (6 years) was not associated with a higher prevalence of infection. In children fewer than 6 years of age, present contact with a community (nursery, school) also was not a risk factor for H. pylori infection. In children attending nursery at the time of the study or at a younger age, socioeconomic status was the following: the father's educational level was high school or higher in 35 cases (76.1% vs. 61.5% in the entire cohort) and less than high school in 11 cases; the father was a nonmanual worker in 36 cases (78.3% vs. 58.2% in the entire cohort) and a nonworker or manual worker in 10 cases; the mother was working outside the home in 31 cases (64.6% vs. 40.7% in the entire cohort).
Table 2 presents the results of the stepwise regression logistic analysis with H. pylori as the dependent variable. The seven parameters significantly associated with H. pylori in the univariate analysis were entered into the model. Only two factors remained independently associated with H. pylori infection: the age of the patient and the number of persons living with the patient.
Epidemiologic studies have shown evidence for an acquisition of H. pylori primary infection at an early age, both in developing countries (15) and in developed countries (13,14,19). How H. pylori is transmitted and whether transmission mainly occurs at home or in the broader community are not known, but a strong association between H. pylori infection and poor living conditions in childhood clearly has been shown (10,15,19). Childhood therefore appears to be an attractive period to understand better when and how H. pylori is acquired, and studies recently have been realized specifically in children (12,22,29).
The present study was performed in children requiring diagnostic upper endoscopy. This population is not reflective of the population at large, and all results of this study therefore reflect this group of selected patients. However, we tried to minimize this selection bias by inclusion of all children undergoing endoscopy whatever the indication and symptoms.
In this pediatric study, the univariate statistical analysis confirmed the association between H. pylori infection and socioeconomic and demographic factors usually observed in adults and children: infection is more frequent in older patients (10,16,18,30), in children with at least one parent who originated from a developing country (16,31,32) or with a low socioeconomic level reflected in the father's low educational level and occupation as manual worker or nonworker (16,18,20,29) and in children living in overcrowded conditions (19,29,33).
However, in the final model of the study, ethnic origin and socioeconomic level appeared to be confounding factors: with the exception of the age of the patient, only the family size remained independently associated with H. pylori infection. Drumm et al. (27) found that parents of children infected with H. pylori were infected significantly more often than parents of noninfected children, with mothers being infected more than fathers, suggesting the role of familial environment in transmission of H. pylori infection, and especially the eventual role of the relation between the mother and her child. The hypothesis of a major role of mother in transmission of H. pylori is supported by a more recently published study (34) :H. pylori infection in German preschool children is higher if their parents are also infected, with an odds ratio after adjustment for potential confounders two times higher if the mother is infected than if the father is infected. In our study, we were interested in the role of the presence of mothers working at home, supposing that mothers working at home were more frequently in contact with their children than mothers who worked outside the home. This factor has been analyzed very rarely in previous studies. In 684 Colombian children with a high prevalence of H. pylori infection, Goodman et al. (35) observed that children whose mothers were employed outside the home had a lower rate of infection compared with children whose mothers had no earnings. In our study conducted in a developed country, we showed that children whose mothers worked at home were infected no more often than children whose mothers worked outside the home. This result could suggest a possible role of siblings in the transmission of H. pylori infection. In Goodman et al.'s study, after a multivariate logistic regression analysis, the authors indeed found that the strongest predictor of H. pylori status was the number of persons who lived in the home, with the number of children apparently being of greater importance than the number of adults (35). In the same population of children younger than 10 years of age, Goodman and Correa (36) more recently concluded that the odds of infection increased with the number of siblings close in age in the household, and therefore their results support the hypothesis that sibling-to-sibling transmission is a major source of infection.
The hypothesis of person-to-person transmission is also supported by the high prevalence of H. pylori infection reported in communities and closed environments such as an orphanage in Thailand (23), submarine crews (24), institutions for neurologically impaired patients in developed countries (25,37), as well as a day care center (38). In an institution for encephalopathic children located in the north of France, we previously found a very high prevalence of infection (38%) and identified the same strain of H. pylori in 7 of the 45 infected children, 5 of whom lived in the same section of the institution (26). However, even if H. pylori prevalence is high in these communities, factors other than overcrowding are probably important to consider for the acquisition of infection. In the present study, we were interested in other communities, such as nursery centers and schools. We did not find that attendance at nursery centers and school at a young age was at risk of infection in children. Baker et al. (39) did not observe any relation between H. pylori infection and nursery attendance in school children. This could be because of good hygiene conditions in most nurseries and schools in developed countries. In our previous study performed in an institution, encephalopathic children were also living in very good sanitary conditions (26). Moreover, compared with the entire cohort, children attending nursery at the time of the study or at a younger age were from families with a higher socioeconomic status than is supposed to be `protective' against H. pylori infection. This could suggest a predominant role of the family environment in acquisition of infection.
In our group of children, prevalence of H. pylori infection was 7.3%. This rate is under the prevalence rates of 14.1% to 32% usually reported in children in developed countries (16,22,29,40–43). This is probably partly the result of the high number of young children (52% were fewer than 3 years of age) in whom prevalence of H. pylori was the lowest (2.2%). Another explanation for a low prevalence of H. pylori in our group of children is that we excluded from this study neurologically impaired patients in whom a high rate of H. pylori infection is usually reported, from 38% to 76%, especially if they are institutionalized (25,26,37). Indeed, these patients have particular living conditions that may influence H. pylori transmission. In our excluded group of 77 neurologically impaired patients, prevalence of H. pylori infection was 18.2%, higher than in the group of nonneurologically impaired patients (P = 0.02).
Our data show that, in a group of selected young patients, the source of H. pylori infection is intrafamilial rather than in other environments such as nursery and school attended at a young age. Among intrafamilial factors, the number of persons living together is more important than socioeconomic status, and the presence of the mother at home does not appear to influence the rate of H. pylori infection in children. Further studies are necessary to elucidate whether the source of H. pylori could be siblings or the father.
1. Czinn SJ, Dahms BB, Jacobs GH, et al. Campylobacter
-like organisms in association with symptomatic gastritis in children. J Pediatr 1986; 109: 80–3.
2. Deltenre M, Nyst JF, Jonas C, et al. Données cliniques, endoscopiques et histologiques chez 1100 patients dont 574 colonisés par Campylobacter pylori
. Gastroenterol Clin Biol 1989; 13: 89B–95B.
3. Ashorn M. What are the specific features of Helicobacter pylori
gastritis in children? Ann Med 1995; 27: 617–20.
4. Rauws EAJ, Tytgat GNJ. Cure of duodenal ulcer associated with eradication of Helicobacter pylori
. Lancet 1990; 1: 1233–5.
5. DeCross AJ, Marshall BJ. The role of Helicobacter pylori
in acid-peptic disease. Am J Med Sci 1993; 306: 382–92.
6. Macarthur C, Saunders N, Feldman W. Helicobacter pylori
, gastroduodenal disease, and recurrent abdominal pain in children. JAMA 1995; 273: 729–34.
7. Parsonnet J, Friedman GD, Vandersteen DP, et al. Helicobacter pylori
infection and the risk of gastric carcinoma. N Engl J Med 1991; 325: 1127–31.
8. Nomura A, Stemmermann GN. Helicobacter pylori
and gastric cancer. J Gastroenterol Hepatol 1993; 8: 294–303.
9. Malaty HM, Graham DY, Klein PD, et al. Transmission of Helicobacter pylori
infection. Scand J Gastroenterol 1991; 26: 927–32.
10. Whitaker CJ, Dubiel AJ, Galpin OP. Social and geographical risk factors in Helicobacter pylori
infection. Epidemiol Infect 1993; 111: 63–70.
11. Pounder RE, Ng D. The prevalence of Helicobacter pylori
infection in different countries. Aliment Pharmacol Ther 1995; 9: 33–9.
12. Sathar MA, Gouws E, Simjee AE, et al. Seroepidemiological study of Helicobacter pylori
in South African children. Trans R Soc Tropl Med Hyg 1997; 91: 393–5.
13. Banatvala N, Mayo K, Megraud F, et al. The cohort effect and Helicobacter pylori
. J Infect Dis 1993; 168: 219–21.
14. Parsonnet J. The incidence of Helicobacter pylori
infection. Aliment Pharmacol Ther 1995; 9: 45–51.
15. Mitchell HM, Li YY, Hu PJ, et al. Epidemiology of Helicobacter pylori
in Southern China: identification of early childhood as the critical period for acquisition. J Infect Dis 1992; 166: 149–53.
16. Fiedorek SC, Malaty HM, Evans DL, et al. Factors influencing the epidemiology of Helicobacter pylori
infection in children. Pediatrics 1991; 88: 578–82.
17. EUROGAST Study Group. Epidemiology of and risk factors for Helicobacter pylori
infection among 3194 asymptomatic subjects in 17 populations. Gut
18. Replogle ML, Glaser SL, Hiatt RA, et al. Biologic sex as a risk factor for Helicobacter pylori
infection in healthy young adults. Am J Epidemiol 1995; 142: 856–63.
19. Mendall MA, Goggin PM, Molineaux N, et al. Childhood living conditions and Helicobacter pylori
seropositivity in adult life. Lancet 1992; 339: 896–7.
20. Malaty HM, Graham DY. Importance of childhood socioeconomic status on the current prevalence of Helicobacter pylori
infection. Gut 1994; 35: 742–5.
21. Galpin OP, Whitaker CJ, Dubiel AJ. Helicobacter pylori
infection and overcrowding in childhood [Letter]. Lancet 1992; 339: 619.
22. Perri F, Pastore M, Leandro G, et al. Helicobacter pylori
infection and growth delay in older children. Arch Dis Child 1997; 77: 46–9.
23. Perez-Perez GI, Taylor DN, Bodhidatta L, et al. Seroprevalence of Helicobacter pylori
infection in Thaïland. J Infect Dis 1990; 161: 1237–41.
24. Hammermeister I, Janus G, Schamarowski F, et al. Elevated risk of Helicobacter pylori
infection in submarine crews. Eur J Clin Microbiol Infect Dis 1992; 11: 9–14.
25. Berkowicz J, Lee A. Person-to-person transmission of Campylobacter pylori
[letter]. Lancet 1987; 2: 680–1.
26. Vincent P, Gottrand F, Pernes P, et al. High prevalence of Helicobacter pylori
infection in cohabiting children. Epidemiology of a cluster, with special emphasis on molecular typing. Gut 1994; 35: 313–6.
27. Drumm B, Perez-Perez GI, Blaser MJ, et al. Intrafamilial clustering of Helicobacter pylori
infection. N Engl J Med 1990; 322: 359–63.
28. Wang JT, Sheu JC, Lin JT, et al. Direct DNA amplification and restriction pattern analysis of Helicobacter pylori
in patients with duodenal ulcer and their families. J Infect Dis 1993; 168: 1544–8.
29. McCallion WA, Murray LJ, Bailie AG, et al. Helicobacter pylori
infection in children: relation with current household living conditions. Gut 1996; 39: 18–21.
30. Rosenstock SJ, Andersen LP, Rosenstock CV, et al. Socioeconomic factors in Helicobacter pylori
infection among Danish adults. Am J Public Health 1996; 86: 1539–44.
31. Malaty HM, Evans DG, Evans Jr, DJ et al. Helicobacter pylori
in Hispanics: comparison with blacks and whites of similar age and socioeconomic class. Gastroenterology 1992; 103: 813–6.
32. Graham DY, Malaty HM, Evans DG, et al. Epidemiology of Helicobacter pylori
in an asymptomatic population in the United States. Effect of age, race, and socioeconomic status. Gastroenterology 1991; 100: 1495–501.
33. Webb PM, Knight T, Greaves S, et al. Relation between infection with Helicobacter pylori and living conditions in childhood: evidence for person to person transmission in early life. BMJ 1994; 308: 750–3.
34. Rothenbacher D, Bode G, Berg G, et al. Helicobacter pylori
among preschool children and their parents: evidence of parent-child transmission. J Infect Dis 1999; 179: 398–402.
35. Goodman KJ, Correa P, Tengana Aux HJ, et al. Helicobacter pylori
infection in the Colombian Andes: a population-based study of transmission pathways. Am J Epidemiol 1996; 144: 290–9.
36. Goodman KJ, Correa P. Transmission of Helicobacter pylori
among siblings. Lancet 2000; 355: 358–62.
37. Proujansky R, Shaffer SE, Vinton NE, et al. Symptomatic Helicobacter pylori
infection in young patients with severe neurologic impairment. J Pediatr 1994; 125: 750–2.
38. Malaty HM. High incidence of Helicobacter pylori
infection among children attending day care centers in the United States [abstract]. Gut 1998; 43: A45.
39. Baker S, Gummet PA, Whittaker L. A pilot study of the epidemiology of Helicobacter pylori
[abstract]. Am J Gastroenterol 1994; 89: 1307.
40. Mitchell HM, Bohane TD, Tobias V, et al. Helicobacter pylori
infection in children: potential clues to pathogenesis. J Pediatr Gastroenterol Nutr 1993; 16: 120–5.
41. Megraud F, Brassens-Rabbe MP, Denis F, et al. Seroepidemiology of Campylobacter pylori
infection in various populations. J Clin Microbiol 1989; 27: 1870–3.
42. Crabtree JE, Mahony MJ, Taylor JD, et al. Immune responses to Helicobacter pylori
in children with recurrent abdominal pain. J Clin Pathol 1991; 44: 768–71.
43. Raymond J, Bergeret M, Benhamou H, et al. A 2-year study of Helicobacter pylori
in children. J Clin Microbiol 1994; 32: 461–3.
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