Risk Factors Associated with Helicobacter pylori Infection in Gaza, Palestine By Rana M. Abu ...

136 Pages·2007·1.05 MB·English

TheIslamicUniversity-Gaza
DeanshipofGraduateStudies
BiologicalSciencesMasterProgram
MedicalTechnology
FacutlyofScience
Risk Factors Associated with Helicobacter pylori Infection in
Gaza, Palestine
By
Rana M. Abu-Mugesieb
Supervisor
Dr. Abdelraouf A. Elmanama Dr. Mofeed M. Mokhallalati
Submitted in Partial Fulfillment for the Master Degree of Science in
Biological Science-Medical Technology
June 2007
Declaration
“I herby declare that this submission is my own work and that, to the best of
my knowledge and belief, it contains no material previously published or
written by another nor material which to a substantial extent has been
accepted for the award of any other higher degree or diploma of the
university or other institute of higher learning, except where due
acknowledgement is made in the text"
Author
Rana Mohammed Abu-Mughesieb
Signature: Rana Date: May- 2007
.
All Rights Reserved © 2007. No part of this work can be copied, translated
or stored inretrieval system, without prior permission of the author.
i
Abstract
Background: Helicobacter pylori (H. pylori) infection is usually acquired in
early childhood. H. pylori infection is associated with several upper
gastrointestinal disorders. Local data on the epidemiology of the infection are
scarce in Palestine. The purpose of this study is to measure the rate and to
explore the associated factors among the population living in Gaza strip.
Method: This study included eighty nine randomly selected participants from
non-hospitalized patients. Age, sex, socioeconomic status and other potential
risk factors were assessed using a structured interview. Ultra Rapid Urease
Test was performed on biopsy specimens followed by histology examined
with Methylene blue stain, HpSAg test to detect antigen in stool specimen
andHp IgM antibody was measured in blood using ELISA technique.
Results: The study subjects comprised of 89 participants. Age ranged
between 13-77 years, with mean age 37.03, (37.1%) were females and
(62.9%) were males. The rate of H. pylori infection was (48.3%). There were
variations between the different tests. URUT was easily performed, reliable
and non-expensive test; HpSAg test was non invasive, simple and could be
used for the diagnosis of H. pylori infection, histology by using methylene
blue stain and serology by detection IgM antibody in blood. In crude analysis,
the rate was associated with type of drinking water during childhood with P
value =0.018. H. pylori infection showed no significant correlation with age,
sex, weight, marital status, smoking, education level, coffee drinking, oral
hygiene, socioeconomic status including number of persons living in the
accommodation, number of persons in each room, income, type of
accommodation, contact with animals, travelling abroad, consumption of
drugs and antibiotics. Tea drinking proved to be a protective factor against H.
pylori infection.
Conclusion: The results of this work supported the hypothesis that H. pylori
acquisition occurs early in childhood and persist through out life. In addition,
H. pylori infection appears to be multifactorial. Tea proved to have a
protective effect against H. pyloriinfection.
Keywords: H. pylori, URUT, HpSAg, ELISA, Biopsy specimen,
socioeconomic status, Gaza.
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ﺔﯿﺑﺮﻌﻟا ﺔﻐﻠﻟﺎﺑ ﺺﻠﺨﺘﺴﻣ
هﺬھ ،ةﺮﻜﺒﻤﻟا ﺔﻟﻮﻔﻄﻟا ﻲﻓ ﺐﺴﺘﻜﺗ ﺎﻣ ًةدﺎﻋ (Helicobacter pylori) ﺎﯾﺮﯿﺘﻜﺒﺑ ىوﺪﻌﻟا:ﺪﯿﮭﻤﺗ
ﺪﺟﻮﯾ ﻻ.ﻲﻤﻀﮭﻟا زﺎﮭﺠﻟا ﻦﻣ يﻮﻠﻌﻟا ءﺰﺠﻟا ﻲﻓ ضاﺮﻣﻷا ﻦﻣ ﺔﻋﻮﻤﺠﻣ ﺎﮭﺒﺣﺎﺼﯾ ىوﺪﻌﻟا
هﺬھ ﻦﻣ ضﺮﻐﻟا.ﻦﯿﻄﺴﻠﻓ ﻲﻓ ﺎﮭﺒﺣﺎﺼﺗ ﺪﻗ ﻲﺘﻟا ضاﺮﻣﻷاو ﺎﯾﺮﺘﻜﺒﻟا هﺬھ ﻦﻋ ﺔﯿﺋﺎﺑو تﺎﻣﻮﻠﻌﻣ
.ﺎﯾﺮﯿﺘﻜﺒﻟا هﺬﮭﺑ ﺔﺑﺎﺻﻹا ﻦﻣ ﺪﯾﺰﺗ ﺪﻗ ﻲﺘﻟا ﺮﻄﺨﻟا ﻞﻣاﻮﻋ ﺪﯾﺪﺤﺗ ﺔﺳارﺪﻟا
عﺎﻄﻗ ﻲﻓ تﺎﯿﻔﺸﺘﺴﻣ ةﺪﻋ ﻦﻣ ﺎﯿﺋاﻮﺸﻋ ﺾﯾﺮﻣ 89 رﺎﯿﺘﺧا ﻢﺗ ﺔﺳارﺪﻟا هﺬھ ﻲﻓ:ﺚﺤﺒﻟا ﺔﻘﯾﺮﻃ
ةﺪﻌﻟ ﺔﻓﺎﺿﻹﺎﺑ ﻲﺿﺮﻤﻟا ﮫﺨﯾرﺎﺗ ،ﮫﺗﺎﯿﺣ مﺎﻈﻧ ،ﺮﻤﻌﻟﺎﺑ ﻖﻠﻌﺘﺗ ﺔﻠﺌﺳأ ةﺪﻌﻟ ﻊﻀﺧ ﺾﯾﺮﻣ ﻞﻛ.ةﺰﻏ
IgM ﺺﺤﻔﻟ مد ﺔﻨﯿﻋ ﺾﯾﺮﻣ ﻞﻛ ﻦﻣ تﺎﻨﯿﻋ 3 ﺬﺧأ ﻢﺗ.يدﺎﺼﺘﻗﻻا ﻊﺿﻮﻟا ﻞﻤﺸﺗ ﺔﻠﺌﺳأ
ﺔﻄﺳاﻮﺑ تﺬﺧأ ةﺪﻌﻤﻟا ﻦﻣ ﺔﻋﺰﺧ ﺔﻨﯿﻋو Antigen ﺺﺤﻔﻟ زاﺮﺑ ﺔﻨﯿﻋ ،مﺪﻟا ﻲﻓantibody
Methylene ﺔﻐﺒﺻ ماﺪﺨﺘﺳﺎﺑ ﻲﺠﯿﺴﻧ ﺺﺤﻓوURUT ﺺﺤﻔﺑ مﺎﯿﻘﻠﻟ رﺎﻈﻨﻤﻟا زﺎﮭﺠﺑ ﺺﺘﺨﻣ
.Blue
-13 ﻦﯿﺑ ﺎﻣ حواﺮﺘﺗ ﻰﺿﺮﻤﻟا رﺎﻤﻋأ ﺖﻧﺎﻛ ﺾﯾﺮﻣ 89 ﺖﻠﻤﺷ ﻲﺘﻟا ﺔﺳارﺪﻟا هﺬھ ﻲﻓ :ﺞﺋﺎﺘﻨﻟا
لﺎﺟﺮﻟا ﺔﺒﺴﻧ ﺖﻧﺎﻛ ﺎﻤﻨﯿﺑ%37.1 ﺖﻧﺎﻛ ءﺎﺴﻨﻟا ﺔﺒﺴﻧ.ﺔﻨﺳ 37 ﺮﻤﻌﻟا لﺪﻌﻣو ﺔﻨﺳ 77
ﻦﻣ .ﻊﺑرﻷا تﺎﺻﻮﺤﻔﻟا ﻦﯿﺑ ﺎﻣ فﻼﺘﺧا كﺎﻨھ ،(%48.3) H. pylori رﺎﺸﺘﻧا ﺔﺒﺴﻧ ،%62.9
ءﺎﻤﻟا بﺮﺷ ردﺎﺼﻣو ﺎﯾﺮﯿﺘﻜﺒﻟا هﺬﮭﺑ ﺔﺑﺎﺻﻹا ﻦﯿﺑ ﺔﻤﮭﻣ ﺔﻗﻼﻋ دﻮﺟو ﺔﺳارﺪﻟا هﺬھ ﻲﻓ ﺞﺋﺎﺘﻨﻟا ﻢھأ
عﻮﻧ ،ﺮﻤﻌﻟاو ﺎﯾﺮﯿﺘﻜﺒﻟﺎﺑ ﺔﺑﺎﺻﻹا ﻦﯿﺑ ﺎﻣ ﺔﻤﮭﻣ ﺔﻗﻼﻋ يأ كﺎﻨھ ﻦﻜﯾ ﻢﻟ.ﺔﻟﻮﻔﻄﻟا ﺔﻠﺣﺮﻣ ﻲﻓ
ﻦﯿﺧﺪﺘﻟا ،ﺎﮭﻣﺪﺨﺘﺴﯾ ﻲﺘﻟا ﺔﯾودﻷا عاﻮﻧأ ،ﮫﺘﻠﺋﺎﻋ داﺮﻓأ دﺪﻋ ،ﺾﯾﺮﻤﻠﻟ يدﺎﺼﺘﻗﻻا ﻊﺿﻮﻟا ،ﺲﻨﺠﻟا
ﻦﻣ ﺔﯾﺎﻤﺣ ﻞﻣﺎﻌﻛ ﻞﻤﻌﯾ يﺎﺸﻟا بﺮﺷ نأ ﺪﺟو ﺔﺳارﺪﻟا هﺬھ ﻲﻓ ﺞﺋﺎﺘﻨﻟا ﻢھأ ﻦﻣ.ةﻮﮭﻘﻟا بﺮﺷ و
.ﺎﯾﺮﯿﺘﻜﺒﻟا
ﺔﻠﺣﺮﻣ ﻲﻓ نﻮﻜﺗ(H. pylori) ﺎﯾﺮﺘﻜﺒﺑ ﺔﺑﺎﺻﻹا نأ ﺖﺘﺒﺛأ ﺔﺳارﺪﻟا هﺬھ ﻦﻣ ﺞﺋﺎﺘﻨﻟا:جﺎﺘﻨﺘﺳﻻا
ةﺪﺋﺎﻓ ﺔﺳارﺪﻟا هﺬھ ﻦﻣ ﺞﺘﻨﺘﺳا ﺎﻤﻛ.ءﺎﻤﻟا بﺮﺷ ردﺎﺼﻣ ﻞﺜﻣ ﺮﻄﺧ ﻞﻣاﻮﻌﺑ ﺔﻄﺒﺗﺮﻣ ﺔﻟﻮﻔﻄﻟا
.ﺎﯾﺮﯿﺘﻜﺒﻟاهﺬﮭﺑﺔﺑﺎﺻﻼﻟ دﺎﻀﻤﻛ يﺎﺸﻟا
iii
Dedication
This thesis is dedicated to my fatherDr. Mohammed, my Mother and my
brothers, Ahmed, Sameh and my sister Sawsan who supported me all
the way since the beginning of my study and always encouraged me to
pursue my ambitions and my goals.
Finally, this thesis is dedicated to all those who believe in the richness of
learning.
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Acknowledgment
First I would like to thank Allah for helping me to finish this thesis.
I would in particular like to thank:
Dr. Abdelraouf A. Elmanama and Dr. Mofeed M. Mokhallalati my
supervisors, for sharing their skills in the world of research and always
making time in their busy schedule when needed. I have beenespecially
fascinated by, and learnt from, their remarkable ability to always move
forward.
I also would like to thank Dr. Ahmed Shahwan, Dr. Mohamed Adwan, Dr.
Abdul-latif Alhaj, Dr. Mohammed Abu-humied, Dr. Abdul-Aziz Alfarra, Dr.
Eiad Al-jabri, Dr. Yousef Moa’amer, Dr. Samir Al-Ghazali , Dr. Majed
Hassona at Gaza hospitals for their cooperation. Kamal Huliel, Nahed Al-
Halabi, Rehab Al-Najar and Yaser for facilitating sample collection and their
advisingduring mywork.
Thanks to Al-Amal lab supervisor; Yaser Hamdona and Mohamed for
helping and allowing me to perform some of my laboratory work in their lab.
Computer engineerMahmood Al-azbat who helped me in my work on SPSS
software.
Thanks to the Deanship of science and research at the Islamic University-
Gaza for their support and generosity through its grants to the faculty
members in the University.
Thanks to the laboratory staff of the Islamic University-Gaza for allowing
me open access to the laboratory and facilities. Lastly but not least I would
like to thank my friends and family for all the help and support and for
keeping me aware of the fact that there is life out- side of work.
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Table of Contents
Items Page
Declaration i
Abstract ii
Arabic Abstract iii
Dedication iv
Acknowledgment v
Table of contents ix
List of tables x
List of figures xi
List of abbreviation xii
Chapter I Introduction 1
1.1 Overview 1
1.2 Statement of the problem 4
1.3 Objective 4
1.4 Significance 5
Chapter II Literature Review 6
2.1 The Microorganism 6
2.1.1 History of the microorganism 6
2.1.2 General aspects of H. pylori microbiology and infection 7
2.1.2.1 H. pylori characteristics 7
2.1.2.2 Bacterial infection 8
2.1.2.3 Structures 9
A.Flagella 9
B. Outer membraneproteins 10
C. Lipopolysaccharide 11
D. The genome 11
2.1.2.4 Biodiversity 12
A. Habitat diversity 12
B. Genetic diversityand species diversity 13
2.1.2.5 Virulence factor 14
A. The cag PAI and Vac A 14
B. Adhesion 16
C. H. pylori enzymes 20
2.1.3 Gastric helicobacter species 20
2.1.4 Taxonomy ofH. pylori 21
2.2 Epidemiology ofH. pylori Infection 22
2.2.1 Prevalence of H. pylori infection 22
2.2.2 Incidence of H. pylori infection 23
2.2.3 Risk factor for H. pylori infection 23
2.2.3.1 The family 24
2.2.3.2 Environmental and behavioural factor 25
vi
2.2.3.3 Host and bacterial factor 26
2.2.4 Transmission of H. pylori infection 28
2.2.4.1 Fecal oral and gastro-oral routs 28
2.2.4.2 Oral-oral rout 29
2.2.4.3 Environmental source: water and food 30
2.2.4.4 Animal reservoir 31
2.2.4.5 Intra familial transmission 32
2.3 Clinical Manifestation of H. pylori Infection 33
2.3.1 Natural course of H. pylori infection 33
2.3.2 Gastritis 34
2.3.3 Peptic ulcer disease 34
2.3.4 Gastriccancer 34
2.3.5 OtherH. pylori associated condition 35
2.3.6 Extra gastric manifestation of H. pylori in children 36
2.3.6.1 Iron deficiency anemia 36
2.3.6.2 Atopic disease 36
2.3.6.3 Acute intestinal infection 37
2.3.6.4 Diminished growth 37
2.3.7 Barrette’s esophagus 38
2.3.8 Gastresophagal reflux 38
2.3.9 Idiopathic thrombocytopenic purpura 39
2.4 Diagnostic Tests for Detection of H. pylori Infection 39
2.4.1 Biopsy-based test 39
2.4.2 Tests based on detection of specific anti H. pylori antibodies 40
2.4.3 Urea breath test 42
2.4.4 Test based on detection of bacterial antigen or bacterial DNA 42
in feces
2.5 Treatment of H. pylori Infection 43
2.5.1 Indication of treatment 43
2.5.2 Combined antibacterial regimens against H. pylori infection 45
2.5.3 Factor influencing treatment results 46
2.5.4 Alternative for treatment of H. pylori infection 47
2.5.5 Recurrence of H. pylori infection after eradication 48
2.5.6 Prevention of H. pylori associated disease 49
Chapter III Materials and Methods 52
3.1 Material and Reagents 52
3.2 Permission and Ethical Consideration 53
3.3 Patients 53
3.4 Sample Size 53
3.5 Sample Collection 53
3.5.1 Gastric biopsy 53
3.5.2 Blood sample for serological evaluation 55
3.5.3 Stool sample for antigen detection 55
3.6 Sample Processing 55
3.6.1 Blood sample 55
3.6.1.1 Principle of the ELISA test 55
vii
3.6.1.2 Assay procedure 56
3.6.1.3 Calculation of result 56
3.6.2 Biopsyspecimen 57
3.6.2.1 Ultra rapid urease test (URUT) 57
3.6.2.2 Microscopy 57
3.6.3 Stool sample 58
3.6.3.1 Kit components 58
3.6.3.2 Pre assay control and operations 58
3.6.3.3 Assay procedure (Quantitative Assay ) 60
3.6.3.4Calculation of result 60
3.7 Questionnaire 60
3.8 Analysis of Data 61
Chapter IV Results 62
4.1 Study Sample Description 62
4.2 Ultra Rapid Urease Test 63
4.3 Gastric biopsiesStained with Methylene Blue 63
4.4 H. pylori Serum IgM 64
4.5 H. pylori Antigen DetectionFrom Stool 64
4.6 True Positive forH. pylori Infection. 65
4.7 Statistical Analysis of H. pylori Tests Results (Chi square) 66
4.8 H. pylori Infection among the Study Sample 69
4.9 Risk Factors For H. pylori Infection. 69
4.9.1 Personal variables 70
4.9.2Life style variables 71
4.9.3 Drug history 73
4.9.4 Antibiotics intake during the last month 73
4.9.5 Socioeconomic status 74
Chapter V Discussion 76
5.1 H. pylori tests 77
5.1.1 Evaluation of H. pylori Tests 77
5.1.2 The rate of H. pyloriinfection 80
5.2 RiskFactors Associated withH. pylori infection 80
5.2.1 Age 80
5.2.2 Sex 81
5.2.3 Weight 81
5.2.4 Marital status 82
5.2.5 Smoking 82
5.2.6 Coffee drinking 83
5.2.7 Tea drinking 83
5.2.8 Type of drinkingwater 84
5.2.9 Oral hygiene 85
5.2.10 Antibiotic consumption 86
5.2.11 Drugs consumption 86
5.2.12 Education 87
viii
5.2.13 Income 88
5.2.14 Number of persons in the accommodation 88
5.2.15 Type of accommodation 89
Chapter VI Conclusion and Recommendations 90
References 92
Appendices 111
Appendix A: Questionnaireform in English 112
Appendix B: Questionnaireform in Arabic 114
ix