Prevalence study of Helicobacter pylori infection in Zaltan City, Libya.pdf

2518-5799
Journal of Total
Volume (7) Issue ( 7)
(DEC.2023)
ISSN: 2518-5799
Higher Institute of Science & Technology
Raqdalen
Libya
Prevalence study of Helicobacter pylori infection in Zaltan City, Libya
Authors
1. Miloud Asarat1* 2. Omar Ahmed Amar2
1. Department of food hygiene, Faculty of Veterinary Medicine, Tripoli University Libya.
2. Department of medical laboratory, High Institute of Science and Technology, Zaltan,
Libya.
* Corresponding author; m.asarat@uot.edu.ly
Abstract
High incidence of H. pylori infection in Libya is alarming. Thus, intensive epidemiological studies on H. pylori
prevalence are crucial. There are few epidemiological and prevalence studies on H. pylori from large cities of
Libya. Moreover, there are lack of studies in small Libyan towns. Therefore, the aim of this study was to determine
the prevalence of H. pylori and its associated risk factors in the North-west city of Libya, Zaltan and its surrounding
areas. Our study was conducted on symptomatic and asymptomatic participant patients. Socioeconomic, lifestyle,
and gastrointestinal characteristics of patients were collected through a prepared questionnaire alongside with stool
samples analysis. A total of 69 participants were included in this study and were tested for H. pylori using the stool
antigen test (SAT). The result showed that 45% was H. pylori SAT positive with a significant relation between H.
pylori infection and age (p < 0.05). The infection was higher among female 46 (66.6 %) and most positive result
was among 10-11 years old 16 (23.18%). Food and drinking water hygiene has correlation with transmission of
infection (p < 0.05). Significantly, 87% of positive H. pylori SAT patients suffered from chronic gastrointestinal
symptoms. Among other chronic illness anemia was significantly related to the infection incidence (p < 0.05)
while cardiovascular and diabetes mellitus were not significantly related. Lifestyle and financial status
significantly influenced the infection incidence trend with more important of personal and food hygiene (p < 0.05).
Based on the outcomes the study, we suggest that people and public health authorities should consider to apply
worthy preventive measures food hygiene in particular against H. pylori infection transmission.
Key words: H. pylori, risk factors, stool antigen test, personal and food hygiene, gastrointestinal inflammation,
H. pylori infection.
.
(SAT)
SAT
.(P <0.05)
P
<0.05
SAT
(P<0.05)
(P<0.05)
.

Prevalence study of Helicobacter pylori infection in Zaltan City, Libya Authors. Asarat.Amar
Raqdalen
Libya
1. Introduction
Helicobacter pylori (H. pylori) is a gram-negative microaerophilic bacterium that colonizes
gastric mucosa of human and resist gastric acidity by its powerful urease, which acts on the
urea passing through the gastric mucosa to generate ammonia, and this may neutralize the
acidity around the bacteria [Greenwood et al. 2012].
It has reported that, more than 50% is infected. The infection rate is variable
based on socioeconomic factor, as the infection is higher in developing countries [Bakir W.,
2012]. Generally, H. pylori infection is acquired during childhood and persists life-long due to
negligence of treatment with proper antibiotics; most of the infected individuals remain
asymptomatic for a long period. As a result, long-term colonization of H. pylori can damage
the gastric mucosa causing various diseases of the upper gastrointestinal tract such as chronic
gastritis, peptic ulcer, and gastric malignancies, particularly gastric cancer and gastric
lymphoma [Pacifico L, et. al., 2010]. Furthermore, H. pylori infection has been linked with
several non-digestive conditions such as iron-deficiency anemia [Haile K, et. al., 2021].
H. pylori has been documented as one of the strongest known risk factors for gastric malignant
tumors [Kumar, S, et. al., 2020]. Thus, eradication of H. pylori infection may reduce cancer
cases [Lee, Y, et. al., 2013] and many other gastric diseases such as peptic ulcer and gastritis;
therefore, implementation of screening and eradication program is cost-effect strategy to
overcome H. pylori related diseases and cancers [ Wu JY., et. al., 2019]. Successful strategies
to implement an eradication plan involves up-to-date information regarding the epidemiology
and prevalence of H. pylori and its diagnosis, prevention and proper treatments. Firstly, it is
impotent to determine sources of the infection and probable routes of transmission of H. pylori
within the community. Then, determine proper, accurate reliable laboratory diagnosis test
followed by effective treatment and preventive measures. However, all this information have
been well documented in literature it is important to study each socio-economical status and
lifestyle for each community. For example, it well known that H. pylori infection transmission
is fecal oral route, or oro-oral, which more likely to happen intra-familial [Dominici P, et. al.,
1999]. Consequently, interpretation the risk factors for H. pylori infection closely associated
with personal and food hygiene within the family and community. Other known risk factors
associated to H. pylori infection include age, socioeconomic status, number of siblings,
household crowding, ethnicity, migration from high prevalence areas, infection status of family
members, and sanitary facilities [Borka Balas R, et. al., 2022; Mhaskar RS, et. al., 2013]. Which
are variable amongst communities even within the same country.
Nowadays, diagnosis of H. pylori is including invasive, such as urease breathe test,
histopathology, and polymerase chain reaction; and non-invasive methods; serological tests and
stool antigen test (SAT). The invasive tests require endoscopic examination for obtaining the
diagnostic sample and therefore they are difficult to use in epidemiological and prevalence
studies. The H. pylori STA has improved in the recent years and has gained an interest to be
used in H. pylori antigen detection [Talebi B, 2018]. Several studies have demonstrated that
SAT is reliable, accurate and sensitive for detection of H. pylori infection and therefore
facilitate robust clinical and epidemiological studies, particularly in children and toddlers
[Omar E., 2023].
Globally, the epidemiology of H. pylori infection has changed with improvements in sanitation
and methods of eradication. However, the prevalence of H. pylori is still high. In developing
countries, the prevalence remains the highest, and this is related to socioeconomic status and
levels of hygiene [Borka Balas R, et. al., 2022].

Raqdalen
Libya
In Libya, H. pylori prevalence has not been excessively studied, one study has been reported
that the overall prevalence was 57% of asymptomatic population and 37% among the dyspeptic
patients population in Sabha city, while in Tripoli city the results were 85.1% and 83.2% in
asymptomatic and symptomatic population respectively [Nami, A, et. al., 2019]. An earlier
study reported that the infection was very high 94% in elder age residents [Bakka AS, et.al.,
2002 ]. Recently, a study on blood donors reported the incidence of H. pylori was at 85% among
healthy individuals whereas another recent study showed that the prevalence of H. pylori
infection was 53.84% of tested participants [Omar E., 2023].
The novelty of our study resides in being the first study to estimate the prevalence of H. pylori
and its associated factors in Zaltan city taking into consideration the population existing in each
region of Libya. Understanding the prevalence pattern of H. pylori in western Libya and its
associated factors will aid in prioritizing and customizing public health efforts to better
managing the problem of H. pylori infection and its associated diseases. To our knowledge,
Libya lacks of H. pylori prevalence studies, and the few available ones indicates that H. pylori
infection is highly fluctuating. Thus, we designed this study to investigate prevalence of
infection in the Zaltan city.
2. Materials and Methods
2. 1. Specimen collection and H. pylori antigen detection.
The present study was carried out in the Department of Medical Laboratory at Zaltan institute
of science and technology, Permission and approval of samples collection and analyses were
obtained from the department of Medical Laboratory, during September 2022 to December
2022. Total of 69 stool samples were randomly collected from patients of different ages based
upon requesting of physician for doing H. pylori antigen detection. The feces specimens were
collected in clean, dry, waterproof containers, which free of detergents, preservatives or
transport media. To obtain maximum antigens, 1-2 ml or 1-2 g of specimen were tested for
antigens detection within 6 hours according to the manufacture instructions (ACON
Laboratories, Incorporated. USA, 2018). Collected specimens may be stored for 3 days at 2-
8°C if not tested. For long-term storage, specimens were kept below -20°C until analyze.
2.2 Questionnaire of the subjected patients to qualitative detection of H. pylori antigen.
A questionnaire was carefully prepared and build-up to determine the correlation between the
incidences of H. pylori in subjected patients whom has positive result of H. pylori antigen test.
Moreover, to determine the risk factors such as personal and food hygiene that related to
prevalence of H. pylori infection.
2.3 Statistical analysis
Chi-Square was used to analyze the obtained data and if p value is less than 0.05 (p < 0.05) the
result is considered statistically significant difference.
3. Results and discussion
Qualitative detection of H pylori antigen in the stool samples [Figure1.]; indicated that 44.9%
were infected with H. pylori this was similar to prevalence percentage in developed countries
and it is lower than previous studies in Libya [Bakka AS, et.al., 2002; Nami, A, et. al., 2019]
and closer to the results reported recently by Omar E., 2023. Fluctuating of H. pylori incidence
may related to heavily misuse of antibiotic by some of patients, misuse of antibiotic has been
reported as a big concern in Libya [Hosien, B et. al., 2022]. However. This may have some
benefits but it significantly adverse affects on the H. pylori strains antibiotics susceptibility

Raqdalen
Libya
which may lead to spread of super strains which could not be treated with ordinary antibiotics
[Argueta EA et. al., 2022]. Moreover, the low incidence of H. pylori in our study population
comparing to other studies may related to demographic reason as crowded population in Tripoli
comparing to Zaltan and surrounding areas, and also dining out is more common in Tripoli
comparing to our study population.
However, H. pylori infection can occur at any age, but it has been reported that the H. pylori
infection is most likely occurred during childhood and teenage [Park JS. et.al., 2021]. Similarly,
our results show most of positive antigen test was among 11-20 years old [Table.1]. H. pylori
infection acquired during childhood and teenage is important in terms of its effect in
development of gastric cancer [Cam S., 2014], chronic gastritis, gastric atrophy, ulceration of
the gastric mucosa and other gut diseases which act as predispose factors for other illness such
as enteritis, diarrhea and iron deficiency anemia [Adeniyi OF., et. al., 2019]. Thus, it is vital to
eradicate the H. pylori in children infection to prevent the possibility of subsequent
development these illness. Furthermore, symptomatic H. pylori is crucial in childhood if not
treated properly may affects general child health and leads to growth retardation. In our results,
antibiotics exposure or different protective immunity may explain the differences of observed
results between young and older patients [de Martel C, and Parsonnet J., 2006].
The role of gender differences as a risk factor of H. pylori infection has been reviewed in many
literatures indicating that males are more susceptible than females [Ibrahim A et. al., 2017]. In
this study, the result reveled that female gender was more infected than male, [Table. 1] that
may due to females get the infection from their children whom acquired the infection from
school or contacting other children. However, children are normally acquired the infection from
their parents, but they can pass the infection to their mothers as they are considered as a dining
out people when they have their lunch from canteens [Hu J. et. al., 2020] also by inappropriate
hygiene when using school toilets.
H. pylori infection could be symptomatic or asymptomatic based on many factors [Mungazi G.
et. al., 2018, Oztürk H. et. al., 1996]. Significantly, in our study, most of positive SAT patients
were suffering from digestive system symptoms [Figure 2]; this may because most of them
attending clinics only when they are feeling unwell. Moreover, H. pylori infection is the most
common cause of chronic gastritis and associated with peptic ulcer disease, dyspepsia,
idiopathic thrombocytopenic purpura, iron deficiency anemia and gastric adenocarcinoma thus
trigger any symptom of these conditions in considered as a symptomatic H. pylori infection.
H. pylori infection has been correlated to chronic diseases other than gastrointestinal (GIT)
diseases; a study reported that the infection is more prevalent in type 2 diabetic patients than
non-diabetic patients or healthy people [Hosseininasab Nodoushan A. and Nabavi A., 2019].
Another study highlighted that H. pylori contributes to the genesis, progression, and severity of
cardiovascular disease and considered as a risk factor of cardiovascular diseases [Torres, A.M.
and Gaensly, M.M., 2002]. In our study, there is no significant relation between the infection
and cardiovascular disease or diabetes militias (p > 0.05) [Table. 2]. Whereas we have found
significant relation between the infection and anemia (p < 0.05), similar correlation has been
reported elsewhere as H. pylori considered as a risk factor of anemia via different pathogenesis
[Haile K, et. al., 2021; Xu, M.Y., et., al., 2017].
H. pylori infection is usually acquired in childhood and school age acquisition of the infection
is associated with poor personal and household hygiene in particular among children and
youths. Significant risk factors for H. pylori infection are mostly related to living conditions,
for instance: living in high-density and poor sanitary homes, crowded schools, poor personal
hygienic practices and direct contact with infected people.

Raqdalen
Libya
Recently, H. pylori is an emergent foodborne pathogen of concern. It is entering the food chain
through the contamination of fresh or semi processed food, and infected food handlers
particularly whom are asymptomatic [Pina-Pérez, M.C., et.al, 2018]. H. pylori has been
detected in drinking water, vegetables and animal origin foods. It survives in complex
foodstuffs such as milk, vegetables and ready-to-eat foods [Quaglia NC, and Dambrosio A.
2018]. Foods that incriminated for H. pylori contamination are raw food including fresh fruits
and vegetables, fresh dairy product and meat [Quaglia NC, and Dambrosio A., 2018; Atapoor
S, et. al., 2018]. The use of irrigation water and soils contaminated with faecal or sewage is the
main factor that possibly leads to contamination of fruits and vegetables with pathogens
(Atapoor et al., 2014, Nutt et al., 2003). The contamination of vegetables with H. pylori and the
subsequent introduction of these minimally processed vegetables into the food chain is being
suggested as one of the contributing factors to the transmission of the pathogen to humans,
increasing the prevalence of the infection (Atapoor et al., 2014, Yahaghi et al., 2014).
Moreover, increasingly using public desalination water, which distributed almost at Mosques
may increase the possibility of pathogen contamination to drinking water. In this study most of
interviewed patients said that their drinking water sources were from small public desalinization
water units (p < 0.05) [Table. 3] which may be a possible source of contamination if it is
improperly sanitized.
Poor hygienic and low quality livings condition are considered as main predisposing factor of
H. pylori this reflects significant differences of the infection prevalence between developing
and developed countries, economic factor is another factor considered as a risk factor.
Significant relation between income and H. pylori provenances, which, significantly increases
in association with low income [Bakka AS, Salih BA., 2002]. This is expected as most other
risk factors are associated with low income such as education level and nutritional quality. In
our study, the relation was insignificant (p > 0.05) [Table. 3]. Which may due to the most of
the questionnaired patients were at the middle-income category.
Conclusion
This study shows high prevalence of H. pylori within the community with a significant relation
between the infection and socioeconomic status particularly food hygiene and drinking water,
gastrointestinal symptoms and financial status. More studies are required to understand about
spreading of infection via food and water also to determine way of transmission among schools
children. Based on the outcomes current study, we suggest that people and public health
authorities should consider strong worthy preventive measures against H. pylori infection
particularly personal and food hygiene transmission.

Raqdalen
Libya
Results
Figure 1. Results of H. pylori stool antigen test.
Figure 2. Gastrointestinal (GIT) symptoms; asymptomatic and symptomatic of patients.
Table 1. Relation between H. pylori and age and gender.
Questionnaire Age (Years) and
gender criteria
Distribution of
patients based on
age and gender
H. pylori antigen
test
P-value
Positive Negative
The age of patients (Years)
0 0 0
0.003
11-20 15 4 11
21-30 21 16 5
31-40 14 3 11
41-50 11 6 5
< 50 08 2 6
31
38
0
5
10
15
20
25
30
35
40
H. pylori antigen detection test
Number
Tested
Samples
infection
Positive negative
5
33
0
5
10
15
20
25
30
35
Asymptomatic Symptomatic
Number
of
patients
GIT symptoms

Raqdalen
Libya
The gender
Male 23 7 16 0.087
Female 46 24 22
Table 2. Relation between H. pylori infection and chronic illness.
Questionnaire Infected patients Non infected patients P-value Total
Yes No Yes No
Diabetes mellitus 2 29 5 33 0.000 69
Cardiovascular diseases 3 28 01 37 0.213 69
Anemia 24 7 16 22 0.003 69
Table 3. Correlation between H. pylori infection and income, lifestyle and, personal and food
hygiene.
Questionnaire Number of Infected
patient
Number of Non-Infected
patient
P-value
Yes No Yes No
Personal hygiene practice 5 26 20 18 0.002
Smoking 17 14 6 32 0.001
Fast food eating 11 20 11 27 0.003
Source of drinking water
Bottled water 5 26 8 30
0.001
Desalination water 3 28 18 20
Well water 23 8 12 26
Income and lifestyle
High 3 35 6 32
0.440
Middle 24 14 30 39
Low 4 34 2 67
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