Nizam D. Nilai diagnosis uji serologi inIeksi Helicobacter pylori dengan B0 tes kualitatiI dan kuantitatiI pada dyspepsia ono ulkus di poliklinik gastroenterologi ...
Paediatrica Indonesiana September
VOLUME 49
NUMBER 5
Original Article
Seroepidemiology of Helicobacter pylori in primary school students in Krotek, Cibeber Village, Serang District, Banten, Indonesia Ratu Nurjanah, Pramita G. Dwipoerwantoro, Darlan Darwis
Abstract Background Helicobacter pylori infection is a common infection. 5LVNRILQIHFWLRQLQUXUDODUHDVLVVL[WLPHVKLJKHUWKDQLQXUEDQ areas. Objectives To study the prevalence of H. pylori infection in primary school students in rural area and its contributing factors. Methods$FURVVVHFWLRQDOVWXG\ZDVSHUIRUPHGLQDUXUDOSULPDU\ VFKRROLQ6HUDQJGLVWULFW%DQWHQ:HVW-DYD6HURORJ\RIH. pylori ZDVWHVWHGXVLQJ%LR0S\ORULNLW 0DWDUDP,QGRQHVLD Results)RUW\WZRRIVXEMHFWV KDGSRVLWLYHH. pylori serologies. Bivariate analysis found that the the family habit of HDWLQJWRJHWKHUIURPRQHFRQWDLQHULQFUHDVHGWKHLQIHFWLRQULVN WLPHV &, WR 6RXUFH RI GULQNLQJ ZDWHU IURPFRPPRQULYHULQFUHDVHGWKHULVN WLPHV &, WR %HGDQGEHGURRPVKDULQJLQFUHDVHGWKHULVNWLPHV &, WR DQG WLPHV &, WR respectively. Multivariate logistic regression analysis including all YDULDEOHVZLWK3 VKRZHGWKDWWKHPRVWVLJQLILFDQWIDFWRU contributing to H. pylori infection is common river as family GULQNLQJZDWHUVRXUFH 25 &, WR IROORZHG E\IDPLO\KDELWRIHDWLQJWRJHWKHUIURPRQHFRQWDLQHU 25 &,WR DQGEHGRUEHGURRPVKDULQJ 25 &,WR Conclusion Prevalence of H. pylori infection in rural school VWXGHQWV LV 7KHUH DUH VLJQLILFDQW DVVRFLDWLRQV EHWZHHQ H. pylori infection and family habit of eating together from one container, bed sharing with other family members, and family GULQNLQJ ZDWHU VRXUFH IURP FRPPRQ ULYHU [Paediatr Indones. 2009;49:269-74]. Keywords: recurrent abdominal pain, nutrition status, Bio M pylori kit, reverse flow immunochromatographic test
I
nfection of Helicobacter pylori is a common LQIHFWLRQ DIIHFWLQJ HVWLPDWHG RI ZRUOG population. 1 Incidence of H. pylori is high especially in developing country such as Bangladesh. Incidence in rural areas of West Virginia, Unites States, is reported to be higher than in urban DUHDV 5LVN RI H. pylori infection in rural areas is six times higher than in urban areas. +XPDQ transmissions of H. pylori WKURXJKRUDORUDOIHFDORUDO DQG JDVWULFRUDO URXWHV KDYH EHHQ ZLGHO\ VWXGLHG4 Epidemiology of the infection is very complex, many factors can contribute to the infection of H. Pylori. 6HYHUDOVWXGLHVLGHQWLILHGORZVRFLRHFRQRPLFVWDWXV DVULVNIDFWRUIRUKLJKLQFLGHQFHRILQIHFWLRQLQFOXGLQJ several people sharing a house, bedrooms or beds with infected individuals, no access to clean water source, and poor sanitation. This study was a part of a large study on H. pylori infection screening, diagnosis and management of HUDGLFDWLRQLQ*DVWURKHSDWRORJ\'LYLVLRQ'HSDUWHPHQW RI &KLOG +HDOWK 0HGLFDO 6FKRRO 8QLYHUVLW\ RI Indonesia. The aim of this study was to find the
)URP WKH 'HSDUWPHQW RI &KLOG +HDOWK 0HGLFDO 6FKRRO 8QLYHUVLW\ RI ,QGRQHVLD&LSWR0DQJXQNXVXPR+RVSLWDO-DNDUWD,QGRQHVLD Reprint request to:5DWX1XUMDQDK0''HSDUWPHQWRI&KLOG+HDOWK 0HGLFDO6FKRRO8QLYHUVLW\RI,QGRQHVLD&LSWR0DQJXQNXVXPR+RVSLWDO -O 6DOHPED -DNDUWD ,QGRQHVLD 7HO )D[
264Paediatr Indones, Vol. 49, No. 5, September 2009
Ratu Nurjanah et al: Seroepidemiology of H. pylori in primary school students
SUHYDOHQFHDQGHSLGHPLRORJLFDOULVNIDFWRUVRIH. pylori infection in rural primary school students.
Methods 7KHVWXG\ZDVSHUIRUPHGLQ.URWHN9LOODJH&LEHEHU 6HUDQJ 'LVWULFW %DQWHQ ,QGRQHVLD 7KH YLOODJH DUHD ZDVNPZLWKSRSXODWLRQRIDQGGHQVLW\ RISHRSOHNP. Education facilities in the village FRQVLVWHGRIWZRNLQGHUJDUWHQVIRXUSULPDU\VFKRROV DQGWZRMXQLRUKLJKVFKRROV+HDOWKIDFLOLWLHVFRQVLVWHG of one large community health centre, two small FHQWHUVDQGWKUHHVHUYLFHSRVWVIRUEDVLFPDWHUQDODQG child care. Public transportation facility was bicycle. 7KH HFRQRP\ ZDV PDLQO\ IURP IDUPLQJ DQG EULFNV production. Education level was mostly primary school. 7KLVYLOODJHZDVVHOHFWHGEHFDXVHLWZDVRQO\NPIURP the district capital and was easily reached. This study was s a cross sectional designed on SUHYDOHQFHDQGULVNIDFWRUVRIH. pylori infection in primary school students in rural area. The study was conducted by the Gastrohepatology subdivision, 'HSDUWPHQW RI &KLOG +HDOWK 0HGLFDO 6FKRRO 8QLYHUVLW\ RI ,QGRQHVLD -DNDUWD ,W ZDV VWDUWHG LQ $XJXVWXQWLOWKHWDUJHWQXPEHURIVXEMHFWVZDV achieved. 4XHVWLRQQDLUH ZDV XVHG WR FROOHFW WKH VXEMHFW profile, anthropometry, number of siblings, history of UHFXUUHQWDEGRPLQDOSDLQLQVXEMHFWVDQGWKHLUSDUHQWV HSLGHPLRORJ\DQGVRFLRHFRQRPLFVGDWD(DFKVWXGHQW then had their venous blood samples collected for serology test of H. pylori XVLQJ%LR03\ORULNLWIURP Mataram Laboratory, Indonesia).
Bio M pylori kit %LR0S\ORULNLWLVDVHURORJ\WHVWPDQXIDFWXUHGE\ Mataram Laboratory, Indonesia, using local antigen to be examined by reverse flow immunochromatographic test principle. (YHU\ NLW FRQVLVWV RI QLWURFHOOXORVH membrane coated with H. pylori antigen in the test line. Antibody in the serum will bind to the antigen RQWKHVXUIDFHPHPEUDQHWKHQWKHDQWLERG\ RI,J* W\SH ERXQG WR WKH DQWLJHQ ZLOO FDSWXUH SURWHLQ$ labelled with gold colloid and show a red line. In the membrane, there is a control line that will always show in every test.
Data analysis 'DWD DQDO\VLV ZDV SHUIRUPHG XVLQJ 6366 SURJUDP YHUVLRQ VRIWZDUH 5HVXOWV ZHUH VKRZQ LQ SDUDPHWULFDQGQRQSDUDPHWULFWHVWXVLQJ.ROPRJRURY Smirnov test. The effect of multiple variable was evaluated using logistic regression. The study was DSSURYHGE\7KH&RPPLWWHHRI7KH0HGLFDO(WKLFV of Medical School, University of Indonesia. A P value RIZDVFRQVLGHUHGVLJQLILFDQW
Results 7KLV VWXG\ FROOHFWHG EORRG VDPSOHV IURP SULPDU\ VFKRRO VWXGHQWV DJHG \HDUV Table 1). Prevalence of H. pylori LQWKLVVWXG\ZDV VXEMHFWV 7KHUHODWLRQVKLSVEHWZHHQSRVLWLYH H. pylori UHVXOWDQGVXEMHFWFKDUDFWHULVWLFVDQGRWKHU variables are described in Table 2. Bivariate analysis from Table 2 shows that the family habit of eating and GULQNLQJWRJHWKHUIURPRQHFRQWDLQHUZDVDVVRFLDWHG with incidence of H. pylori LQIHFWLRQ 25 &, WR EHG DQG EHGURRP VKDULQJ with other family members also showed significant association with H. pylori infection LQFLGHQFH 25 &, WR DQG 25 &, WR 6RXUFHRIIDPLO\GULQNLQJZDWHUIURP ULYHUKDGLQFUHDVHGULVNRI WLPHV &, WR IRUH. pylori infection, compared to other water sources. Parental history of dyspepsia also had significant association with incidence of H. pylori infection in children. Table 3 shows logistic regression analysis of several significant variables. Variables affecting H. pyloriLQIHFWLRQZDVIDPLO\KDELWRIHDWLQJRUGULQNLQJ together from one container, bed or bedroom sharing ZLWKRWKHUIDPLO\PHPEHUVDQGIDPLO\GULQNLQJZDWHU source. Table 1. Subjects characteristics grouped by age and sex Variables Sex Male Female Age (years) 6-8 9-10 11-12
Number
Percentage
57 68
45.6 54.4
62 40 23
49.6 32 18.4
Paediatr Indones, Vol. 49, No. 5, September 2009265
Ratu Nurjanah et al: Seroepidemiology of H. pylori in primary school students Table 2. Relationships between various risk factors and infection risk of H.pylori Test Results
Variables Sex Age (years)
Nutrition status Family income Father education
Mother education
Father occupation
Mother occupation
Habit of eating/drinking together from one container
Number of siblings
Sharing of room with other family members Sharing of bed with other family members Family drinking water source
Child history of stomach complaint Parent history of stomach complaints Parent with diagnosis of dyspepsia * = Non-parametric test Kolmogorov-Smirnov
266Paediatr Indones, Vol. 49, No. 5, September 2009
Positive Negative Male Female 6–8 9 – 10 11 – 12 Low Good Under minimum Minimum or higher No school Primary (not graduate) Primary (graduate) Junior high school Senior high school Academy / university No school Primary (not graduate) Primary (graduate) Junior high school Senior high school Academy / university Labor Trade Farm Civil government Private / business Labor Trade Farm Housewife Private / business Never Sometimes Often 0–1 2–3 More than 3 Yes No Yes No Well Government water system River Yes No Yes No Ever Never
20 22 17 17 8 18 24 32 10 0 7 25 9 1 0 2 16 19 5 0 0 16 7 11 0 8 9 5 9 15 4 2 13 27 1 18 23 36 6 36 6 22 4 16 3 39 34 8 8 34
37 46 45 23 15 26 57 62 21 5 20 45 9 3 1 10 31 35 6 1 0 20 15 14 7 27 24 5 13 34 7 38 36 9 4 35 44 46 37 32 51 74 4 5 8 75 66 17 4 79
P 0.747 0.287
0.202 0.855 0.694*
0.998*
0.137*
0.998*
0.000
1.000*
0.001 0.000 0.000
0.642 0.850 0.011
Ratu Nurjanah et al: Seroepidemiology of H. pylori in primary school students Table 3. Multivariate analysis of several variables with infection Variables
OR
95% CI
P
Nutrition status Father occupation (labor) Habit of eating together from one container Sharing of room with other family member Sharing of bed with other family member Family water drinking source Parent with dyspepsia
1.5 0.3 10.2 2.7 9.4 24.9 0.7
0.5 to 4.7 0.1 to 1.1 3 to 34.2 0.7 to 10.4 2.4 to 36.3 3.9 to 159.7 0.1 to 4.9
0.4 0.07 0.00 0.13 0.001 0.001 0.7
Discussion Prevalence of H. pylori infection in primary school FKLOGUHQDJHG²\HDUVLQWKLVVWXG\ZDV Another epidemiological serology study in Erzurum, 7XUNH\UHSRUWHGSUHYDOHQFHRILQFKLOGUHQDJHG ²\HDUV5 The prevalence from this study is higher then those in several European countries. Prevalence of H. pylori infection in developing countries increases VRRQDIWHUELUWKDQGUHDFKHV DWWKHDJHRI years. In developing countries, H. pylori infections are OHVVWKDQDQGLQFUHDVHHDFK\HDU &RPSDUHGWRVWXGLHVLQXUEDQDUHDVDVWXG\E\ +HJDUHWDO9LQ-DNDUWD XVLQJVHURORJ\WHVWRQ primary school students reported that H. pylori infection in urban area was lower than in rural area, respectively YV6WXGLHVXVLQJVHURORJ\SHUIRUPHGLQ Taiwan and Australia reported similar results, showing WKDWLQIHFWLRQULVNLQUXUDODUHDVZHUHWLPHVDQGVL[ times higher, respectively, compared to urban areas. &RPPXQLW\OLYLQJHQYLURQPHQWKDVLQFUHDVHGH. pylori LQIHFWLRQLQFLGHQFHDVVRFLDWHGZLWKRWKHUULVNIDFWRUV VXFKDVORZVRFLRHFRQRPLFVWDWXVKLJKSRSXODWLRQ personal hygiene, and poor sanitation. Based on this study, prevalence of H. pylori in FKLOGUHQ DJHG \HDUV ZDV LQ DJH \HDUV ZDV DQG LQ DJH \HDUV RU ROGHU ZDV 39.5%. These results are in accordance with studies by Selimoglu et al,5 Lin et al, and Windsor et al, showing increasing prevalence with age. In this study, WKHSHDNSUHYDOHQFHZDVLQDJHJURXSRI\HDUV $ VWXG\ LQ -DNDUWD UHSRUWHG GHFUHDVLQJVHURSRVLWLYH SUHYDOHQFHRILQFKLOGUHQDJHG²\HDUV LQFKLOGUHQDJHG\HDUVDQGLQFKLOGUHQ DJHG\HDUV9 These differences may be due to ORZ QXPEHU RI VXEMHFWV DQG XQHTXDO SURSRUWLRQ RI QXPEHURIVXEMHFWVEHWZHHQDJHJURXSV
In this study, there was no significant difference EHWZHHQVH[DQGULVNRIH. pyloriLQIHFWLRQ 3 7KLVUHVXOWLVVLPLODUWRVWXGLHVLQ:HVW9LUJLQLD VHURSRVLWLYH VDPSOHV DQG 7XUNH\ VHURSRVLWLYH VDPSOHV ZKLFKUHSRUWHGWKDWVH[ZDVQRWDULVNIDFWRU of H. pylori infection in children. On the other KDQG+HJDUHWDO9 SHUIRUPHGDVWXG\LQ-DNDUWDZKLFK revealed that prevalence of H. pylori infection was KLJKHULQJLUOVWKDQER\V YV 3! This difference may be due to unequal proportion of QXPEHURIVXEMHFWV Nutritional status was not associated with incidence of H. pylori LQIHFWLRQ 3= 7KLVUHVXOWLVVLPLODUWR D VWXG\ E\ 4XLQRQH] HW DO11 RQ VFKRRO FKLOGUHQ DJHG\HDUVLQ*XDWHPDODUHSRUWLQJQRFRUUHODWLRQ between H. pylori infection and nutritional status. Number of siblings was suggested to affect H. pylori infection. Selimoglu et al5 DQG&DPDUJRHWDO reported more number of sibling enabled close human contacts in transmission of H. pylori. In this study, there was no correlation between number of siblings and incidence of H. pylori infection, but there was a trend of increasing infection with increasing number RIVLEOLQJV DQG!VLEOLQJVZHUH and 34.3%, respectively). In this study, bed and bedroom sharing with other family members showed significant association with incidence of H. pylori LQIHFWLRQ 3 DQG 3 7KHULVNVRIWUDQVPLVVLRQLQFKLOGUHQZKR shared room with other family members were 1.55 &,WR DQGLQWKRVHEHGVKDULQJZLWK RWKHU IDPLO\ PHPEHUV ZHUH &, WR 7KHVHUHVXOWVZHUHLQDFFRUGDQFHZLWKSUHYLRXV studies by Farrel et al13DQG0F&DOOLRQHWDO14. Logistic regression multivariate analysis showed significant association between bed sharing with other family members and H. pyloriLQIHFWLRQ 3=25 &, WR %HG VKDULQJ DOORZHG FORVH SHUVRQDOFRQWDFWDNH\IDFWRUIRULQFUHDVLQJULVNRI infection. Bed sharing may facilitate transmissions WKURXJKRUDORUDOJDVWULFRUDORUIHFDORUDOURXWHVYLD saliva, vomit or poor personal hygiene.14 Studies by Farrel et al13 and Rothenbacher et al15 reported that children who slept with parents, infected by H. pyloriDOVRKDGULVNRILQIHFWLRQ3DUHQWVZKR had habit of sleeping together with their child under the age of 5 years old allowed infection transmission from parents to children.
Paediatr Indones, Vol. 49, No. 5, September 2009267
Ratu Nurjanah et al: Seroepidemiology of H. pylori in primary school students
In this study, parents with history of dyspepsia showed significant association with H. pylori infection 3 but logistic regression analysis did not show any significant corelation. Further investigation is required to confirm H.pylori infection in parents ZLWK G\VSHSVLD NQRZLQJ WKDW LQIHFWLRQ UDWH LV KLJK LQSDWLHQWVZLWKHSLJDVWULFSDLQGXHWRQRQ ulcer dyspepsia. Prevalence of infection in children with history of recurrent abdominal pain in this study LV 3 6LPLODU UHVXOWV ZDV UHSRUWHG E\ &KHQHWDOLQ&KLQDZKLFKUHYHDOHGWKHLQIHFWLRQ of H. pylori ZDV FKLOGUHQZLWKUHFXUUHQW abdominal pain). This result is much lower compared WRSUHYLRXVVWXG\E\'DVHWDO which revealed the infection of H. pylori ZDV FKLOGUHQ DJH \HDUVZLWKUHFXUUHQWDEGRPLQDOSDLQFRQILUPHG by histopathology). Those differences may be due to different host responses, bacterial strains, and number of colonies. We also need to consider that recurrent abdominal pain may be caused by a psychosomatic condition, especially in adolescences. )DPLO\KDELWRIHDWLQJDQGGULQNLQJWRJHWKHUIURP one container also showed significant correlation with H. pyloriLQIHFWLRQ 3 7KLVIDPLO\KDELWFOHDUO\ IDFLOLWDWHG WUDQVPLVVLRQV WKURXJK RUDORUDO JDVWULF RUDODQGIHFDORUDOURXWHVYLDVDOLYDYRPLWRUSRRU personal hygiene.145LVNRIWUDQVPLVVLRQLQFKLOGUHQ XVLQJWKHVDPHFRQWDLQHUIRUIRRGRUGULQNZLWKRWKHU IDPLO\PHPEHUVLQFUHDVHGWKHLQIHFWLRQWLPHV &,WR )DPLO\ VRXUFH RI GULQNLQJ ZDWHU KDG VWURQJ correlation with prevalence of H. pylori infection. )DPLOLHVZLWKVRXUFHRIGULQNLQJZDWHUIURPULYHUKDG SUHYDOHQFHRI 3 /RJLVWLFUHJUHVVLRQ DQDO\VLVVKRZHGGULQNLQJZDWHUIURPULYHULQFUHDVHG WKH ULVN RI LQIHFWLRQ WLPHV &, WR 7KLV UHVXOW LV VLPLODU WR SUHYLRXV VWXG\ E\ Nurgalieva et al19LQ.D]DNKVWDQZKRUHSRUWHGWKDW the prevalence of H. pylori infection using ELISA GHWHFWLRQ LQ IDPLOLHV GULQNLQJ ZDWHU IURP ULYHU ZDV DV KLJK DV :DWHU VRXUFH IURP ULYHU LQFUHDVHG WKH ULVN RI LQIHFWLRQ WLPHV FRPSDUHG WR WKDW IURPWKHJRYHUPHQWZDWHUV\VWHP 3 :DWHU from river can be source of infection because of fecal contamination from infected human or animals.19 Infection can be prevented by boiling the water before GULQNLQJ
268Paediatr Indones, Vol. 49, No. 5, September 2009
In conclusion, prevalence of H. pylori infection in UXUDOVFKRROVWXGHQWVDJHG\HDULV7KHUH are significant associations between H. pylori infection and family habit of eating together from one container, bed sharing with other family members, and source of IDPLO\GULQNLQJZDWHUIURPFRPPRQULYHU
References +DUULV$:0LVLHZLF]--+HOLFREDFWHUS\ORULVWHG/RQGRQ %ODFNZHOO+HDOWKFDUH&RPPXQLFDWLRQ S (OLWVXU
