Helicobacter Pylori: A brewing threat in the Middle East and North Africa

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma, gastric cancer, and peptic ulcers are serious gastroduodenal diseases that can develop from a stomach infection known as Helicobacter pylori (H. pylori). The symptoms of an H. pylori infection can be diverse, and many individuals with the infection may not exhibit any noticeable signs. Nevertheless, when symptoms manifest, they can encompass nausea, loss of appetite, stomach pain, burping, dark stools or hematemesis, a sense of fullness or bloating, and unintentional weight loss.

The asymptomatic nature of an H. pylori infection often means individuals carry the bacteria unknowingly for extended periods. Furthermore, H. pylori has been linked to an increased risk of stomach cancer. The transmission mechanisms of the bacteria remain unclear to health experts. Nevertheless, maintaining rigorous hygiene practices is crucial for personal safety. This involves regular handwashing with soap and water, thorough cooking of food, and steering clear of potentially contaminated food or water. The Middle East and North Africa (MENA) region grapples with a notably high prevalence of H. pylori infection, primarily attributed to the aggregation of risk factors in emerging nations.

Some diagnostic methods that are being used in the MENA region include:

• Serology: In regions with a high frequency of pylori infection, such as the MENA region, serology is thought to be sufficient for diagnosis.
• Urea breath test: A widely used noninvasive diagnostic technique.
• Endoscopy: An invasive diagnostic technique employed to identify H. pylori infection and its associated consequences.

Due to the complications associated with H. pylori, routine screening for H. pylori infection is recommended in all gastroenterology patients in the MENA region. Preventive measures must also be implemented to manage the infection such as,

• Improving sanitation: Since pylori are thought to spread mostly through the fecal–oral route, improving sanitation can help stop the development of the infection.
• Avoiding contaminated food and water: pylori can also be transmitted through contaminated food and water, so avoiding these sources can help prevent infection.
• Antibiotic stewardship: Testing for antibiotic susceptibility, monitoring for antibiotic resistance, and antibiotic stewardship are all necessary to eradicate pylori.
• Screen-and-treat strategies: The association between chronic pylori infection and the emergence of gastric cancer offers the potential for preventive screen-and-treat approaches.
• Eradication therapy: To reduce the risk of stomach cancer and peptic ulcers in people with pylori infection, eradication therapy is advised. Antibacterial medications with a high eradication rate include tetracycline, metronidazole, and amoxicillin.

Treatment Scenario of H. Pylori in the MENA region

According to a systematic review and network meta-analysis of research carried out in the Arab world, concomitant medication, which consists of proton pump inhibitor (PPI), amoxicillin, clarithromycin, and metronidazole, is found to be the most successful treatment for H. pylori infection.

The first-line H. pylori eradication therapy involves clarithromycin-based triple therapy. If first-line therapy fails, clarithromycin-based sequential therapy, esomeprazole-based sequential therapy, and quadruple therapy are recommended.

Information on the H. pylori infection treatment pattern in the MENA region is scarce. Nevertheless, some research has been conducted in nations like Saudi Arabia and Egypt. The 10-day sequential therapy and the 14-day standard triple therapy for treating H. pylori infection were contrasted in a prospective experiment conducted in Saudi Arabia. According to the study, sequential and traditional triple therapy were equally successful at removing H. pylori in two-thirds of Saudi participants. A study conducted in Egypt looked into how the virulence genotypes and susceptibility patterns of H. pylori affected the effectiveness of eradication therapy in patients with gastroduodenal illnesses. Although the patients received triple therapy for 14 days, the study did not specify the exact treatment plan applied.

Several organizations, including the Japanese Society for Helicobacter Research, the Asia-Pacific Consensus Guidelines, and the Maastricht V/Florence Consensus Report, have released international guidelines for managing H. pylori infection. These recommendations include a variety of treatment plans, such as quadruple therapy with a proton pump inhibitor, bismuth, metronidazole, and tetracycline, as well as triple therapy with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole.

It is significant to note that H. pylori antibiotic resistance may rise due to needless or ineffective eradication treatment. Thus, adhering to current worldwide recommendations for diagnosing and treating H. pylori infection is essential.

In summary, limited information on the treatment trend for H. pylori infection in the MENA region is available. However, research from Saudi Arabia and Egypt indicates that sequential therapy and the usual triple therapy are good treatment alternatives. Numerous treatment plans, including triple therapy and quadruple therapy, are advised by international guidelines. Although concomitant medication is the most successful treatment for H. pylori infection in the Arab world, the MENA region was not the focus of this investigation.

Despite the availability of various treatment options, several unmet needs persist for H. pylori infection in the MENA region. These include:

• Diagnostic techniques: The prevalence of pylori infection in the MENA region is high, but there is a lack of standardized diagnostic methods. Improving diagnostic methods can help identify infected individuals and improve treatment outcomes.
• Antibiotic resistance: The MENA region has a high rate of antibiotic resistance in pylori, which might result in treatment failure. This emphasizes the necessity of alternate treatment choices and responsible antibiotic use.
• Vaccination research and development: There is a significant unmet need for a vaccine to protect against diseases related to pylori infection, especially gastric cancer.
• Alternative treatment options: pylori infections are generally asymptomatic and can re-appear within a year following therapy, so the accuracy of determining cure rates is important. Addressing the unmet needs of H. pylori treatment through alternative treatment options and antimicrobial stewardship can help improve treatment efficacy.

In addition to these unmet demands, it is crucial to realize that H. pylori infection can lead to persistent stomach inflammation, thereby increasing the risk of stomach cancer. Consequently, improving public health outcomes to effectively address the unmet needs associated with H. pylori infection in the MENA region becomes paramount.

Epidemiological Insights in the MENA region

A case series study highlights the common occurrence of H. pylori infection in Middle Eastern countries. Yemen exhibits a high prevalence of H. pylori infection at 80.6%, a figure comparable to other nations in the MENA region. Reports indicate that H. pylori infections are more widespread in Eastern Mediterranean countries compared to European countries, where the incidence is less frequent, occurring in less than 20% of cases. However, there is a scarcity of high-quality research on the prevalence of various H. pylori genotypes across the MENA region, emphasizing the need for standardized diagnostic procedures and screening protocols. Consequently, a collaborative effort is required to establish regional guidelines with customized cut-off values for interpreting diagnostic tests that are both reasonably priced and accurate.

In general, the prevalence of H. pylori infection among the countries of the MENA region varies widely, ranging from 7% to 50% in young children and up to 36.8–94% in adults.

Some commercial aspects of H. pylori infection in the MENA region:

• Diagnostic procedures: Many diagnostic techniques are available, including endoscopy, urea breath testing, stool antigen testing, and serology. The choice of diagnostic technique may be influenced by price, accessibility, and patient need.
• Treatment: A combination of antibiotics and proton pump inhibitors is the usual course of action for pylori infection. However, the MENA region is concerned about the rising incidence of antibiotic resistance. This may lead to the need for alternative treatment options or the development of new antibiotics.
• Healthcare market: Improved diagnosis could lead to growth in the healthcare market for pylori-related products and services.
• Research: To better understand the prevalence and risk factors linked to pylori infection, research is ongoing in the MENA region. These studies could produce fresh understandings of the condition and perhaps even new remedies.

The MENA region’s high rate of H. pylori infection presents both challenges and large potential for a lucrative therapy market.