INTRODUCTION

Helicobacter pylori (H. pylori) is the main cause of gastric ulcer, duodenal ulcer, and non-ulcer dyspepsia.¹ It is also an important risk factor for stomach cancer.² Worldwide, more than 50% of the population is infected with H. pylori. It is more commonly found in developing countries³ due to risk factors including low socioeconomic levels, poor hygiene conditions, and overcrowding.⁴ Both non-invasive and invasive tests can be used for H. pylori diagnosis. The most commonly used non-invasive tests are the urea breath test, the stool antigen test, and serology. The invasive tests are histology and the campylobacter-like organism (CLO) test. The urea breath testing and stool antigen testing are favored due to their easy implementation and reasonable cost.⁵ H. pylori is highly prevalent throughout the world, although its prevalence is declining. In a nationwide study in Australia with 1355 participants, the infection prevalence varied between 5%–32% with a higher prevalence in low-socioeconomic cities.⁶ In Europe, it is more common in eastern European countries than in western European countries.^7,8 In a study in Denmark, the average prevalence of H. pylori infection was determined to be 20%.⁹ The seroprevalence in Israel was determined to be 45%¹⁰ and the Turkey Helicobacter pylori Prevalence (TURHEP) study designed in Turkey in 2003 found the prevalence of H. pylori to be 82.5% in the population over the age of 18 years of age.¹¹ However, no research study had been performed in Northern Cyprus regarding the prevalence of H. pylori to date. As previously mentioned, there is a high prevalence of H. pylori in Turkey and other southeastern Mediterranean countries. Therefore, the aim of this study was to determine the prevalence of H. pylori in Northern Cyprus.

MATERIALS AND METHODS

Patients over 18 years of age who were admitted to the gastroenterology and internal medicine department with dyspeptic complaints from December 2012 to April 2018 and evaluated for H. pylori infection were included in this study. In a total of 1226 patients, H. pylori serology was detected using the stool antigen and urea breath test results from the hospital database. The results for post-eradication control were not included in this study. The files of the patients who were evaluated for H. pylori infection were examined and H. pylori test results were noted in terms of age, sex, and ethnicity. The patients were divided into age groups of 18–30, 30–40, 40–50, 50–60, and over 60 years of age. The patients were also divided by ethnicity as Turkish Republic of North Cyprus (TRNC) citizens, Turkish Republic (TR) citizens, and those from Middle Eastern countries. Ethics committee approval was received from the Ethics Committee of Scientific Research (31.05.2018-58/578).

Statistical Analysis

The data were analyzed using the Statistical Package for Social Science software version 24.0 (IBM Corp., Armonk, NY, USA). The frequencies for the age groups, sex, and ethnicity were calculated. The data were expressed as percentiles and numbers.

RESULTS

H. pylori positivity was detected in 286 of 1226 patients (23.3%) with 147 of the 693 (21%) females showing H. pylori positivity and 139 of 533 males (26%). One hundred and nineteen (19.8%) of the 599 TRNC citizenship patients were H. pylori positive. For the TR citizens, 148 (25.6%) out of 571 patients were H. pylori positive and 12 (36.4%) out of the 33 patients from Middle Eastern countries were H. pylori positive. When H. pylori positivity was examined according to age, 133 out of 517 patients were aged 18–30 (25.8%), 48 out of 206 patients were 30–40 years of age (25.8%), 39 out of 170 patients were 40–50 years of age (22.9%), 40 out of 176 patients were 50–60 years of age (22.7%), and 26 out of 159 patients were 60 years of age or older (16.4%). When the distribution of H. pylori positivity was examined according to age and ethnicity the 18- to 30-year-old TRNC patients had statistically significantly lower H. pylori positivity (p<0.05).

DISCUSSION

To the best of our knowledge, this is the first prevalence study performed on H. pylori in TRNC. The primary findings of this study were that Cypriot Turks have a lower H. pylori positivity compared to citizens of Turkey and Middle Eastern countries.

H. pylori is the most common chronic infection in the world. Its prevalence varies between countries and populations due to social and economic features. Its prevalence is much more common in developing countries but this is decreasing. In Japan, H. pylori prevalence in individuals born before 1950 is over 90%, while those born after 2000 are at a 2% level.¹² In 1992, the prevalence of H. pylori in Taiwan was 54.4%, but in a recent study, its prevalence in asymptomatic patients was 21.2% and 37.9% in patients with dyspepsia.¹³ A Turkish study conducted with a pediatric population compared the years 2002–2003 and 2012–2013 and found that the prevalence of infection decreased from 48% to 23%.¹⁴

The current study is the first study concerning the prevalence of H. pylori infection in Northern Cyprus and it found a very low prevalence compared to the surrounding countries. The disease is more common in developing countries than in developed countries. In European countries, the prevalence is 20%–40%, and in Belgium, H. pylori prevalence is 11%.¹⁵ However, the infection prevalence in developing countries is extremely high. For example, H. pylori prevalence is 79% in Kazakhstan, 95%–100% in Indonesia and 88.3% in Serbia. Recent prevalence studies show 41% of asymptomatic patients from the United Arab Emirates are infected and 44.5% of the asymptomatic population are infected with H. pylori in northern Iran.^16,17 A recent prevalence study from Jordan showed very high seropositivity (88.6%).¹⁸ According to the TURHEP study carried out in Turkey in 2003, the prevalence of H. pylori infection was found to be 82.5%. In addition, H. pylori prevalence is over 80% in southeast Mediterranean countries.¹⁹ The current study found H. pylori frequency to be 23.3%. Although Cyprus is an eastern Mediterranean country, the prevalence of the disease is quite low in comparison to its geographic region and is similar to European countries. This may be attributed to a stable socio-cultural structure, high education level, better hygiene conditions, and a lack of overcrowding in the population.

In a study conducted by Perez-Perez et al.²⁰, the prevalence of H. pylori in Turks living in Germany was 30.4%, which was a lower prevalence in Turkey. In our study, H. pylori prevalence was 19.8% among Cypriot patients and 25.6% among Turkish patients who were born in Turkey but lived in Cyprus. Compared with the studies performed in Turkey, both Cypriot and Turkish patients who lived in Cyprus had a lower prevalence. It could be suggested that these results are related to the non-crowded population of Cyprus and that Turks living there enjoy a better socio-cultural structure.

When disease frequency was evaluated according to age, the lowest frequency of H. pylori infection was for those over 60 years and the infection was most commonly detected between 30–40 years of age. Our results are compatible with previously published results. Meyer et al.²¹ stated that this may be related to a spontaneous remission of infection through aging. However, in a study from Armenia, H. pylori seropositivity was most commonly detected in patents over 60 years old.²² This may be related to a lack of evaluation and treatment of H. pylori in dyspeptic patients. We detected the lowest prevalence in individuals over 60 years of age and believe that this was related to a spontaneous remission of infection through aging and the successful evaluation and treatment of H. pylori in Northern Cyprus in recent years.

Our study was a retrospective study and we only evaluated age, gender, and ethnicity. Also, we only evaluated dyspeptic patients. These were the limitations of our study. Prospective studies on this subject may be planned to evaluate an asymptomatic population with more demographic features.

H. pylori is still a common infection but with a decreasing frequency. Despite the fact that TRNC is an eastern Mediterranean country, the prevalence of H. pylori in TRNC is much lower than in other southeastern Mediterranean countries. More cohort studies are needed which include quality of life and education levels in both dyspeptic and asymptomatic populations.

ACKNOWLEDGMENT

I would like to thank our medical faculty student Omar Mohamed Mohamed Hasan Shoeib for help in collecting the data.

MAIN POINTS

● H. pylori is a still common infection, but with decreasing frequency all over the world. Worldwide, more than 50% of the population is infected with H. pylori.

● H. pylori is commonly found in developing countries due to risk factors including low socioeconomic levels, poor hygiene conditions, and overcrowding.

Despite the fact that TRNC is an eastern Mediterranean country, the prevalence of H. pylori in TRNC is much lower than in other southeastern Mediterranean countries.

ETHICS

Ethics Committee Approval: Ethics committee approval was received from the Near East University Ethics Committee of Scientific Research. (date and number: 31.05.2018-58/578)

Informed Consent: Informed consent was not taken because this was a retrospective study.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: Ö.S., T.U., Design: Ö.S., T.U., E.E.S., Supervision: Ö.S., T.U., Data Collection and/or Processing: Ö.S., T.U., Analysis and/or Interpretation: T.U., E.E.S., Literature Search: Ö.S., E.E.S., Writing: Ö.S., T.U. E.E.S., Critical Reviews: T.U., E.E.S.

DISCLOSURES

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.