The epidemiology of Helicobacter pylori infection in African refugee children resettled in Australia.
ABSTRACT To determine the prevalence and associated epidemiological features of Helicobacter pylori infection in child refugees in Western Australia.
Cross-sectional study of 193 eligible African refugee children (aged < 16 years) at their initial health assessment after resettlement in Australia between 1 February and 30 November 2006.
(i) Prevalence of H. pylori infection determined by monoclonal faecal antigen enzyme immunoassay testing (MFAT); (ii) associations of H. pylori infection with epidemiological factors (age, sex, transit through refugee camps, comorbidities and treatment interventions).
MFAT was performed in 182 of the 193 children; 149 of these 182 (82%) had H. pylori infection. Age was an independent predictor of H. pylori infection (odds ratio [OR], 1.18; 95% CI, 1.07-1.31). No sex differences were observed. Premigration antimalarial therapy (with sulfadoxine-pyrimethamine and artesunate) significantly reduced the prevalence of H. pylori infection (age-adjusted OR, 0.33; 95% CI, 0.15-0.75).
African refugee children have a high prevalence of H. pylori infection. Increasing age is a strong predictor of infection and antimalarial treatment may have a protective effect.
- SourceAvailable from: Berit Smestad Paulsen[show abstract] [hide abstract]
ABSTRACT: Gastrointestinal diseases are major reasons for morbidity in Mali. As Helicobacter pylori is known to play a major role in gastritis and gastric ulcer we wanted to find a simple method for detection. Twenty-nine volunteers with confirmed gastric ulcer by gastroscopy and 59 randomly selected volunteers were diagnosed by using the rapid serological test Clearview(®) H. Pylori. The ImmunoCard STAT!(®) HpSA(®)test was applied on stool from 65 volunteers seeking help for gastrointestinal related ailments. A Helicobacter pylori prevalence of 21% was found among the individuals with confirmed gastric ulcer, 44% among the randomly selected volunteers and 14% in individuals with gastrointestinal related ailments. According to what is already known about the aetiology of gastric ailments and the prevalence of Helicobacter pylori in neighboring countries, the infection rates in our study appear strikingly low. This might indicate that Clearview(®) H. Pylori and ImmunoCard STAT!(®) HpSA(®) have low sensitivities in the populations studied. Strain variability of H. Pylori may be an explanation. The tests need to be properly evaluated in Mali before they can be relied upon as diagnostic tools.The Pan African medical journal. 01/2013; 14:72.
- [show abstract] [hide abstract]
ABSTRACT: Increasing numbers of refugees from Burma (Myanmar) are resettling in Western countries. We performed a retrospective study of 156 Burmese refugees at an Australian teaching hospital. Of those tested, Helicobacter pylori infection affected 80%, latent tuberculosis 70%, vitamin D deficiency 37%, and strongyloidiasis 26%. Treating these diseases can prevent long-term illness.Emerging Infectious Diseases 11/2009; 15(11):1769-72. · 6.79 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: The antimalarial drug artemisinin from Artemisia annua demonstrated remarkably strong activity against Helicobacter pylori, the pathogen responsible for peptic ulcer diseases. In an effort to develop a novel antimicrobial chemotherapeutic agent containing such a sesquiterpene lactone endoperoxide, a series of analogues (2 natural and 15 semisynthetic molecules), including eight newly synthesized compounds, were investigated against clinical and standard strains of H. pylori. The antimicrobial spectrum against 10 H. pylori strains and a few other bacterial and fungal strains indicated specificity against the ulcer causing organism. Of five promising molecules, a newly synthesized ether derivative β-artecyclopropylmether was found to be the most potent compound, which exhibited MIC range, MIC(90), and minimum bactericidal concentration range values of 0.25 to 1.0 μg/ml, 1.0 μg/ml, and 1 to 16 μg/ml, respectively, against both resistant and sensitive strains of H. pylori. The molecule demonstrated strong bactericidal kinetics with extensive morphological degeneration, retained functional efficacy at stomach acidic pH unlike clarithromycin, did not elicit drug resistance unlike metronidazole, and imparted sensitivity to resistant strains. It is not cytotoxic and exhibits in vivo potentiality to reduce the H. pylori burden in a chronic infection model. Thus, β-artecyclopropylmether could be a lead candidate for anti-H. pylori therapeutics. Since the recurrence of gastroduodenal ulcers is believed to be mainly due to antibiotic resistance of the commensal organism H. pylori, development of a candidate drug from this finding is warranted.Antimicrobial Agents and Chemotherapy 06/2012; 56(9):4594-607. · 4.57 Impact Factor
438MJA • Volume 189 Number 8 • 20 October 2008
The Medical Journal of Australia ISSN:
0025-729X 20 October 2008 189 8 438-
©The Medical Journal of Australia 2008
in industrialised nations have a lower preva-
lence of H. pylori infection.3,8 Increased preva-
lence is also found in migrants and indigenous
populations; adverse socioeconomic condi-
tions in these groups account for some of the
Western Australia resettles about 1300
humanitarian refugees annually, represent-
ing over 10% of Australia’s refugee intake.11
Currently, many families are African, and
about half the refugees are children.12
In this study, we investigated the preva-
lence and epidemiological associations of
H. pylori infection in a high-risk paediatric
population. The main outcome measure was
H. pylori infection diagnosed by monoclonal
faecal antigen enzyme immunoassay testing
(MFAT). The effects of age, sex, transit
through refugee camps, comorbidities and
treatment interventions were investigated.
elicobacter pylori infection is usually
acquired in childhood.1,2 Acute infec-
tion is often silent, with symptoms
and disease manifesting later in life, as does an
increased risk of H. pylori-related malignancy.
The prevalence of H. pylori infection is
markedly increased in developing countries,3,4
and risk factors include increasing age, large
family size and socioeconomic deprivation.5-7
Refugees resettled in developed countries gen-
erally come from regions of high H. pylori
prevalence, whereas those who have grown up
We conducted a cross-sectional study at the
Migrant Health Unit (MHU) in Perth, WA,
the sole screening unit for humanitarian refu-
gees resettled in WA. About 80% of targeted
refugees in WA receive an initial health
assessment at the MHU.12 African children
(aged less than 16 years) who presented for
initial health assessment between 1 February
and 30 November 2006 were included.
Blood samples were obtained for routine
screening investigations at the first clinic visit
as part of standard clinical care and stool
samples were collected 1 week later. Children
were excluded from our study if they had
received antibiotics or proton-pump inhibi-
tors in the preceding month, if they had an
immunodeficiency or active tuberculosis.
Ethical approval was obtained from the
Women and Children’s Ethics Committee,
Princess Margaret Hospital for Children.
Informed consent was obtained in the pres-
ence of trained interpreters, as appropriate.
Data on age, sex, ethnicity, country of last
transit, transit period, country of birth, type
of dwelling in country of transit, and recent
drug administration were obtained at the
first visit by means of a structured question-
naire. Breastfeeding history was recorded for
children under 2 years of age. Details of
premigration antihelminthic and antimalar-
ial treatment were obtained from accom-
panying International Office of Migration
The epidemiology of Helicobacter pylori infection in African
refugee children resettled in Australia
Sarah Cherian, David Forbes, Frank Sanfilippo, Angus Cook and David Burgner
Objective: To determine the prevalence and associated epidemiological features of
Helicobacter pylori infection in child refugees in Western Australia.
Design and participants: Cross-sectional study of 193 eligible African refugee children
(aged <16 years) at their initial health assessment after resettlement in Australia
between 1 February and 30 November 2006.
Main outcome measures: (i) Prevalence of H. pylori infection determined by
monoclonal faecal antigen enzyme immunoassay testing (MFAT); (ii) associations of
H. pylori infection with epidemiological factors (age, sex, transit through refugee camps,
comorbidities and treatment interventions).
Results: MFAT was performed in 182 of the 193 children; 149 of these 182 (82%) had
H. pylori infection. Age was an independent predictor of H. pylori infection (odds ratio
[OR], 1.18; 95% CI, 1.07–1.31). No sex differences were observed. Premigration
antimalarial therapy (with sulfadoxine–pyrimethamine and artesunate) significantly
reduced the prevalence of H. pylori infection (age-adjusted OR, 0.33; 95% CI, 0.15–0.75).
Conclusion: African refugee children have a high prevalence of H. pylori infection.
Increasing age is a strong predictor of infection and antimalarial treatment may have a
MJA 2008; 189: 438–441
1 Ethnicity, country of birth and transit profiles of the 193 African refugee children in the study
EthnicityCountry of birthCountry of last transit
GroupNo.CountryNo. Country No. Median transit time (IQR)
Democratic Republic of Congo
6.1 years (3.0–9.0)
5.5 years (4.0–9.4)
2.0 years (1.2–2.9)
5.8 years (4.0–7.3)
6.4 years (3.3–9.4)
7.0 years (3.3–10.0)
IQR=interquartile range. *Other ethnicity: Sierra Leonian (7). †Other countries of birth: Liberia (11); Egypt (9); Guinea (9); Zambia (8); Sierra Leone (6); Ethiopia (2);
Ghana (2); Zimbabwe (2); Ivory Coast (1); Nigeria (1). ‡Other transit countries: Zambia (11); Ghana (3); Ethiopia (3); Uganda (3); Zimbabwe (2); Nigeria (1).
MJA • Volume 189 Number 8 • 20 October 2008
Helicobacter pylori diagnosis
Fresh faecal samples were obtained from
each child and frozen at −20°C for batch
analyses. We assessed H. pylori status using
Amplified IDEIA HpStAR kits (Dako, Glos-
trup, Denmark) following the manufac-
turer’s instructions and as previously
Identification of other infections
Details of helminth infection, tinea capitis,
tuberculosis and malaria were obtained for
each child. Helminth infection was defined
as the presence of any of the following
results: positive serological test for schisto-
somiasis and/or strongyloidiasis, positive
stool microscopy for ova, cysts or parasites
of pathogenic helminths, peripheral eosino-
philia (?0.7? 109/L) or elevated immuno-
globulin E (IgE) levels (>280kU/L). Pre-
migration administration of albendazole was
documented in 80% of children, with the
remainder receiving empiric albendazole at
the first health assessment visit.
A clinical diagnosis of tinea capitis was
made at the initial visit based on skin exam-
ination. Latent or active tuberculosis infec-
tion was diagnosed by QuantiFERON-TB
Gold testing (Cellestis International, Mel-
bourne, Vic) in children over 2 years of age,
with chest radiographs as indicated. All
children had a single blood film and smears
and rapid immunochromatographic testing
(BinaxNOW, Portland, Ore, USA), irrespec-
tive of symptoms or premigration antimalar-
All data were analysed with SPSS, version
14.0 for Windows (SPSS Inc, Chicago, Ill,
USA). Continuous variables were compared
by independent t tests or Mann–Whitney
tests, as appropriate. Associations between
categorical variables and H. pylori infection
were initially analysed by Pearson χ2 or
Fisher’s exact tests. Logistic regression was
used to determine the effect of independent
variables separately on H. pylori infection,
adjusting only for age and sex. Multivariate
logistic regression was used to evaluate the
effect of covariates on H. pylori infection.
Statistical significance was set at the 5% level
and two-sided P values were calculated.
Two-hundred and one African refugee chil-
dren presenting for screening at the MHU
were recruited consecutively, with a 100%
response rate. Eight children were excluded
2 Adjusted odds ratios for factors tested for independent associations with
Helicobacter pylori infection
Age strata (sex-adjusted)
Protracted refugee stay (>5 years)
Type of dwelling
Last transit country
Premigration antihelminthic treatment
Premigration antimalarial treatment
QuantiFERON-TB Gold test result
Plasmodium falciparum infection
*Odds ratios are age- and sex-adjusted by logistic regression. †Other transit countries: Zambia (11);
Ghana (3); Ethiopia (3); Uganda (3); Zimbabwe (2); Nigeria (1). ‡No odds ratio reported for positive
QuantiFERON-TB Gold test results because of small numbers.
No. infected with
1.51 (0.69–3.31) 0.3
1.03 (0.38–2.80) 0.95
1.05 (0.41–2.68) 0.92
106 1.01 (0.40–2.55)0.98
0.85 (0.27–2.71) 0.79
166 2.06 (0.57–7.23)0.26
15 11 (73%)
167 1.84 (0.52–6.46)0.34
440MJA • Volume 189 Number 8 • 20 October 2008
(five received antibiotics before screening
and three were of non-African ethnicity). Of
the 193 eligible children, 100 (52%) were
male. The mean age was 7.9 years (SD, 4.4
years). Box 1 shows the main demographic
features of the cohort.
Eighteen children (9%) were breastfeed-
ing at the time of enrolment (mean age of
breastfeeding children, 11.3 months; SD,
5.2 months). There were 116 children
(60%) who had lived in refugee camps, with
the remainder living in urban dwellings
(apartments or houses). Almost all children
who transited through Tanzania or Kenya
(96 of 97; 99%) had lived in refugee camps,
while all 28 who transited through Egypt
had lived in apartments. The overall median
transit time before resettlement in WA was
5.5 years (interquartile range [IQR], 3.0–
8.4). Protracted refugee stays (more than 5
years in transit) were common (98 of 193;
51%); the median transit time for these 98
children was 8.0 years (IQR, 6.5–10.0).
Helicobacter pylori infection
MFAT was performed in 182 children, and
H. pylori infection was diagnosed in 149
(82%). MFAT results clearly discriminated
between populations that were infected
(median positive optical density [OD], 2.85;
IQR, 1.18–3.61) and uninfected (median
negative OD, 0.10; IQR, 0.08–0.18), with
no equivocal results (P<0.001).
Children with H. pylori infection were
significantly older (mean age, 8.5 years [SD,
4.2] v mean age, 5.8 years [SD, 4.5];
P<0.001) with no sex differences. The
prevalence of H. pylori infection was 63%
for children under 2 years of age, rising to
95% for those older than 14 years. When
analysed by age strata, the odds of infection
were more than fourfold higher for children
aged over 10 years compared with those
aged less than 5 years (odds ratio [OR],
4.42; 95% CI, 1.58–12.35). Where two or
more children in a family were enrolled (51
families), 45 of the 51 oldest siblings (88%)
had H. pylori infection compared with 35 of
the youngest siblings (69%; OR 3.43; 95%
Logistic regression was used to assess
the effect of various factors on the odds of
H. pylori infection (Box 2). Age was a signifi-
cant predictor of H. pylori infection, with the
odds of infection increasing by 17% for each
year of age (OR, 1.17; 95% CI, 1.07–1.28).
While the odds of infection were numer-
ically largest for children transiting through
Kenya, the overall relationship between
country of transit and infection was not
significant after adjusting for age and sex.
Premigration antimalarial treatment (79 of
182 children; 43%) significantly reduced
the odds of H. pylori infection after adjusting
for age and sex (OR, 0.31; 95% CI, 0.14–
0.72). Multivariate regression showed that
only age and premigration antimalarial
treatment were significantly associated
with H. pylori infection (Box 3).
Effect of other infectious diseases on
Helicobacter pylori infection
In total, 76 of the 182 children (42%) had
evidence of helminth infection, 15 (8%) had
tinea capitis, 16 (9%) had Plasmodium falci-
parum infection, and 11 of the 153 children
(7%) tested had positive QuantiFERON-TB
Gold results (with normal chest radio-
graphs), indicative of latent tuberculosis
infection. After adjusting for age and sex,
the prevalence of H. pylori infection was not
affected by the presence any of these infec-
tions (Box 2). No difference in IgE levels or
peripheral eosinophilia counts were found
in children with or without H. pylori infec-
tion (data not shown).
Our study shows a high prevalence of
H. pylori infection in African refugee chil-
dren, confirming that children from develop-
ing countries are at greater risk of infection.14
Our results support the observation that
early childhood is the main period of acqui-
sition of H. pylori infection in high-preva-
lence populations.1,2,4 H. pylori infection was
present in 82% of this cohort, and the odds
of infection increased significantly with age.
In comparison, the prevalence of H. pylori
infection in Australian children is low,8
although the prevalence in Australian
Aboriginal children is significantly higher,
especially in those from remote areas,9
reflecting differences in socioeconomic status.
The protective effect of antimalarial treat-
ment on H. pylori infection is a potentially
important and unexpected finding. In chil-
dren who received empirical premigration
antimalarial treatment, this was given about
6 weeks before study enrolment. This cor-
related with the median time between arrival
in Australia and the MHU health screening
(Dr A Thambiran, Medical Director, MHU,
Perth, WA, personal communication).
Empirical premigration antimalarial treat-
ment was ceased in mid 2006 because of
concerns about efficacy and coverage.15
The antimalarial therapy may have eradi-
cated existing H. pylori infection. The period
between administration of antimalarial
drugs and collection of faecal samples was
short, and so reacquisition of H. pylori infec-
tion during this intervening period is
unlikely. The elimination half-lives of
pyrimethamine and sulfadoxine are rela-
tively long (3–4 and 6–9 days, respectively)
and that of dihydroartemisinin, the active
metabolite of artesunate, is less than 1
hour.16 Antimalarial therapy is unlikely to
have affected MFAT performance. The effect
of antimalarial therapy remained significant
in our final regression analyses, and was
independent of albendazole therapy. To our
knowledge, this in-vivo association has not
been previously reported, although artemi-
sinins are known to have antibacterial prop-
erties.17 It has been postulated that
artemisinin derivatives may interact with
iron-dependent bacteria (such as H. pylori)
and potentially provide a mechanism for
targeted bacterial death.18 The possible
therapeutic role of artemisinins, which are
cheap and well tolerated, in H. pylori eradi-
cation warrants further investigation.
A limitation of our study is the lack of a
traditional “gold standard” for the diagnosis
of H. pylori infection. Methods based on
endoscopy and biopsy, or urea breath test-
ing, are neither practical nor ethical for
population-based screening of children, par-
ticularly in non-English speaking and often
traumatised families. Recent international
guidelines now recommend MFAT as an
alternative in both adult and paediatric pop-
3 Multivariate logistic regression model of variables associated with
Helicobacter pylori infection
with H. pylori
Premigration antimalarial treatment
182 149 (82%)1.18 (1.07–1.31)<0.05
0.33 (0.15–0.75) <0.05
MJA • Volume 189 Number 8 • 20 October 2008
In this study, we investigated potential
epidemiological risk factors that may predis-
pose refugee children to H. pylori infection.
Surprisingly, transit through refugee camps
did not place children at increased risk of
infection, despite harsh environmental and
nutritional conditions. The ubiquitous dep-
rivation and overcrowding that characterise
urban refugee conditions (eg, Egyptian
apartments) may instead contribute to the
non-significant association between dwell-
ing type and H. pylori infection.
Intrafamilial spread of H. pylori, particu-
larly mother-to-child transmission2,21,22 or
from infected older siblings,2,23 is a poten-
tially important mechanism for acquisition.
In our cohort, older siblings had odds of
H. pylori infection three times higher than
those of their youngest siblings, supporting
this premise. Parental H. pylori infection was
not assessed in this study, but a high preva-
lence would be expected, in keeping with
analogous published results.22-24 Reliable
data on family size could not be obtained, as
many siblings and/or parents were displaced
The relationship between breastfeeding
and infection was not found to be statist-
ically significant; however, the number of
children being breastfed at the time of enrol-
ment was small. Our study did not address
the phenomenon of transient H. pylori infec-
tions.25 Over 60% of children aged under 2
years had H. pylori infection, which is simi-
lar to other reports of African infants.4 Given
the high levels of overall infection in this
cohort, reinfection is likely even if there
were cases of transient infection in infancy.
Clinicians should be aware of the high
prevalence of H. pylori infection in resettled
refugee children, including the potential devel-
opment of chronic complications. Longitud-
inal studies of this population are warranted.
We thank Dr Aesen Thambiran and the staff of the
Migrant Health Unit for their assistance.
Sarah Cherian received a 2007 Royal Australasian
College of Physicians Research Grant and a 2007
University of Western Australia Research Grant for
consumables used in this study. Sarah Cherian also
received a 2007 Paediatric Research Society of
Australia and New Zealand (PRSANZ) travel grant
and a 2007 UWA Graduate Travel Award to present
related data at the 2007 RACP Congress. Faecal
antigen kits were supplied by Dako, Denmark and
Oxoid, Australia without charge. Neither company
had any influence on the design, analyses, inter-
pretation or content of this manuscript.
Sarah Cherian, MBBS(Hons), FRACP, PhD
Candidate,1 and Paediatrician2
David Forbes, MBBS, FRACP, Associate
Professor, School of Paediatrics and Child
Health,1 and Paediatric Gastroenterologist2
Frank Sanfilippo, BPharm, PhD, Research
Fellow, School of Population Health1
Angus Cook, MBChB, PhD, Senior Lecturer,
School of Population Health1
David Burgner, MBChB, FRACP, PhD, Senior
Lecturer, School of Paediatrics and Child
Health,1 and Paediatric Infectious Diseases
1 University of Western Australia, Perth, WA.
2 Princess Margaret Hospital for Children,
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(Received 6 Feb 2008, accepted 3 Jun 2008)