Memorandum by the Helicobacter Working
The bacterium Helicobacter pylori causes
chronic gastritis, predisposes to gastric and duodenal ulcers,
and has been recognized as a class I gastric carcinogen.
Infection with Helicobacter pylori is very common throughout
the world, occurring in 40-50 per cent of the population in developed
countries and 80-90 per cent of the population in developing regions.
An estimated total of 7.5 million people living
in England and Wales have an active infection, Helicobacter
pylori being acquired at an early age and unlikely to be resolved
unless suitable antibiotic treatment is sought.
The discovery that Helicobacter pylori
is a gastroduodenal pathogen has affected the management of many
gastroenterological diseases. The management of dyspepsia which
is the single largest area of cost for primary care in the UK,
now includes the diagnosis and treatment of Helicobacter pylori.
The eradication of Helicobacter pylori in patients with
peptic ulcers offers the prospect of reducing the enormous costs
of these drugs.,
is of cost effective benefit to both patients and society. The
Maastricht 2-2000 Consensus Report published in 2002 gives useful
guidelines for current concepts in the management of Helicobacter
A recent MDA bulletin describes the transmission
of Helicobacter pylori via endoscopes.
1. What are the main problems facing the
surveillance, treatment and prevention? 
Currently the UK has no system for identifying
this problem. We would recommend a system such as that in Germany,
known as ResiNet, where a small number of strategically placed
units (gastroenterology and microbiology), undertake a programme
of surveillance and feedback.
Monitor national and regional trends
in incidence of infection and antibiotic resistance.
Assess rates and determinants of
Assess determinants and risks of
re-infection after successful eradication.
Determine significance of strain
resistance type on clinical outcome.
2. Will these problems be adequately addressed
by the Government's recent infectious disease strategy, Getting
Ahead of the Curve?
There is no specific mention of Helicobacter
pylori disease in this document; the section on management
of chronic diseases should include HELICOBACTER PYLORI. We are
concerned that this important, common and costly issue of public
health could get overlooked.
There is no comprehensive nationally coordinated
surveillance of Helicobacter pylori infection in the UK
and it is recommended that a Helicobacter pylori surveillance
network of sentinel centres should be established in the United
It should be noted:
A US Helicobacter pylori antimicrobial
resistance monitoring project (HARP) based at CDC Atlanta was
initiated in 2001. A multi-site network of academic medical centres
was formed to submit isolates to CDC for antimicrobial susceptibility
A German National Reference Centre
for Helicobacter pylori (located in Freiburg) was established
by the German Ministry of Health in April 2000. A network (ResiNet)
was initiated, now comprising 14 local gastroenterological sentinel
centres in different parts of Germany. Gastric biopsies and patient
data will be collected systematically for continuous nationwide
surveillance of Helicobacter pylori and prevalence of antimicrobial
In Canada, a nationwide study was
initiated in 1999 with microbiologists working with gastroenterologists
at eight sites to monitor resistance rates.
In France, cross-sectional studies
were initiated in 1997 to understand the epidemiology of Helicobacter
pylori infections based on prevalence, risk factors, and antibiotic
Other multicentred European studies,
coordinated by the European Helicobacter pylori Study Group,
were performed in the mid 1990s to standardise methods and to
compare resistance rates in different countries.
3. Is the United Kingdom benefiting from
advances in surveillance and diagnostic technologies; if not,
what are the obstacles to its doing so?
As the consequences of infection with Helicobacter
pylori are chronic and do not show a marked temporal variation
in incidence from year to year, surveillance of this infection
cannot be based upon systems used for the surveillance of acute
infections. Detection of infection is also complex, as non-invasive
diagnosis is expensive and detection of antibiotic resistance
is dependent on specimens taken at endoscopy for histology and
culture. A focused and carefully tailored programme across the
UK is required.
4. Should the United Kingdom make greater
use of vaccines to combat infection and what problems exist for
developing new, more effective or safer vaccines?
There is no vaccine work in the UK. In general
vaccine development for Helicobacter pylori is progressing slowly
and is not an area in which we would recommend involvement at
5. Which infectious diseases pose the biggest
threats in the foreseeable future?
Infections such as Helicobacter pylori
may result in chronic ill health of the population over time.
The very real risk of an increased incidence of stomach cancer,
resulting from exposure to Helicobacter pylori, remains
a possibility. Without effective surveillance and feedback regarding
information about this organism, we could be in danger of delaying
diagnosis and effective treatment, resulting in chronic disease
of the population of immense proportions.
6. What policy interventions would have the
greatest impact on preventing outbreaks of and damage caused by
infectious disease in the United Kingdom?
Appropriate treatment of Helicobacter pylori
related peptic ulceration. Prevention of development of antibiotic
resistance by reducing indiscriminate use of antimicrobials.
The Helicobacter Working Group recognises the
need for continued surveillance of Helicobacter pylori
prevalence rates over time in the general population, and associations
with trends in non-ulcer dyspepsia and with other selected diseasesnotably
general practice diagnosis of duodenal ulcer and gastric ulcer;
hospital admissions for perforated ulcer, and longer term trends
in gastric cancer. The Maastricht 2-200 Consensus Report commented
that surveillance of antibiotic susceptibility of Helicobacter
pylori in the paediatric population is urgently required,
especially in areas or populations with a high resistance rate
against macrolides (clarithromycin). 84
1. The identification of strategically placed
laboratories and their associated gastroenterological units across
the UK, including several with strong paediatric endoscopy units,
with the objective that they should be involved in a comprehensive
programme of collecting endoscopy samples, histology, culture
and other tests as agreed. The results of the Helicobacter Working
Group survey within the PHLS carried out in 2001 showed that while
most laboratories accepted samples for serology, just 10 laboratories
routinely performed microbiology (isolation) with nine of those
laboratories performing susceptibility testing. The appropriate
laboratories, which should include laboratories with expertise
in the field, should be selected to form a strategically located
network that is representative of the population.
2. The development of schemes to monitor
emergence of changes in antibiotic susceptibility to selected
antibiotics by age of patient, diagnosis and previous treatment,
and to establish trends with time.
3. The collation of available microbiological
laboratory data from laboratories performing testing to produce
a minimum data set for monitoring Helicobacter pylori susceptibility.
The data set should be completed and collated, and information
4. Schemes should be developed to monitor
rates and determinants of treatment failure and risks of re-infection
after successful eradication. Resulting information should be
evaluated to determine if it is of practical value in guiding
decisions regarding the most effective antimicrobial prescribing.
To develop laboratory methods to assist surveillance
1. Harmonisation and standardisation of
methods to facilitate meaningful inter-laboratory comparisons
of antimicrobial susceptibility test data. Establish Standard
Operating Procedures (SOPs) to provide a benchmark for evaluation
and validation of techniques and ensure that the Helicobacter
pylori has a key role in advising on development and validation
of new diagnostic methods and their performance. As there are
no published nationally agreed standards for disc diffusion testing
of Helicobacter pylori, The Helicobacter Working Group
has recently published a recommended method for disc diffusion
tests. 84 A recommended method should be developed for the Etest
which provides information on the level of individual strain resistance.
These methods need to be evaluated in relation to methods recommended
by other bodies (BSAC, and NCCLS Performance Standards).
2. Design of minimum data set (mds) (demographic,
clinical and microbiological details) for each isolate.
3. Promote initiatives to extend this surveillance
activity by contributing to international collaborations particularly
with other European countries such as Germany where a surveillance
scheme has been put in place (ResiNet), and the US. The projected
outcome will be to establish international networks to develop
harmonised approaches for testing, data collation and dissemination.
Members of the Working Group
Dr Jeffrey Graham, Dr Peter Hawtin, Prof Kenneth
McColl, Dr Cliodna McNulty, Dr Robert Owen, Dr Gillian Smith and
Dr Louise Teare
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