The truth about increasing cases of H Pylori

There is a new disease in town. Well, the disease is not new, the diagnosis has just become more common than ever. The bug causing the disease is H Pylori and it’s now the new normal. If you haven’t been diagnosed with H Pylori recently, you know someone who is being treated for it.

So common is H Pylori in the country that it is estimated more than a million Kenyans have been treated for it this year. Data exclusively obtained from the government’s disease registry shows the numbers have been increasing in the past two years.

From January to last week Tuesday, 1,058,327 Kenyans had been treated for H Pylori. In 2017, the total was 899,213 and this increased to over 930,000 in 2018.

Helicobacter Pylori bacteria have lived peacefully in the human gut for at least 58,000 years without making people sick, according to research. Africa is the original home of H Pylori, which moved to the other parts of the world with migration. Therefore, test any African for H Pylori and it would most likely be a positive. So, why the many cases now? What has disturbed the decades of peace?

Startled by the numbers, a researcher sought to find out the underlying cause. The result of his findings, shared with HealthyNation, was that the tool used to test for H Pylori is flawed.

H Pylori causes ulcers and stomach inflammation. It has also been associated with gastric and duodenal ulcers, and stomach cancer. However, like all other bacteria, the good H Pylori does no harm to the gut. Bad or good, people consume H Pylori in contaminated water or food.

Urban residents are the hardest hit, with Nairobi leading the pack at 87,774 cases this year, followed by Meru (84,283) and Nakuru (72,258). Kiambu and Machakos recorded 60,524 and 44,384 cases respectively.

The least affected counties are Bomet (5,977), Samburu (4,257), Turkana (4,059), Tana River (2,535) and Lamu (2,069).

When asked whether he has handled cases of the bacteria, Dr Allan Rajula — a gastroenterologist (digestive system expert) from the Aga Khan Hospital — told HealthyNation: “Very many, and in the advanced stages. Some of the cases have resulted in ulcers and cancers.”

UNNECESSARY TREATMENT

The patients show different symptoms and the treatment is usually rigorous. For Paul Otieno, the bacteria wreaked havoc in his life, a pain he remembers all too well. One chilly morning, he woke up feeling unwell, with discomfort in his tummy. Three days later, he was even more tired and the stomach discomfort had worsened.

At the hospital, his stool and blood tested positive for H Pylori. That result marked the beginning of a very long treatment process. “I had to go to the hospital for three days for an intravenous injection of an antibiotic. Afterwards, I had to take at least four pills a day for the next one month,” Otieno tells HealthyNation. For a week, he was too weak to go to work.

But Otieno might not have needed to undergo the treatment. According to a microbiologist from Kenya Medical Research Institute (Kemri), like Otieno, a large number of people who have undergone the rigorous treatment for H Pylori should not have been on medication.

Dr John Kiiru, an expert on infectious diseases at Kemri’s Centre for Microbiology, tells HealthyNation his studies indicate the testing kit licensed to diagnose H Pylori in Kenya discovers its presence, but the tool is unable to check whether the bacteria are good or bad, which is crucial in the treatment.

Knowing there are two types of the bacteria, Dr Kiiru and his team at Kemri ran tests on 100 people who had been put on medication for H Pylori in Nairobi hospitals and the results shocked them. “Of the 100 people on medication, only five were supposed to be taking the drugs,” he says.

The pattern is predictable: a patient has a stomachache, goes to the hospital, tests positive for H Pylori and is put on treatment for two weeks and after a couple of weeks, the cycle begins again.

The microbiologist says thousands of Kenyans have been subjected to the medication while they may be suffering from other diseases that are not detected by the tests. He blames a faulty diagnostic technology which gives erroneous results, misleading doctors who end up prescribing drugs for H Pylori.

ANTIBODY TEST

Kenyan hospitals use what is called an antibody-antigen technology to test for H Pylori, says Dr Kiiru. He says the downside to this is that the test only relies on the presence of antibodies in the body to make a diagnosis. Antibodies are triggered by a disease causing germ. Antigens trigger the body to go on defence mode. In many instances, even a person who has healed could still have antibodies in their body.

“You can complete the H Pylori dose, but three months later, the antibodies are still detected in your system, but that does not mean you are sick,” says Dr Kiiru.

Prof Omu Anzala, an expert on the immune system and viruses, tells HealthyNation he would advise any patient to “run from a hospital that suggests an antibody only based test for H Pylori”. Prof Anzala, also the Director of University of Nairobi’s KAVI Institute of Clinical Research, expresses uncertainty on the accuracy of the testing tools. The university lecturer says the antibody-antigen test used at the moment may fail to identify bacterial cross activity. This means a situation in which there are multiple bacteria in the gut also causing disease, but the testing kit only picks the one that is most populous. The populous one may not be responsible for the disease.

He has called on the National Microbiology Reference Laboratory to work with the university to validate the tests.

There are other tests that could give accurate results, but are expensive and painful. One such test is a stomach biopsy, where a surgeon inserts a tube through the mouth, down the food pipe and into the stomach and collects tissues that will be taken to the laboratory for examination. Doctors mostly use this in cases where they suspect cancer.

It does not help that H Pylori in Kenya is not cultured — allowed to grow so that it is studied as an “adult”. It is a long, expensive procedure many cash-strapped labs avoid. This makes the flawed antibody-antigen test a favourite for public and lower level private hospitals where resources are scarce and the people to be served are in their millions.

Two doctors from public hospitals in Nairobi, who did not want to be named due to the sensitivity of the issue, said although the ideal would be to wait for advanced tests before prescribing antibiotics, they give the drugs anyway as neither money nor time is on their side when a patient needs urgent care. This only worsens the situation.

AGENCY RESPONSE

Prof Gunturu Revathi, the head of microbiology at the department of pathology at the Aga Khan University Hospital, adds the H Pylori crisis is worsened by another challenge: Poor interpretation of the results. “Microbiology training in Kenya is very poor and so is the supervision, and this affects the collection, testing and interpretation of samples sent to a lab,” she says.

When HealthyNation reached out to the Ministry of Health to clarify on the kits’ effectiveness, the Pharmacy and Poisons Board (PPB) failed to divulge details on the tools or their appropriateness. PPB is the agency mandated by government to ensure the equipment used in Kenyan hospitals is safe.

Instead, PPB said: “The Pharmacy and Poisons Board’s role in the regulation of medical devices is to facilitate importation through listing and registration depending on the risk classification.”

When asked about the specificity and sensitivity of the kits in the market, PPB directed HealthyNation to share the concerns about the “specific kits for testing or validating” with the National Public Health Laboratory.

PPB said after registration of any equipment, the “applicants are free to market their products in various hospitals”.

HealthyNation has since learnt that the ministry has quietly funded the Kemri microbiology lab to develop a testing kit for H Pylori, syphilis and chlamydia whose diagnosis has always been faulty.

The new technology, the one Dr Kiiru used to test the 100 patients during his research, yields results faster and is more accurate. It is still in its piloting phase and is only being used in Kemri.

The method used in this test is called “real time PCR”, a 40-year-old test that involves multiplying a section of the unique hereditary material of an organism into a million copies and studying these to see exactly where the disease causing element is in a strand.

Prof Anzala, who is not part of the team making the new kit at Kemri, terms the ambition “really good”. “PCR would be more accurate, even though it is a little more expensive,” he adds.

Under a microscope, H Pylori looks like a spiral and is often about two to four microns long — smaller than a grain of sand. The tiny, stubborn microorganism survives the extremely acidic environment in the stomach. H Pylori attaches itself to the walls of the stomach, leaving its lining bare and exposing it to acid.

ANTIBIOTIC RESISTANCE

Dr Andrew Odhiambo, an oncologist and a lecturer at University of Nairobi, says a repetition of this cycle provides the perfect conditions for the development of stomach ulcers.

Very few people knew what role H Pylori played in the gut until the early 1980s when two scientists, J Robin Warren and Barry Marshall, discovered it is the principal cause of peptic ulcers and gastritis. Later, the bacteria were linked to stomach ulcers.

The discovery was met with consternation and opposition because it was assumed before this that stress — not bacteria — was responsible for ulcers. In places like India, the cause of stomach ulcers was simple: “hurry, worry and curry”.

Professors in medicine had to admit they were wrong in their teachings that the stomach was barren and no organism would endure the hot, corrosive acids in the gut. The message that ulcers could be treated with antibiotics was a bitter pill to swallow.

There were also commercial interests. Perhaps the same could be at play in Kenya now. Doctors cashed in on performing surgeries, removing burnt and charred parts of the stomach from the ulcers. Then mental health professionals treated stress.

Pharmaceutical companies made drugs like Tagamet which seemed to calm the ulcers. However, the ulcers would erupt again and as long as there were patients, there was money flowing.

Efforts by HealthyNation to establish who supplies the country with the test kit for H Pylori and how many have been sold so far have been futile as the ministry did not respond to our questions. For a disease that involves taking more than four pills a day for two weeks, the entire drug supply chain stands to benefit.

Unfortunately, this taking of pills unnecessarily has birthed more medical problems.

The abuse of antibiotics has led to resistance of bacteria to well-known and established drugs in Kenya. Augmentin, an antibiotic which ideally should have been a controlled drug, has been prescribed to patients suffering from H Pylori, resulting in resistance to it.

Antibiotics also alter the delicate balance of the gut bacteria and this comes with health implications.

In a past interview, Prof Sam Kariuki, a microbiologist, said the gut bacteria is essential to human health as it serves several protective roles. It has been estimated that the gut contains 100 trillion bacteria which break down food and toxins, make vitamins and train our immune systems. In 2017, a researcher from South Africa’s Stellenbosch University implicated gut bacteria in mental illness, where those that had lower than normal were linked to post traumatic stress disorder.

When people abuse antibiotics, they wipe out even the good bacteria necessary for the body.