Trends in Helicobacter pylori prevalence, force of infection, and attributable disease burden in China: a systematic review and Bayesian modelling study

Background: 

Helicobacter pylori infection is the leading cause of gastric cancer (GC) and peptic ulcer disease (PUD). China has one of the world's largest populations living with H. pylori infection, but long-term age-specific infection dynamics and attributable disease burden remain incompletely characterised. 

Methods: 

We systematically reviewed studies reporting H. pylori prevalence in China and extracted age-specific prevalence data. We developed a Bayesian catalytic model to jointly synthesise current infection, seropositivity, and ever-infection prevalence, estimating age-specific force of infection (FOI) and prevalence from 1990 to 2023 while accounting for study-level heterogeneity and diagnostic misclassification. Modelled prevalence estimates were combined with published relative risks and national case counts to estimate population attributable fractions (PAFs) and numbers of GC and PUD cases attributable to H. pylori. 

Findings:

We included 181 studies in the Bayesian model fitting. Cohorts born after 1980 experienced substantially lower childhood FOI than earlier cohorts, indicating reduced early-life acquisition. However, population prevalence declined only modestly, from 43.1% (95% credible interval 39.1–47.4) in 1990 to 36.3% (33.2–39.6) in 2023. In 2023, estimated PAFs were 70.1% (95% uncertainty interval 51.4–82.4) for non-cardia GC and 49.4% (20.5–70.7) for cardia GC. H. pylori was associated with approximately 340,000–370,000 GC cases and 160,000–210,000 PUD cases, predominantly duodenal ulcers. 

Interpretation: 

H. pylori prevalence and attributable disease burden remain high in China. Our estimates suggest a more gradual decline than implied by previous studies, supporting consideration of active H. pylori control strategies. Funding: China Scholarship Council, EU4Health.