Helicobacter pylori recurrence after eradication in Latin America: Implications for gastric cancer prevention

Table 3 Implementation of Helicobacter pylori eradication programs for gastric cancer prevention in Latin America

Components	Challenges and considerations	Implementation approaches
Public policy	Lack of awareness among the Ministries of Health, stakeholders, and the public	Large scale education campaigns for cancer and gastric cancer Joint initiatives with international stakeholders: WHO, IARC, PAHO, UICC, NCI, and CDC
Economic investment	Cost of H. pylori eradication program Economics of growing gastric cancer burden	Conduct CEAs at the country and regional level. The CEAs may differ for HICs and LMICs
Program design	Uncertainties and regional variation for target age, screening approach, treatment regimen, and follow-up	Pilot-test eradication campaigns and perform community implementation trials Adapt evidence from cost-effectiveness models and available epidemiologic data. Incorporate screening into existing public health practices (e.g., cervical cancer)
Appropriate technologies	Technical difficulties in H. pylori testing Consistent eradication confirmation norms Management of high risk patients	Develop economic, point-of-care H. pylori testing Coordinate endoscopy protocols for high risk patients (e.g., premalignant lesions) Implement information networks to coordinate eradication programs, health centers, and endoscopy centers
Adherence measures	Poor compliance with H. pylori eradication regimen, leading to treatment failure and increased infection recrudescence	Consider medication side effect profiles Pre-regimen counseling for common side effects Consider adherence measures, usual (e.g., direct observed therapy), or novel (e.g., cell phone contact)
H. pylori recurrence	Elevated reinfection rate may affect program efficacy and feasibility	Improve living conditions to reduce potential environmental sources of reinfection Consider the family or the village as the intervention target
Potential overall program risks and unknowns	Alteration of the human microbiome Induction of antibiotic resistance Potential increased risk for certain diseases (e.g., allergic diseases, esophageal cancers) Unknown role(s) of H. pylori as a component of the human microbiome: Commensal and pathogen, which may be strain and/or age dependent	H. pylori eradication programs should be considered investigational, with use of rigorous methodology and long term surveillance Monitoring of antibiotic resistance and microbiome profiles Global antibiotic stewardship programs (e.g., OTC antibiotic use, veterinary use)
Parallel research agendas	Incorporate evolving approaches and technologies	Develop novel biomarkers for host risk and H. pylori virulence Develop biomarkers for premalignant lesions (e.g., intestinal metaplasia) to facilitate endoscopy surveillance Incorporate endoscopy technologies, including advanced imaging and low-cost approaches
H. pylori Vaccination	Unknown long-term effectiveness and side effects Lack of data showing impact in clinical outcomes	Evaluate long-term (> 3 yr) effectiveness in other centers, populations and countries[23] Complete regulatory evaluations, collect additional safety data and approval by national agencies. Phase IV studies

WHO: World Health Organization; IARC: International Agency for Research on Cancer; PAHO: Pan American Health Organization; UICC: Union for International Cancer Control; NCI: National Cancer Institute; CDC: Centers for Disease Control and Prevention; HIC: High income country; LMIC: Low/middle income country; OTC: Over the counter; CEAs: Cost-effectiveness analyses; H. pylori: Helicobacter pylori.