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Evidence-based examination of the African enigma in relation to Helicobacter pylori infection

Objective The African enigma describes the dissociation between the prevalence of Helicobacter pylori infection and H. pylori-related diseases. The aim of this study was to use an evidence-based review of endoscopic data from African countries to test whether there are data to support the concept of an African enigma. Material and methods A Medline search was carried out to identify prospective endoscopic studies in African populations. Data collected included: the number of endoscopies, age range (or mean age if available), indications for endoscopy, country, years during which data were collected, male to female ratio, and specific outcome of duodenal ulcer, gastric ulcer, or gastric cancer. Results Forty prospective endoscopic studies from 17 African countries were identified (20,531 patients) and evaluated between 1972 and 2001. Mean ages ranged from 31 to 53.1 years and male to female ratios from 0.67:1 to 4.64:1. H. pylori-related clinical outcomes were common; duodenal ulcers in 4326 patients (21.1%), gastric ulcers in 691 patients (3.4%), and gastric cancers in 503 patients (2.4%). Conclusions Prospective upper endoscopic trials suggest that the clinical outcomes associated with H. pylori infection in Africa are similar to those seen in industrialized countries. No dissociation between the prevalence of H. pylori infection and H. pylori-related diseases existed; the African enigma as such does not exist and the continued study of the mechanism of a non-existent phenomenon is a misuse of resources. The myth resulted from reliance on anecdotal data and selection bias in populations with extremely limited access to health care and a relatively short life expectancy.