The only good Helicobacter pylori is a dead Helicobacter pylori

We presume that Martin Blaser (April 5, p 1020)1Blaser MJ Not all Helicobacter pylori strains are created equal: should all be eliminated?.Lancet. 1997; 349: 1020-1022Summary Full Text Full Text PDF PubMed Scopus (177) Google Scholar wrote his viewpoint about the effects of eradication of Helicobacter pylori infection to stimulate discussion and debate. In order to make a decision about global or selective eradication, one must have data on the natural history of the infection in an individual as well as the risk of the infected individual to the uninfected population. This is not a new dilemma, the same argument has recurred, for example, with regard to symptom-free syphilis or tuberculosis.2Winn RE Prechter GC Pulmonary tuberculosis.in: Hoeprich PD Jordan MC Ronald AR Infectious diseases. 5th edn. JP Lippincott Co, Philadelphia1994: 447-464Google Scholar The lifetime risk of serious disease for a symptom-free US citizen with H pylori gastritis is about one in six for the development of peptic-ulcer disease and one to three per 100 people for gastric cancer.3Seer cancer statistics review, 1973–1992: tables and graphs, National Cancer Institute. Bethesda: NIH Publications no 96-2789, 1995.Google Scholar, 4Graham DY. Can therapy ever be denied for Helicobacter pylori infection? Gastroenterology (in press).Google Scholar There are also geographical differences in the risk of developing H pylori-related disease—eg, an adult Korean man has a lifetime risk of developing gastric cancer in excess of 7%. The lifetime risk for a patient with symptom-free H pylori infection is at least as great, and probably greater than that for an individual with symptom-free syphilis or tuberculosis.4Graham DY. Can therapy ever be denied for Helicobacter pylori infection? Gastroenterology (in press).Google Scholar H pylori differs in one important way from symptom-free syphilis or tuberculosis in that it is always active and therefore always transmissible. The risks and consequences of transmission must be considered in addition to the risks and consequences to the individual. Blaser's argument that because H pylori has been with man for millennia, it may provide some benefit is intriguing. Unfortunately, there are no data to support or refute the hypothesis that the worldwide spread of H pylori infection is not a contemporary event. The data about two other major pathogens, Streptococcus mutans, the cause of dental caries, and tuberculosis are better, because these organisms have been with man for millennia. The suggestion that because these pathogens have been with us for a long time they might be beneficial or that their elimination will allow other diseases to emerge has yet to find a champion. Blaser follows up on our suggestion that the recent increase in oesophageal disease may reflect changes in the epidemiology of H pylori infection.5Genta RM Huberman RM Graham DY The gastric cardia in Helicobacter pylori infection.Hum Pathol. 1994; 25: 915-919Summary Full Text PDF PubMed Scopus (187) Google Scholar Elimination of H pylori will prevent the development of corpus gastritis which impairs acid secretion. An increase in the proportion of adults with normal to high acid secretion should result in an increased frequency of gastric oesophageal reflux disease and its complications—Barrett's oesophagus and adenocarcinoma of the distal oesophagus or the upper stomach. This increase has already occurred despite H pylori infection and will only be accelerated by the worldwide eradication of H pylori. The change in the pattern of H pylori gastritis in western countries from that of a pangastritis with multifocal atrophy to superficial and predominantly antral gastritis took place decades ago and allowed duodenal ulcer and gastroesophageal reflux disease to emerge as common disorders, whereas gastric cancer has become rare. Elimination of H pylori would probably increase the risk of oesophageal cancer in the small group of infected individuals who develop atrophic gastritis, and the trade off would be a reduced rate of peptic ulcer and gastric cancer. Excess acid secretion is easily managed by current drugs and the surgeons are becoming more skilled in preventing gastroesophageal reflux. All decisions involve trade-offs and elimination of a transmissible pathogen that causes worldwide morbidity and mortality should not be reconsidered. Vaccination for diphtheria increased the number of individuals who died from heart disease and cancer, but no one wants to bring back the the enteric and respiratory pathogens that plagued mankind throughout history. Although it is important to keep a few H pylori strains to preserve biological diversity and to protect against the outside chance that some new use may be found, we should have no qualms that our main objective should be to eliminate H pylori.