Zeng ZQ, Yang HY, He LY, Sun C, Wang JH, Dong L, Gong J, Li L, Zhao P. Decade of decline: Unraveling Helicobacter pylori trends in Northwest China. World J Gastroenterol 2026; 32(45): 121414 [DOI: 10.3748/wjg.121414]
Corresponding Author of This Article
Ping Zhao, MD, Chief Physician, Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, No. 157 Xiwu Road, Xincheng District, Xi’an 710004, Shaanxi Province, China. peggyzhao@163.com
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Zeng ZQ, Yang HY, He LY, Sun C, Wang JH, Dong L, Gong J, Li L, Zhao P. Decade of decline: Unraveling Helicobacter pylori trends in Northwest China. World J Gastroenterol 2026; 32(45): 121414 [DOI: 10.3748/wjg.121414]
Zi-Qin Zeng, Hai-Yan Yang, Liu-Ying He, Ceng Sun, Jin-Hai Wang, Lei Dong, Jun Gong, Lu Li, Ping Zhao, Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
Author contributions: Zeng ZQ wrote the manuscript; Zeng ZQ and Zhao P conceived and designed the study and analyzed the data; Yang HY, He LY, Sun C, Wang JH, Dong L, Gong J, and Li L contributed to data analysis, literature review, and manuscript revision; Li L and Zhao P played important and indispensable roles in the experimental design as co-corresponding authors; all authors have read and approved the final manuscript.
AI contribution statement: AI tools were used solely for linguistic refinement and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors.
Institutional review board statement: The study protocol was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Xi’an Jiaotong University (No. 2024-134).
Informed consent statement: As a retrospective study utilizing existing clinical data, we performed no interventions on patients, collected no patient samples, and disclosed no personal information. Informed consent was waived, as this does not affect patients’ rights or health. The study protocol, including the statistical analysis plan, was reviewed and approved by the same committee that conducts integrated scientific and ethical review of all clinical studies.
Conflict-of-interest statement: The authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.
Data sharing statement: The datasets generated and analyzed during the current study are not publicly available due to patient privacy concerns but are available from the corresponding author on reasonable request.
Corresponding author: Ping Zhao, MD, Chief Physician, Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, No. 157 Xiwu Road, Xincheng District, Xi’an 710004, Shaanxi Province, China. peggyzhao@163.com
Received: March 25, 2026 Revised: May 18, 2026 Accepted: June 25, 2026 Published online: December 7, 2026 Processing time: 204 Days and 13.3 Hours
Abstract
BACKGROUND
Helicobacter pylori (H. pylori) infection is a major risk factor for gastric cancer. The northwestern region of China has a high prevalence of this condition; therefore, long-term trend data from this region are highly valuable for optimizing gastric cancer prevention efforts.
AIM
To evaluate the prevalence and trends of H. pylori infection in Northwest China from 2014 to 2023.
METHODS
This retrospective, cross-sectional study was a large-scale investigation. General data for outpatients who underwent the 13C-urea breath test for H. pylori infection at a tertiary hospital in Northwest China from 2014 to 2023 were analyzed on the basis of sex, age, and year of testing.
RESULTS
This study included 69633 participants. The age-standardized prevalence of H. pylori infection decreased from 38.72% in 2014 to 27.94% in 2023, with similar decreasing trends observed across all age and sex subgroups. According to subgroup analyses, the infection rates for both sexes gradually shifted from an initial lack of difference to a trend in which males were more commonly infected than females (interaction P value < 0.001). Logistic regression with restricted cubic splines revealed a nonlinear relationship between age and infection risk; the risk increased with age up to age 29.64 [odds ratio = 1.06, 95% confidence interval (CI): 1.05-1.06, P < 0.001], after trended downward (odds ratio = 0.99, 95%CI: 0.99-0.99, P < 0.001).
CONCLUSION
The prevalence of H. pylori in Northwest China decreased substantially from 2014 to 2023, with a rapid decline in women. A nonlinear association between age and infection risk was identified, with a distinct inflection point.
Core Tip: In this large-scale study, trends in Helicobacter pylori infection in northwest China over a decade were analyzed using data from 69633 outpatients. Our study identified three main findings. First, infection rates declined across all subgroups. Second, there was initially no significant difference in infection rates between the two sexes; however, infection rates among females declined faster than those among males, leading to the emergence and a progressive widening of sex disparity. Third, age and infection risk exhibited a nonlinear relationship with an inflection point. These findings provide evidence to guide targeted gastric cancer prevention strategies.
Citation: Zeng ZQ, Yang HY, He LY, Sun C, Wang JH, Dong L, Gong J, Li L, Zhao P. Decade of decline: Unraveling Helicobacter pylori trends in Northwest China. World J Gastroenterol 2026; 32(45): 121414
Helicobacter pylori (H. pylori) is a gram-negative bacterium first discovered in 1983 and classified as a group 1 carcinogen by the International Agency for Research on Cancer in 1994[1,2]. Moreover, evidence shows that H. pylori is closely linked to chronic gastritis and peptic ulcers and contributes to the development of gastric cancer (GC)[3,4]. Recent research has also connected H. pylori to many other disorders, including autoimmune disorders, metabolic syndrome-related diseases, cardiovascular diseases, neurological diseases, and colorectal cancers[5,6].
While H. pylori is widespread and has infected over half of the global population, infection levels greatly differ across countries and even across regions within a single nation. Furthermore, existing work confirms that this gap is closely tied to socioeconomic status and public health conditions, such that infection is generally more common in less developed areas[7-9].
Data from 1983 to 1994 indicate that approximately two-thirds of the Chinese population harbored H. pylori. Since then, the overall infection rate has fallen substantially, reaching 42.8% in the past decade[10,11]. However, the rate of decline has slowed in recent years, and infection rates in the northwest region remain persistently high, reaching 51.3%, significantly exceeding those in most other parts of the country[10,12]. H. pylori infection is a major factor driving China’s GC burden. A Chinese study demonstrated a significant positive correlation between adjusted H. pylori infection rates and the national incidence of GC (r = 0.393 for males, r = 0.470 for females)[13]. Even among younger people, H. pylori infection is closely associated with the progression of precancerous lesions[14]. Moreover, infection has a marked age-cumulative effect. A study of GC patients revealed that H. pylori infection rates increased from 16.0% in the 0-30 age group to 29.1% in those aged 55 and above, which highlights the impact of long-term exposure on GC development[15]. Given the high prevalence of H. pylori and China’s large population, GC has become a major health issue in the country. Although the age-standardized incidence rate has decreased from 70.46 per 100000 in 1990 to 40.12 per 100000 in 2021, with projections indicating a further decrease to 25.43 per 100000 by 2036, the absolute number of cases remains substantial[16]. H. pylori eradication has been proven to be a cost-effective strategy for GC prevention; in studies conducted in Fujian Province and Shandong Province in China, H. pylori-positive individuals were randomly assigned to an eradication group, a placebo group, or other intervention treatment groups, and after more than 20 years of follow-up, results confirmed that that eradication treatment significantly reduced the risk of GC and GC-associated mortality[17-19].
The overall prevalence of H. pylori infection in China has declined, albeit at a slowing rate, with significant regional disparities. The situation remains particularly severe in high-prevalence areas such as the northwest region. As a major urban center in Northwest China, Xi’an has population characteristics and healthcare resource distribution representative of this region. A systematic description of H. pylori infection trends among outpatient populations in this area provides crucial regional data for understanding the epidemiological patterns of infection in Northwest China. Therefore, this study employs a large-scale retrospective cross-sectional approach to analyze the current status and long-term trends of H. pylori infection among outpatient populations in Xi’an from 2014 to 2023. It further investigates sex differences in infection risk and their evolving characteristics, identifies nonlinear relationships between age and infection risk, and pinpoints critical inflection points. We aim to provide a reference basis for optimizing regional GC prevention strategies and enabling the precise allocation of healthcare resources.
MATERIALS AND METHODS
Study design and population
This study was conducted at the Second Affiliated Hospital of Xi’an Jiaotong University and included all outpatient patients who underwent a 13C-urea breath test (13C-UBT) between 2014 and 2023. All included participants had not taken any antibiotics, proton pump inhibitors, bismuth compounds, traditional Chinese medicines with known antibacterial properties, or other agents known to interfere with the result of the ¹³C-UBT within 4 weeks before the examination. Patients with a history of gastrectomy were excluded from the study. Records from individuals who underwent multiple tests were deduplicated by retaining only the first test entry, resulting in the exclusion of 5993 duplicate records; 49 cases were excluded because of missing or abnormal dependent variables. Ultimately, 69633 valid study subjects were obtained.
The study protocol was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Xi’an Jiaotong University (No. 2024-134).
Data collection
In this study, we used the 13C-UBT to diagnose H. pylori infection. It is essential that this test is conducted in a fasting state or 2 hours after a meal. During the test, the first breath sample is collected, followed by the ingestion of a diagnostic reagent, and a 30-minute waiting period during which food and water are not consumed. After this period, the patient exhales into a second collection tube. The two tubes containing the collected gas are then analyzed using the testing instrument to obtain results. According to the instructions, if the difference in δ values between the breath samples taken before and after reagent ingestion is greater than 4 dpm/mmol, the result is positive, indicating H. pylori infection.
Statistical analysis
The dependent variable was a positive 13C-UBT result, whereas the independent variables included sex, age, and the year of testing. Continuous variables are expressed as the mean ± SD, and categorical variables are expressed as n (%). Sex, age group, and year of testing were used as categorical variables, and the χ2 test was used to analyze the relationships between these variables and H. pylori infection. Logistic regression analysis was conducted to explore relationships among age, sex, and the risk of H. pylori infection, and the results are presented as 95%CI and odds ratios (ORs). All statistical tests were two-sided, with statistical significance defined as P < 0.05. Data management and baseline characteristics were generated using Empower Stats 4.2. Restricted cubic spline (RCS) modeling and threshold effect analysis were performed with Zstats software. Age standardization and all other statistical analyses were conducted in R 4.3.3.
In this study, the age structure of the seventh national census in 2020 was used as the standard population to perform direct age standardization on the data, aiming to eliminate confounding bias caused by differences in age composition across years when infection rates were compared. Trends in H. pylori infection prevalence from 2014 to 2023 were subsequently analyzed. Next, participants in the periods 2014-2017, 2018-2020, and 2021-2023 were selected and stratified by sex and age (e.g., 0-9 years, 10-19 years, 20-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, and ≥ 70 years). Associations between infection rates and these variables were analyzed, with sex differences presented using forest plots. Finally, a logistic regression model was combined with RCSs to assess the nonlinear relationship between age and H. pylori infection risk. Threshold effect analysis using a two-stage logistic regression model was conducted to identify the age at which infection risk significantly changed (Figure 1).
Figure 1 Study flow chart. H. pylori: Helicobacter pylori.
RESULTS
Prevalence of H. pylori infection among all eligible participants from 2014 to 2023
The study involved a total of 69633 eligible participants, with a mean age of 43.6 ± 16.1 years. Among these participants, 37.3% (25992/69633) had a positive 13C-UBT result. Table 1 shows the individuals’ baseline demographic information and the prevalence of H. pylori infection for each group. Males were slightly more likely than females to have H. pylori infection (38.5% vs 36.4%, P < 0.001). Furthermore, the prevalence tended to increase with increasing age, but then decreased (P < 0.001), increasing from 17.7% in the under 10 age group to 41.2% in the 30-39 age group, and then decreasing to 34.4% in the over 70 age group (Table 1).
Table 1 Baseline characteristics of the 69633 eligible participants, n (%)/mean ± SD.
Comparison of the age-standardized prevalence of H. pylori infection between 2014 and 2023 revealed that despite some fluctuations during the study period, the overall prevalence significantly decreased (P < 0.001) from 38.72% (95%CI: 35.53%-41.92%) in 2014 to 27.94% (95%CI: 26.95%-28.94%) in 2023. Furthermore, the analysis revealed that compared with females, males consistently had higher age-standardized prevalence rates throughout most of the study period, and the decreasing trend was statistically significant for both sexes (P < 0.001; Table 2, Figure 2).
Comparison of H. pylori infection prevalence among participants in the periods 2014-2017, 2018-2020, and 2021-2023
Participants who underwent a 13C-UBT during 2014-2017, 2018-2020, and 2021-2023 were stratified by sex and age for comparative analysis, revealing a notable decrease in H. pylori infection prevalence over the years (Figures 3 and 4).
Figure 3 Prevalence of Helicobacter pylori infection among eligible participants who underwent 13C-urea breath testing during 2014-2017, 2018-2020, and 2021-2023, stratified by sex. H. pylori: Helicobacter pylori.
Figure 4 Prevalence of Helicobacter pylori infection among eligible participants who underwent 13C-urea breath testing during 2014-2017, 2018-2020, and 2021-2023, stratified by age group. H. pylori: Helicobacter pylori.
Across these three time periods, the prevalence of H. pylori infection tended to decrease for both sexes (P < 0.001; Figure 3). Additionally, forest plot results indicate significant differences in the association between sex and H. pylori infection risk. Between 2014 and 2017, there was no significant difference in infection between males and females (OR = 0.96, 95%CI: 0.91-1.02, P = 0.236), whereas males had a significantly greater risk of H. pylori infection compared with females from 2018-2020 (OR = 1.11, 95%CI: 1.06-1.18, P < 0.001) and from 2021-2023 (OR = 1.16, 95%CI: 1.10-1.22, P < 0.001). Interaction tests revealed that the effect of sex on infection risk was modified by period (interaction P < 0.001), indicating that sex differences gradually increased over time (Figure 5).
Over time, all age groups showed a notable decrease in the prevalence of H. pylori infection (P < 0.05). Notably, the prevalence among younger age groups decreased more rapidly than that among older age groups. Additionally, during 2014-2017, 2018-2020, and 2021-2023, the prevalence initially increased but then decreased with age, peaking in the 30-39 year age group (Figure 4).
Nonlinear relationship between age and H. pylori infection risk
Figure 6 illustrates the logistic regression model fitted with RCSs to evaluate the nonlinear relationship between age and H. pylori infection risk. After adjusting for potential confounders, we observed a nonlinear association between age and H. pylori infection risk (Table 3). Among the total participants, a two-piecewise logistic regression model revealed an inflection point at 29.64 years of age (P for likelihood ratio test < 0.001). An age ≤ 29.64 years was significantly positively associated with infection risk (OR = 1.06, 95%CI: 1.05-1.06, P < 0.001). In contrast, when age was > 29.64 years, the association became significantly negative (OR = 0.99, 95%CI: 0.99-0.99, P < 0.001). Sex-stratified analysis revealed similar inflection points in both males and females (males: 28.00 years; females: 30.89 years).
Our study indicates that the overall standardized infection rate of H. pylori in the study population decreased from 38.72% in 2014 to 27.94% in 2023, indicating a sustained downward trend. Stratified analyses by sex and age consistently demonstrated this temporal trend. This decline aligns with findings from multiple domestic and international studies. A global study reported that adult H. pylori infection rates decreased from 52.6% before 1990 to 43.9% between 2015 and 2022[8]. In another related study, the overall global infection rate decreased from 58.2% between 1980 and 1990 to 43.1% between 2011 and 2022, with the most significant decrease occurring in the past decade[7]. Furthermore, meta-analysis examining the prevalence of H. pylori infection in mainland China from 1983 to 2019 revealed a decreasing trend, but the rate of decrease has slowed in recent years compared with earlier periods[10]. This downward trend likely stems from socioeconomic development and improved sanitation over the years. Nevertheless, China remains a country with high incidence rates of GC and H. pylori infection because of its large population. Therefore, sustained screening and eradication efforts remain crucial, not only for preventing the progression of GC and other H. pylori-related diseases, but also for guiding future health policies[17,20].
The temporal decline in H. pylori infection rates correlates with national development levels and is likely attributable to improvements in urban sanitation, wastewater treatment, and healthcare environments – advances achieved alongside socioeconomic progress that limit transmission[7,21]. Additionally, regular updates to relevant guidelines and consensus statements have also been important drivers. With respect to H. pylori infection management and GC prevention, both global and Chinese consensus statements emphasize that eradication therapy reduces GC risk. Gradually promoting widespread H. pylori eradication in high-risk regions and enhancing public awareness of its hazards contribute to comprehensive GC prevention and control[20,22]. China’s consensus reports on H. pylori infection management have undergone iterative updates in response to national circumstances and the latest international guidelines. Diagnostic criteria have evolved from simple infection confirmation to detailed management protocols that exclude contraindications for eradication, consistent with the principles of the Kyoto Consensus[23-25]. With respect to treatment regimens, triple therapy has progressively evolved into quadruple therapy with bismuth compounds. The latest consensus further recommends high-dose dual therapy for non-penicillin-allergic patients[26-28]. These ongoing guideline revisions have directly supported improvements in clinical practice and health policies. The infection control achievements observed in this study likely directly stem from these sustained efforts.
Age-stratified results showed that H. pylori infection rates rose and then fell with advancing age, with the highest level detected in the 30-39 year age group. Further analyses based on RCS and logistic regression confirmed a statistically significant nonlinear association between age and infection risk. The age threshold where risk shifted from ascent to descent was calculated as 29.64 years for the overall population, 28.00 years for males, and 30.89 years for females. Findings from Chengdu, China, revealed a similar pattern: Infection rates peaked in the 50-59 age group but then declined across all age groups[29]. A published meta-analysis also presented similar results, showing that H. pylori prevalence increased with age and decreased among people aged 70 years and above[30]. The rising trend of infection prevalence in younger and middle-aged populations is primarily linked to the birth cohort effect. People born in earlier periods tend to have higher infection prevalence. As these older, higher-prevalence cohorts are gradually replaced by younger cohorts with lower infection rates, a downward trend in age-specific prevalence over time may emerge[31,32]. For the declining prevalence after the threshold in the present study, multiple underlying causes can be explained. First, the decrease may be due to a greater percentage of older individuals receiving H. pylori eradication therapy than younger individuals, as a Korean study revealed that individuals over 60 years of age were more likely to receive eradication therapy[33]. A domestic study also found that patients aged ≥ 40 years achieved better eradication outcomes, and advanced age was an independent predictor of successful treatment[34]. Second, a large national cross-sectional survey in China demonstrated that the prevalence of atrophic gastritis markedly increased along with age growth[35]; this gastric disorder alters the internal gastric environment and is unfavorable for H. pylori survival, which reduces bacterial quantity and may lead to negative test results in clinical detection[36,37]. Survivor bias may also play a role, as individuals with severe H. pylori-related diseases may have died before reaching older ages, leading to an apparent decline in prevalence among the oldest age groups. However, other studies have reported that the rate of H. pylori infection increases with age, indicating that rates continue to increase among middle-aged and elderly individuals[7,10]. Of note, the threshold age estimated by RCS in this study was earlier than the peak age of infection prevalence reported in previous studies. Such divergence can be attributed to the varied analytical accuracy of different statistical approaches. Because the threshold was calculated based on cross-sectional prevalence data, additional research is needed to verify whether this value represents a real biological cutoff for H. pylori infection risk. Compared with traditional linear models, the combined RCS and threshold effect analysis employed in this study offers greater flexibility in revealing the nonlinear relationship between age and infection risk, enabling more sensitive detection of precise inflection points in risk trends. It is worth clarifying that the age-related risk described in this paper reflects population prevalence characteristics instead of the actual risk of new H. pylori infection acquisition.
In this study, the prevalence of H. pylori infection significantly decreased over time in both sexes, with infection rates higher in males than in females. However, it is noteworthy that during the initial phase of the study (2014-2017), the risk of H. pylori infection was comparable between men and women. The risk among men subsequently became significantly greater than that among women, and this disparity continued to widen over time (interaction P < 0.001). These findings indicate that the rapid decline in infection rates among women was the key factor driving the emergence and gradual increase in sex disparity. This sex difference is consistent with the results of several other studies, which reported similar differences among children, adolescents, and adults[10,29,38,39]. There are several potential explanations for the observed sex difference in this study. First, compared with females, males are more likely to smoke and consume alcohol, possibly contributing to this difference, as both are risk factors for H. pylori infection[40,41]. Second, females are significantly more likely than males are to receive antibiotic prescriptions throughout their lives, even if these antibiotics are not specifically prescribed for H. pylori infection[42]. Third, a Turkish study suggested that males tend to engage in more outdoor activities and unhealthy toileting practices than females do, which may increase their risk of infection[39]. However, other studies have also shown that the probability of H. pylori infection is actually comparable between men and women[7,11,30].
From a public health perspective, the findings from this study suggest that the following targeted, tiered measures could be adopted in strategies for the prevention and control of H. pylori in Northwest China. For males who exhibit a slower decline in infection rates, interventions targeting modifiable risk factors such as smoking, alcohol consumption, and hygiene habits should be strengthened to accelerate the rate of decline in infection rates and narrow the widening sex gap. For the general population, screening and eradication programs should be implemented before the inflection point of approximately 29.64 years to increase the efficiency of prevention and control, thereby maximizing the overall benefits of GC prevention in this high-burden region.
This study has several limitations. First, the representativeness of the study population is limited. The study participants were all outpatients who underwent 13C-UBT testing at a single tertiary hospital in Xi’an for more than a decade. Individuals presenting for clinical testing may differ from the general community population in terms of symptom profiles and healthcare-seeking behavior; therefore, the prevalence estimates obtained in this study may not fully reflect the true infection levels in the general community. In addition, a notable urban-rural disparity exists in of H. pylori infection prevalence in China, and our sample predominantly comprised urban residents with ready access to tertiary medical services. This may partly explain why the infection rates observed in this study were lower and declined more rapidly than those reported in some other Chinese studies[10,43]. Therefore, whether the temporal trends and age-specific and sex-specific infection patterns observed in this study can be generalized to broader regional populations remains unknown. Second, this was a retrospective study, and certain data that would have enabled a more in-depth and comprehensive analysis were not available. Specifically, information on previous H. pylori eradication therapy could not be collected, and this factor may have influenced the observed infection rates across different age groups and over time. In addition, individual lifestyle and socioeconomic factors, including smoking, alcohol consumption, dietary habits, household crowding, sanitation conditions, and antibiotic exposure history, were not recorded in the clinical testing records and could not be retrospectively retrieved. Moreover, these unmeasured confounding factors may have partly influenced the observed sex and age differences in infection risk.
CONCLUSION
In conclusion, the overall prevalence of H. pylori infection tended to decrease from 2014 to 2023. Additionally, the prevalence rates across all sex and age groups also showed a downward trend over time. These findings suggest potential future changes in GC and other related upper gastrointestinal diseases, providing a foundation for the revision and implementation of relevant health policies.
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Footnotes
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific quality: Grade A, Grade B, Grade B, Grade C, Grade C, Grade C
P-Reviewer: Khan A, Pakistan; Men CJ, PhD, China; Zhou HXX, Associate Professor, Associate Research Scientist, PhD, Post Doctoral Researcher, China S-Editor: Luo ML L-Editor: Filipodia P-Editor: Lei YY
