Prevalence of Helicobacter Pylori infection, Vitamin B12, Vitamin D, and iron deficiency, and possible association of H pylori infection as a potential cause among Ezidi Refugees in rural Armidale: Findings from a Retrospective Cohort Study

Prevalence of Helicobacter Pylori infection, Vitamin B12, Vitamin D, and iron deficiency, and possible association of H pylori infection as a potential cause among Ezidi Refugees in rural Armidale: Findings from a Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of Helicobacter Pylori infection, Vitamin B12, Vitamin D, and iron deficiency, and possible association of H pylori infection as a potential cause among Ezidi Refugees in rural Armidale: Findings from a Retrospective Cohort Study Grace Noh, Nelson Tran, Oliver McMorran, Edric Hu, Joëlle V.F. Coumans, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5469028/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in Journal of Immigrant and Minority Health → Version 1 posted 10 You are reading this latest preprint version Abstract In Australia, Middle Eastern refugees, notably the Ezidi community (an ethnic and religious minority from Northern Iraq and Syria) are disproportionately affected by high rates of vitamin and iron deficiencies. These deficiencies pose significant health risks and can impact overall well-being. Recent studies have suggested a possible correlation between Helicobacter pylori (H. pylori) infection and deficiencies in essential vitamins and iron, highlighting an important area of research that warrants further exploration. For several reasons, understanding the relationship between H. pylori infection and nutrient deficiencies in newly arrived Ezidi refugees is critical. First, it may provide insights into the underlying health challenges this population faces, who often arrive with pre-existing health issues. Second, establishing this association could inform current screening practices, allowing for targeted interventions that address both H. pylori infection and nutritional deficiencies. Ultimately, this research aims to contribute to the development of effective health strategies that enhance the well-being of Ezidi refugees, ensuring they receive the necessary support to thrive in their new environment. By focusing on this intersection of infectious disease and nutritional health, we can better understand and mitigate the risks this vulnerable group faces. Methods : A retrospective cohort study was performed using data collected from Ezidi refugees in Armidale Medical Centre and Armidale Hospital from 2018 to 2024. The data was analysed to determine the prevalence of H. pylori and deficiencies in iron, vitamin B12, and vitamin D. Further analysis was done with data from Armidale Medical Center only, to study any potential association between H. pylori infection and those same micronutrient deficiencies. Results : H. pylori infection was detected in 76.7% of refugees tested. The rates of iron deficiency were 35.2% at Armidale Medical Centre and 41.9% at Armidale Hospital. Vitamin B12 deficiency was found in 50.7% and 58% of individuals, and vitamin D deficiency was present in 79.6% and 82.6%, respectively. No statistically significant associations were found between H. pylori infection and iron or vitamin D deficiency. However, a statistically significant association was observed between the absence of H. pylori and vitamin B12 deficiency. Conclusion : This is a significantly higher prevalence of H. pylori infection, iron deficiency, vitamin B12 deficiency, and vitamin D deficiency among Ezidi refugees in Armidale. The relationship between H. pylori infection and micronutrient deficiencies remains unclear. Further research is needed to clarify these associations and guide future screening protocols for Ezidi refugees. Helicobacter pylori Ezidi refugees vitamin B12 and D iron Figures Figure 1 Background Helicobacter pylori (H. pylori ) is a gram-negative, rod-shaped bacteria that infects the stomach’s lining ( 1 ) and is one of the most common bacterial infections globally. H. pylori infection is associated with several gastrointestinal diseases, including chronic gastritis, gastric and duodenal ulcers, and in more severe cases, gastric cancer or mucosa-associated lymphoid tissue (MALT) lymphoma ( 2 ). Studies have demonstrated that H. pylori eradication can lower the incidence of gastric cancer ( 2 , 3 ). H. pylori infections have also been associated with micronutrient deficiencies, especially in populations with pre-existing health disparities like refugees. Refugees face a higher risk of malnutrition and micronutrient deficiencies due to factors such as inadequate access to food, displacement, acculturation challenges, and limited access to healthcare ( 4 , 5 ). Middle Eastern countries have a higher incidence of vitamin B12, vitamin D, and iron deficiencies ( 6 ). Given the high prevalence of these deficiencies among Middle Eastern refugees in Australia, it is reasonable to assume that they might also affect Ezidi individuals, a subgroup of refugees from Iraq and Syria. The biological mechanisms behind micronutrient deficiencies are not fully understood but several potential factors have been proposed. These include intestinal bleeding, atrophic gastritis, hepcidin upregulation, and long-term autoimmune changes ( 7 , 8 ). A recent meta-analysis ( 9 ) suggested negative effects of H. pylori infection on serum vitamin B12, folate, vitamin C, and vitamin D levels. While the impact of H. pylori infection on serum vitamin D levels remains unclear, there is evidence that vitamin D supplementation can positively influence the efficacy of H. pylori eradication therapy ( 8 , 10 , 11 ). Systematic reviews have found a significant association between H. pylori infection and depleted iron stores, as well as improvements in serum ferritin and haemoglobin levels following H. pylori eradication therapy ( 12 , 13 ). Australia has one of the highest intake rates of refugee or refugee-like backgrounds. The prevalence of H. pylori infection in refugees in Australia is 1.5 times higher than in the general Australian population ( 14 ). Current Australian guidelines recommend that all refugees undergo a comprehensive health assessment within 12 months of arrival, including screening for anaemia, vitamin B12, and vitamin D deficiency ( 15 ), H. pylori screening is not routinely performed unless symptoms are present (e.g., dyspepsia or peptic ulcer disease) or presence of a family history of gastric cancer ( 15 , 16 ). This approach aims to reduce overtreatment and address concerns about decreased treatment efficacy due to antibiotic resistance ( 17 ). However, H. pylori testing is recommended in cases of unexplained iron deficiency anaemia and vitamin B12 deficiency ( 16 ). Theoretical/conceptual framework Given that H. pylori disrupts gastric function, and potentially impairs nutrient absorption, (e.g., iron, vitamin B12, and D), and that refugees, especially those from conflict-ridden regions, face a higher risk of malnutrition due to limited access to nutritious food and healthcare, there is a need to examine the role of H. pylori in exacerbating these micronutrient deficiencies. Current Australian health guidelines do not mandate routine screening for H. pylori in asymptomatic refugees, potentially overlooking a key factor to malnutrition in this vulnerable population. Therefore, this study aims to clarify the role of H. pylori in exacerbating micronutrient deficiencies (vitamin B12, vitamin D, and iron) in Ezidi refugees resettling in rural Australia. This retrospective cohort study will inform potential changes to refugee health screening practices, addressing both infectious and nutritional challenges in this vulnerable population. Methods Participants All Ezidi refugee data from the Armidale Medical Practice and the Armidale Hospital initial refugee health assessment were included. H. pylori testing was performed in symptomatic individuals (e.g., epigastric pain, fatigue, or bloating), or in refugees with low iron or vitamin B12 levels or if family members tested positive for H. pylori . Data collection Patient data were extracted from Armidale Medical Centre’s Best Practice software and HNE Health's clinical application portal at Armidale Hospital. Data included demographic variables (date of birth, gender), H. pylori testing and treatment details, and levels of ferritin, vitamin D, and vitamin B12 (pre- and post-treatment (At least 6 weeks after the H. pylori therapy, including clarithromycin, amoxicillin, and esomeprazole triple therapy for 7–14 days per Australian guidelines)). Following extraction, the data were de-identified, reviewed for completeness and accuracy, and analysed. This protocol was approved by the University of New England Ethical Committee (HE23-144). Measures Three different commercial pathology laboratories within the Armidale region conducted blood tests for each micronutrient deficiency at Armidale Medical Centre. The blood tests at Armidale Hospital were collected at the onsite pathology lab and transported to Sydney for analysis. All laboratories measured vitamin D concentration using the Diasorin method (imprecision rate of 5.2% or less) ( 18 ). Chemiluminescence and the Siemens method (detection limit: 125 pg/mL − 2.2 pg/mL) were used for vitamin B12 levels ( 19 ). Ferritin concentration was measured using chemiluminescence microparticle immunoassay (CMIA) (sensitivity ≤ 1.0ng/mL ( 20 ) and the Siemens method (detection limit ≤ 1.0ng/mL) ( 21 ). H. pylori infection was identified by urea breath testing (UBT) for patients over 14 years old, and stool PCR for those under 14 or when UBT was unsuitable, such as in cases of intellectual disability. Patients under 3 were not tested. UBT’s sensitivity and specificity are 96% and 93% respectively ( 22 ) in adults, and 96.6% and 97.7% ( 23 ) in children over 6 years. Stool PCR shows a sensitivity of 92% and specificity of 96% ( 24 ). Deficiency criteria for the study were ferritin < 30 µg/L, vitamin D < 50 nmol/L, and total serum B12 < 138 pmol/L in conjunction with low Active vitamin B12 level. B12 testing was performed on total serum B12 levels between 139–250 pmol/L, and Active B12 levels < 50 pmol/L were considered deficient. Post-treatment testing was conducted during follow-up appointments after the appropriate treatment (oral or parenteral supplementation). In some instances, comprehensive testing of all variables didn’t occur. Many patients were lost to follow-up, primarily due to patient relocation. For the missing variables, patients were excluded from analysis. Data analysis The Jamovi software was used to calculate the prevalence rates of H. pylori infection and micronutrient deficiencies. Both the chi-squared test of association and Fisher’s Exact test were used to evaluate the association between H. pylori infection and micronutrient deficiencies. Results Patients H. pylori testing A total of 260 Ezidi refugee patients (female (n = 156), male (n = 104)) of all ages (ranging from 6 months to 75 years) in the Armidale Medical Practice database up until Jan 2024 were included for analysis. As summarised in Fig. 1 , 202 patients underwent H. pylori testing: 155 patients tested positive, 45 tested negative, 2 had equivocal results and 58 were not tested. Following H. pylori guideline-based treatment, 114 patients were retested: 27 remained positive, 82 tested negative, and 5 had equivocal results. Given that 157 patients had positive or equivocal results on initial testing, there is a follow-up gap for 43 patients who possibly relocated or failed to follow up. Prevalence of Vitamin B12, Vitamin D, and Ferritin before and after Treatment Ferritin levels were tested in 230 patients, with 35.2% found to be deficient. After treatment, 125 were retested, and 24% remained deficient (Table 1 ). Of the 260 patients, 230 were tested for vitamin D deficiency, and 183 (79.6%) were found to be deficient. After supplementation, 112 were retested, with 78 (69.6%) still deficient (Table 1 ). For vitamin B12 levels, 223 patients were tested, and 113 (50.7%) were found to be deficient. After receiving dietary advice and parenteral supplementation, 112 were retested, and 19 (17.0%) remained deficient. (Table 1 ). Separately, data from Armidale Hospital included 507 patients. Of these, ferritin levels were tested in 396 patients, with 166 (41.9%) found to be iron deficient. The same 396 were also tested for vitamin D deficiency, and 327 (82.6%) were found to be deficient. For vitamin B12, 388 were tested, with 225 (58.0%) found to be deficient. Table 1 Prevalence of Iron, Vitamin D and B12 Deficiencies. Organisation Context of testing Micronutrient Deficiency Counts % of total Iron (ferritin) Deficiency Armidale Medical Centre Pre-Tx Yes 81 35.2 No 149 64.8 Males and females < 13yo Pre-Tx Yes 24 20.0 No 96 80.0 Post-Tx Yes 30 24.0 No 95 76.0 Armidale Hospital Initial Refugee Health Assessment Yes 166 41.9 No 230 58.1 Vitamin D Armidale Medical Centre Pre-Tx Yes 183 79.6 No 47 20.4 Post-Tx Yes 78 69.6 No 34 30.4 Armidale Hospital Initial Refugee Health Assessment Yes 327 82.6 No 69 17.4 Vitamin B12 Armidale Medical Centre Pre-Tx Yes 113 50.7 No 110 49.3 Post-Tx Yes 19 17.0 No 93 83.0 Armidale Hospital Initial Refugee Health Assessment Yes 225 58 No 163 42 Further focus study was obtained from data extracted from Armidale Medical Centre refugee patients: Association between iron deficiency and H. pylori status Serum ferritin was assessed in 197 of 202 patients tested for H. pylori before treatment. Among 153 H. pylori -positive patients, 53 (34.6%) were iron deficient. Among 42 H. pylori -negative patients, 14 (33.3%) were iron deficient (Table 2). Two patients had equivocal results, one was iron deficient, and the other was not. Statistical analysis showed no significant relationship between H. pylori status and iron deficiency (p-value = 0.887 on chi-squared test of association and 1.00 on Fisher’s exact test). Iron deficient (on initial consult) Iron deficient (post-Tx) H. pylori test result Yes No Total Yes No Total Positive 53 100 153 7 10 17 Negative 14 28 42 13 44 57 Equivocal 1 1 2 2 2 4 Total 68 129 197 22 56 78 χ² Tests Value p Value p χ² 0.239 0.887 3.17 0.205 Fisher's exact test 1 0.181 After H. pylori treatment, serum ferritin was assessed in 78 patients. Among 17 patients who remained H. pylori positive, 7 (41.2%) had persistent iron deficiency. Among 57 patients who tested negative for H. pylori post-treatment, 13 (22.8%) remained iron deficient. Four patients had equivocal results, with two being iron deficient. The association between post-treatment H. pylori status and iron deficiency was not statistically significant (p-value = 0.181 on Fisher’s exact test). Table 2: H. pylori Status and Iron Deficiency Before and After Treatment. Association between vitamin D deficiency and H. pylori status Serum vitamin D was assessed in 190 of 202 patients before H. pylori treatment. Among 148 H. pylori -positive patients, 117 (79.1%) were vitamin D deficient. Of the 40 H. pylori -negative patients, 32 (80%) were vitamin D deficient. Two patients had equivocal results, with one being vitamin D deficient. Statistical analysis showed no significant relationship between H. pylori status and vitamin D deficiency (p-value = 0.554) (Table 3 ). After H. pylori treatment, serum vitamin D was assessed in 76 patients. Of the 17 patients who remained H. pylori positive, 13 (76.5%) were still vitamin D deficient. Among the 55 patients who tested negative for H. pylori post-treatment, 37 (66.7%) remained vitamin D deficient. Four patients had equivocal results, with three being vitamin D deficient. The relationship between post-treatment H. pylori status and vitamin D deficiency was not statistically significant (p-value = 0.815) (Table 3 ). Table 3 H. pylori Status and Vitamin D Deficiency Before and After Treatment Vit D deficient (on initial consult) Vit D deficient (post-Tx) Initial H. pylori test result Yes No Total Yes No Total Positive 117 31 148 13 4 17 Negative 32 8 40 37 18 55 Equivocal 1 1 2 3 1 4 Total 150 40 190 53 23 76 χ² Tests Value p Value p χ² 1.04 0.596 0.576 0.75 Fisher's exact test 0.554 0.815 Association between vitamin B12 deficiency and H. pylori status Serum vitamin B12 was assessed in 190 of 202 patients before H. pylori treatment. Among 147 H. pylori -positive patients, 70 (47.6%) were vitamin B12 deficient. Of the 41 H. pylori -negative patients, 27 (65.9%) were vitamin B12 deficient. Two patients had equivocal results, both of whom were vitamin B12 deficient. Statistical analysis revealed a significant relationship between H. pylori status and vitamin B12 deficiency (p-value = 0.032) (Table 4 ). After H. pylori treatment, serum vitamin B12 was assessed in 74 patients. Among 16 patients who remained H. pylori positive, 1 (6.7%) remained vitamin B12 deficient, and 15 (93.3%) were not. Among 54 patients who tested negative for H. pylori post-treatment, 11 (20.4%) remained vitamin B12 deficient, and 43 (79.6%) were not. Four patients had equivocal results, none of whom were vitamin B12 deficient. The relationship between vitamin B12 deficiency and H. pylori status post-treatment was not statistically significant (p-value = 0.425) (Table 4 ). Table 4 H. pylori Status and Vitamin B12 Deficiency Before and After Treatment Vit B12 deficient (on initial consult) Vit B12 deficient (post-Tx) Initial H. pylori test result Yes No Total Yes No Total Positive 70 77 147 1 15 16 Negative 27 14 41 11 43 54 Equivocal 2 0 2 0 4 4 Total 99 91 190 12 62 74 χ² Tests Value p Value p χ² 6.13 0.047 2.63 0.269 Fisher's exact test 0.032 0.425 Discussion Prevalence of H. pylori Infection The prevalence of H. pylori infection in Ezidi refugees was 76.7%. This is significantly higher than the global rates (43.9% in adults, 35.1% in children) ( 25 ) and higher than the rates reported in Iraq (54.2% in adults, 37.1% in children) ( 25 ). This is consistent with other studies reporting H. pylori prevalence between 72–93% in refugees and immigrants in Western countries ( 26 ). However, it exceeds the 21.5% prevalence observed among newly arrived refugees in South Australia ( 14 ). Factors such as overcrowding, poor sanitation, large family sizes, and food sharing may explain the high rates in the Ezidi population. Iron Deficiency and H. pylori infection Iron deficiency was similar in both study samples (41.9% at Armidale Hospital and 35.2% at Armidale Medical Centre). This is notably higher than the general population ( 35 , 36 ). Despite this, our study found no statistically significant association between H. pylori and iron deficiency as measured by serum ferritin, in contrast to several studies that report a significant association between H. pylori infection and iron deficiency ( 13 , 27 , 28 , 29 ), as well as improvements in serum ferritin following H. pylori eradication ( 13 , 27 , 28 , 29 ). However, persistent iron deficiency or anaemia has been observed for up to two years post H. pylori eradication ( 30 ), raising the possibility of persisting gastritis impacting iron levels after H pylori eradication. Kishore et al. reported higher serum ferritin levels in H. pylori- infected individuals compared to the uninfected group ( 31 ). A physiological immune defence mechanism, which increases iron storage and ferritin levels during infectious diseases and inflammation to limit bacterial access to needed iron for growth, may explain this ( 32 ). Since we could only rely on measured serum ferritin levels to assess iron deficiency, this mechanism may explain our non-statistically significant results. It is possible that the inflammatory response caused by H. pylori infection led to normal or increased serum ferritin levels in our study cohort, masking an underlying iron deficiency. Future research investigating the impact of H. pylori on iron deficiency and iron deficiency anaemia should include additional parameters such as a haemoglobin concentration, mean corpuscular volume, mean corpuscular haemoglobin, total iron binding capacity, ferritin, transferrin, and transferrin saturation. Vitamin B12 deficiency and H. pylori infection Vitamin B12 deficiency was high in both samples (58% at Armidale Hospital, 50.7% at Armidale Medical Centre), exceeding the rates seen in the general Australian population (0.9–2.8%) ( 33 ). These rates are even higher than vulnerable populations such as the elderly (14%) and vegans (26%) ( 34 , 35 ). In comparison, a study that also examined refugees from a similar Middle Eastern background revealed a 16.5% prevalence rate ( 36 ). Interestingly, our study found that Ezidi refugees without H. pylori infection were more likely to be vitamin B12 deficient than those with H. pylori infection, both before and after eradication therapy. This suggests that H. pylori may have a minor protective effect against vitamin B12 deficiency. These findings are inconsistent with previous studies, some of which report no association between H. pylori and vitamin B12 levels ( 9 ), while others identify H. pylor i infection as a significant risk factor for vitamin B12 deficiency ( 9 , 37 , 38 ). H. pylori is known to cause atrophic gastritis and destruction of gastric parietal cells ( 38 ), leading to impaired stomach acidification and reduced intrinsic factor secretion, both of which are required for vitamin B12 transport and absorption ( 9 , 39 ). The higher rate of vitamin B12 deficiency in H. pylori- negative individuals in our study is surprising, as previous research findings align more with vitamin B12 malabsorption mechanisms ( 7 , 40 , 41 ). To explore potential autoimmune causes, blood tests for intrinsic factor and parietal cell antibodies were ordered for all B12-deficient refugees, with only one patient returning a positive result for gastric parietal cell antibodies. Lifestyle factors and comorbid medical conditions may have influenced the vitamin B12 levels observed, but establishing an association between those components is beyond the scope of this study. Among patients who were both H. pylori positive and vitamin B12 deficient, we found a rate of 47.6%, which is close to rates reported in previous studies ( 7 , 37 , 41 ). Additionally, we observed a decrease in the prevalence of vitamin B12 deficiency from 52.1–16.2% after treatment. However, there was a significant number of missing follow-up data, which does introduce some bias. Vitamin D Deficiency and H. pylori Infection Vitamin D deficiency was similar in both study samples (79.6% at Armidale Medical Centre, 82.6% at Armidale Hospital), closely matching a previously reported rate of 89% in Middle Eastern refugees ( 42 ). Nevertheless, this is significantly higher than the approximately 23% prevalence reported in the Australian population ( 43 ). The high prevalence observed in our study may attributed to factors such as the wearing of conservative clothing (scarves or hijabs) and a cultural aversion to tanning. Our study found no statistically significant link between H. pylori infection and vitamin D deficiency, either pre- or post-treatment. As of today, the relationship between these two factors remains unclear ( 11 ). However, some studies suggest that vitamin D may act as a protective factor against H. pylori infection, potentially improving the success of eradication therapy ( 11 , 44 ) but further studies are required to establish a connection between H. pylori infection, vitamin D deficiency, supplementation, and its impact on H. pylori treatment ( 45 ). Limitations Several limitations must be acknowledged. The small sample size of Ezidi refugees in Armidale reduces the study's statistical power. The data extraction process using Best Practice software compared to manual extraction may have introduced inconsistencies, however the data were double-checked by two collectors. The selective nature of pathology testing, based on clinical suspicion, introduces sampling bias, potentially inflating prevalence rates. Additionally, the use of multiple commercial laboratories for pathology testing may have caused minor detection bias. However, this bias is likely limited, as deficiency rates were similar between the Armidale Medical Centre and the Armidale Hospital. Variable treatment durations and inconsistent follow-up times may also influence post-treatment prevalence rates due to bias. The study did not fully account for confounding factors such as age, comorbidities, and diet, which could have affected the results. For example, polyphenol-containing beverages like tea and coffee significantly reduce iron absorption, and conditions like coeliac disease are known to cause micronutrient deficiencies due to malabsorption. Finally, the retrospective nature of the study, relying on past records, may have resulted in incomplete data. Contribution to the literature: This is the first study to assess the prevalence of H. pylori , iron deficiency, vitamin B12 deficiency, and vitamin D deficiency among Ezidi refugees in Armidale, a rural Australian town selected for regional settlement through a specialised program ( 46 ). The study found no significant correlation between H. pylori infection, iron and vitamin D deficiencies, but it did observe a significant association between vitamin B12 deficiency and H. pylori -negative individuals. The overall relationship between H. pylori infection and micronutrient deficiencies remains unclear, as previous studies have reported mixed and inconsistent results. This study emphasises the need for further research to clarify these associations and supports the potential for standardised screening protocols for Ezidi refugees. Declarations Author Contribution Authors' contributions: S.A. acquired the data. G.N. primarily extracted the data. E.H, O.M, G.N, and N.T equally analysed the data under the joint supervision of S.A and J.C . E.H, O.M, G.N, and N.T contributed equally to the first draft of the manuscript, while S. A and J.C. revised it.This paper adheres to the STROBE Checklist: cohort, case-control, and cross-sectional studies (combined) (available upon request). Acknowledgement Acknowledgments: To Armidale Medical Centre and Armidale Rural Referral HospitalMr Ashley Young and team extracted and provided data for patients at Armidale Hospital. Data Availability Unidentified data will be provided if needed, it is saved at Armidale Medical Centre patient confidential file. References Reshetnyak VI, Burmistrov AI, Maev IV. 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Association Between Helicobacter pylori Infection and Serum Iron Profile. Cureus. 2021;13(9):e17925.10.7759/cureus.17925. Kernan KF, Carcillo JA. Hyperferritinemia and inflammation. Int Immunol. 2017;29(9):401 – 9.10.1093/intimm/dxx031. Seifu CN, Fahey PP, Atlantis E. Micronutrient deficiencies and anaemia associated with body mass index in Australian adults: a cross-sectional study. BMJ Open. 2022;12(12):e061442.10.1136/bmjopen-2022-061442. Mirkazemi C, Peterson GM, Tenni PC, Jackson SL. Vitamin B12 deficiency in Australian residential aged care facilities. J Nutr Health Aging. 2012;16(3):277 – 80.10.1007/s12603-011-0348-2. Benham AJ, Gallegos D, Hanna KL, Hannan-Jones MT. Intake of vitamin B(12) and other characteristics of women of reproductive age on a vegan diet in Australia. Public Health Nutr. 2021;24(14):4397 – 407.10.1017/s1368980021001695. Benson J, Phillips C, Kay M, Webber MT, Ratcliff AJ, Correa-Velez I et al. Low vitamin B12 levels among newly-arrived refugees from Bhutan, Iran and Afghanistan: a multicentre Australian study. PLoS One. 2013;8(2):e57998.10.1371/journal.pone.0057998. Ali U, Abbasi W, Huda N. Vitamin B12 Deficiency among Cases of Helicobacter Pylori Gastritis: A Cross Sectional Study. Journal of Health and Rehabilitation Research. 2024;4:553 – 6.10.61919/jhrr.v4i2.907. Krishnegowda R, Joseph J, Thomas D. Helicobacter pylori infection and vitamin B-12 deficiency- A cross sectional study. Asian Journal of Medical Sciences. 2017;8:16.10.3126/ajms.v8i4.17280. Gowdappa HB, Mahesh M, Murthy KV, Narahari MG. Helicobacter pylori associated vitamin B12 deficiency, pernicious anaemia and subacute combined degeneration of the spinal cord. BMJ Case Rep. 2013;2013.10.1136/bcr-2013-200380. Serin E, Gümürdülü Y, Ozer B, Kayaselçuk F, Yilmaz U, Koçak R. Impact of Helicobacter pylori on the development of vitamin B12 deficiency in the absence of gastric atrophy. Helicobacter. 2002;7(6):337 – 41.10.1046/j.1523-5378.2002.00106.x. Sarari AS, Farraj MA, Hamoudi W, Essawi TA. Helicobacter pylori, a causative agent of vitamin B12 deficiency. J Infect Dev Ctries. 2008;2(5):346 – 9.10.3855/jidc.194. Penrose K, Hunter Adams J, Nguyen T, Cochran J, Geltman PL. Vitamin D deficiency among newly resettled refugees in Massachusetts. J Immigr Minor Health. 2012;14(6):941 – 8.10.1007/s10903-012-9603-9. 2013 [ https://www.abs.gov.au/articles/vitamin-d El Shahawy MS, Hemida MH, El Metwaly I, Shady ZM. The effect of vitamin D deficiency on eradication rates of Helicobacter pylori infection. JGH Open. 2018;2(6):270 – 5.10.1002/jgh3.12081. Săsăran MO, Mărginean CO, Lupu A, Koller AM. Vitamin D and Its Association with H. pylori Prevalence and Eradication: A Comprehensive Review. Nutrients. 2023;15(16).10.3390/nu15163549. Affairs AGDoH. Humanitarian Settlement Program: Humanitarian Settlement in Regional Australia 2024 [ https://immi.homeaffairs.gov.au/settling-in-australia/humanitarian-settlement-program/about-the-program/humanitarian-settlement-regional-australia Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in Journal of Immigrant and Minority Health → Version 1 posted Editorial decision: Revision requested 12 Apr, 2025 Reviews received at journal 04 Feb, 2025 Reviewers agreed at journal 13 Jan, 2025 Reviewers agreed at journal 13 Jan, 2025 Reviews received at journal 08 Jan, 2025 Reviewers agreed at journal 07 Jan, 2025 Reviewers invited by journal 23 Nov, 2024 Editor assigned by journal 19 Nov, 2024 Submission checks completed at journal 19 Nov, 2024 First submitted to journal 17 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5469028","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":382580621,"identity":"702478c7-32a3-4532-b2ad-ff1d55a23d7e","order_by":0,"name":"Grace Noh","email":"","orcid":"","institution":"University of New England School of Rural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Grace","middleName":"","lastName":"Noh","suffix":""},{"id":382580622,"identity":"c2961b36-f1f0-4281-bc99-30f6431bb6b1","order_by":1,"name":"Nelson Tran","email":"","orcid":"","institution":"University of New England School of Rural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nelson","middleName":"","lastName":"Tran","suffix":""},{"id":382580623,"identity":"b6d0d2ba-4dbf-44fb-a6a8-07dfd09a08a0","order_by":2,"name":"Oliver McMorran","email":"","orcid":"","institution":"University of New England School of Rural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Oliver","middleName":"","lastName":"McMorran","suffix":""},{"id":382580624,"identity":"3bc89359-2b69-4b0d-ac94-fd51aeb54296","order_by":3,"name":"Edric Hu","email":"","orcid":"","institution":"University of New England School of Rural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Edric","middleName":"","lastName":"Hu","suffix":""},{"id":382580625,"identity":"52ed21ae-9b92-4188-84f8-7420d5c62b6e","order_by":4,"name":"Joëlle V.F. Coumans","email":"","orcid":"","institution":"University of New England School of Rural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Joëlle","middleName":"V.F.","lastName":"Coumans","suffix":""},{"id":382580626,"identity":"d6843d97-e569-410d-8728-f72ab7f61e0c","order_by":5,"name":"Salma Hago Mustafa Ali","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYFAC5oYDH37YQNg8xGlhbDg4syeNRC3MPGyHSdAi336w8QAPz/nE7ewNjA/etjHIGxwgoMXgTGLDAQmL24k7ew4wG85tYzDcQFALA1CLAc/txA03EtikedsYGAlqke9/2HAgge1c4ob7D9h/A7XYE9TCcANoywG2A0BbGNiYgVoSCTvsxsOGg409ycYbziQ2S845J5E8k7DDkg9//vPDTnbD8cMHP7wps7HtI+gwBGBsABISxKsfBaNgFIyCUYAbAABlHkpynKkBVAAAAABJRU5ErkJggg==","orcid":"","institution":"University of New England School of Rural Medicine","correspondingAuthor":true,"prefix":"","firstName":"Salma","middleName":"Hago Mustafa","lastName":"Ali","suffix":""}],"badges":[],"createdAt":"2024-11-17 08:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5469028/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5469028/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10903-025-01715-9","type":"published","date":"2025-07-01T15:58:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70392850,"identity":"bc143adf-237f-445b-8fd6-8eea02fa491b","added_by":"auto","created_at":"2024-12-02 17:49:40","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":205620,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5469028/v1/a5dd8ca6a4ace883d86db5fc.jpg"},{"id":86179888,"identity":"28404498-4dc2-4237-8604-bf39339bcc83","added_by":"auto","created_at":"2025-07-07 16:20:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1052338,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5469028/v1/1d78e797-e656-4f91-b1f4-40fd5c2fee00.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of Helicobacter Pylori infection, Vitamin B12, Vitamin D, and iron deficiency, and possible association of H pylori infection as a potential cause among Ezidi Refugees in rural Armidale: Findings from a Retrospective Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003e \u003cem\u003eHelicobacter pylori (H. pylori\u003c/em\u003e) is a gram-negative, rod-shaped bacteria that infects the stomach\u0026rsquo;s lining (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and is one of the most common bacterial infections globally. \u003cem\u003eH. pylori\u003c/em\u003e infection is associated with several gastrointestinal diseases, including chronic gastritis, gastric and duodenal ulcers, and in more severe cases, gastric cancer or mucosa-associated lymphoid tissue (MALT) lymphoma (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Studies have demonstrated that \u003cem\u003eH. pylori\u003c/em\u003e eradication can lower the incidence of gastric cancer (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eH. pylori\u003c/em\u003e infections have also been associated with micronutrient deficiencies, especially in populations with pre-existing health disparities like refugees. Refugees face a higher risk of malnutrition and micronutrient deficiencies due to factors such as inadequate access to food, displacement, acculturation challenges, and limited access to healthcare (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Middle Eastern countries have a higher incidence of vitamin B12, vitamin D, and iron deficiencies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Given the high prevalence of these deficiencies among Middle Eastern refugees in Australia, it is reasonable to assume that they might also affect Ezidi individuals, a subgroup of refugees from Iraq and Syria.\u003c/p\u003e \u003cp\u003eThe biological mechanisms behind micronutrient deficiencies are not fully understood but several potential factors have been proposed. These include intestinal bleeding, atrophic gastritis, hepcidin upregulation, and long-term autoimmune changes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A recent meta-analysis (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) suggested negative effects of \u003cem\u003eH. pylori\u003c/em\u003e infection on serum vitamin B12, folate, vitamin C, and vitamin D levels. While the impact of \u003cem\u003eH. pylori\u003c/em\u003e infection on serum vitamin D levels remains unclear, there is evidence that vitamin D supplementation can positively influence the efficacy of \u003cem\u003eH. pylori\u003c/em\u003e eradication therapy (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Systematic reviews have found a significant association between \u003cem\u003eH. pylori\u003c/em\u003e infection and depleted iron stores, as well as improvements in serum ferritin and haemoglobin levels following \u003cem\u003eH. pylori\u003c/em\u003e eradication therapy (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAustralia has one of the highest intake rates of refugee or refugee-like backgrounds. The prevalence of \u003cem\u003eH. pylori\u003c/em\u003e infection in refugees in Australia is 1.5 times higher than in the general Australian population (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Current Australian guidelines recommend that all refugees undergo a comprehensive health assessment within 12 months of arrival, including screening for anaemia, vitamin B12, and vitamin D deficiency (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), \u003cem\u003eH. pylori\u003c/em\u003e screening is not routinely performed unless symptoms are present (e.g., dyspepsia or peptic ulcer disease) or presence of a family history of gastric cancer (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This approach aims to reduce overtreatment and address concerns about decreased treatment efficacy due to antibiotic resistance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, \u003cem\u003eH. pylori\u003c/em\u003e testing is recommended in cases of unexplained iron deficiency anaemia and vitamin B12 deficiency (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eTheoretical/conceptual framework\u003c/h3\u003e\n\u003cp\u003eGiven that \u003cem\u003eH. pylori\u003c/em\u003e disrupts gastric function, and potentially impairs nutrient absorption, (e.g., iron, vitamin B12, and D), and that refugees, especially those from conflict-ridden regions, face a higher risk of malnutrition due to limited access to nutritious food and healthcare, there is a need to examine the role of \u003cem\u003eH. pylori\u003c/em\u003e in exacerbating these micronutrient deficiencies. Current Australian health guidelines do not mandate routine screening for \u003cem\u003eH. pylori\u003c/em\u003e in asymptomatic refugees, potentially overlooking a key factor to malnutrition in this vulnerable population. Therefore, this study aims to clarify the role of \u003cem\u003eH. pylori\u003c/em\u003e in exacerbating micronutrient deficiencies (vitamin B12, vitamin D, and iron) in Ezidi refugees resettling in rural Australia. This retrospective cohort study will inform potential changes to refugee health screening practices, addressing both infectious and nutritional challenges in this vulnerable population.\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eAll Ezidi refugee data from the Armidale Medical Practice and the Armidale Hospital initial refugee health assessment were included. \u003cem\u003eH. pylori\u003c/em\u003e testing was performed in symptomatic individuals (e.g., epigastric pain, fatigue, or bloating), or in refugees with low iron or vitamin B12 levels or if family members tested positive for \u003cem\u003eH. pylori\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003ePatient data were extracted from Armidale Medical Centre\u0026rsquo;s Best Practice software and HNE Health's clinical application portal at Armidale Hospital. Data included demographic variables (date of birth, gender), \u003cem\u003eH. pylori\u003c/em\u003e testing and treatment details, and levels of ferritin, vitamin D, and vitamin B12 (pre- and post-treatment (At least 6 weeks after the \u003cem\u003eH. pylori\u003c/em\u003e therapy, including clarithromycin, amoxicillin, and esomeprazole triple therapy for 7\u0026ndash;14 days per Australian guidelines)). Following extraction, the data were de-identified, reviewed for completeness and accuracy, and analysed. This protocol was approved by the University of New England Ethical Committee (HE23-144).\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eThree different commercial pathology laboratories within the Armidale region conducted blood tests for each micronutrient deficiency at Armidale Medical Centre. The blood tests at Armidale Hospital were collected at the onsite pathology lab and transported to Sydney for analysis. All laboratories measured vitamin D concentration using the Diasorin method (imprecision rate of 5.2% or less) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Chemiluminescence and the Siemens method (detection limit: 125 pg/mL \u0026minus;\u0026thinsp;2.2 pg/mL) were used for vitamin B12 levels (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Ferritin concentration was measured using chemiluminescence microparticle immunoassay (CMIA) (sensitivity\u0026thinsp;\u0026le;\u0026thinsp;1.0ng/mL (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and the Siemens method (detection limit\u0026thinsp;\u0026le;\u0026thinsp;1.0ng/mL) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eH. pylori\u003c/em\u003e infection was identified by urea breath testing (UBT) for patients over 14 years old, and stool PCR for those under 14 or when UBT was unsuitable, such as in cases of intellectual disability. Patients under 3 were not tested. UBT\u0026rsquo;s sensitivity and specificity are 96% and 93% respectively (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) in adults, and 96.6% and 97.7% (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) in children over 6 years. Stool PCR shows a sensitivity of 92% and specificity of 96% (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDeficiency criteria for the study were ferritin\u0026thinsp;\u0026lt;\u0026thinsp;30 \u0026micro;g/L, vitamin D\u0026thinsp;\u0026lt;\u0026thinsp;50 nmol/L, and total serum B12\u0026thinsp;\u0026lt;\u0026thinsp;138 pmol/L in conjunction with low Active vitamin B12 level. B12 testing was performed on total serum B12 levels between 139\u0026ndash;250 pmol/L, and Active B12 levels\u0026thinsp;\u0026lt;\u0026thinsp;50 pmol/L were considered deficient. Post-treatment testing was conducted during follow-up appointments after the appropriate treatment (oral or parenteral supplementation). In some instances, comprehensive testing of all variables didn\u0026rsquo;t occur. Many patients were lost to follow-up, primarily due to patient relocation. For the missing variables, patients were excluded from analysis.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe Jamovi software was used to calculate the prevalence rates of \u003cem\u003eH. pylori\u003c/em\u003e infection and micronutrient deficiencies. Both the chi-squared test of association and Fisher\u0026rsquo;s Exact test were used to evaluate the association between \u003cem\u003eH. pylori\u003c/em\u003e infection and micronutrient deficiencies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePatients\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003etesting\u003c/span\u003e\u003c/p\u003e \u003cp\u003eA total of 260 Ezidi refugee patients (female (n\u0026thinsp;=\u0026thinsp;156), male (n\u0026thinsp;=\u0026thinsp;104)) of all ages (ranging from 6 months to 75 years) in the Armidale Medical Practice database up until Jan 2024 were included for analysis.\u003c/p\u003e \u003cp\u003eAs summarised in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 202 patients underwent \u003cem\u003eH. pylori\u003c/em\u003e testing: 155 patients tested positive, 45 tested negative, 2 had equivocal results and 58 were not tested. Following \u003cem\u003eH. pylori\u003c/em\u003e guideline-based treatment, 114 patients were retested: 27 remained positive, 82 tested negative, and 5 had equivocal results. Given that 157 patients had positive or equivocal results on initial testing, there is a follow-up gap for 43 patients who possibly relocated or failed to follow up.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePrevalence of Vitamin B12, Vitamin D, and Ferritin before and after Treatment\u003c/h3\u003e\n\u003cp\u003eFerritin levels were tested in 230 patients, with 35.2% found to be deficient. After treatment, 125 were retested, and 24% remained deficient (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf the 260 patients, 230 were tested for vitamin D deficiency, and 183 (79.6%) were found to be deficient. After supplementation, 112 were retested, with 78 (69.6%) still deficient (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor vitamin B12 levels, 223 patients were tested, and 113 (50.7%) were found to be deficient. After receiving dietary advice and parenteral supplementation, 112 were retested, and 19 (17.0%) remained deficient. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeparately, data from Armidale Hospital included 507 patients. Of these, ferritin levels were tested in 396 patients, with 166 (41.9%) found to be iron deficient. The same 396 were also tested for vitamin D deficiency, and 327 (82.6%) were found to be deficient. For vitamin B12, 388 were tested, with 225 (58.0%) found to be deficient.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of Iron, Vitamin D and B12 Deficiencies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganisation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eContext of testing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMicronutrient Deficiency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCounts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% of total\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eIron (ferritin) Deficiency\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eArmidale Medical Centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePre-Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e35.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMales and females\u0026thinsp;\u0026lt;\u0026thinsp;13yo Pre-Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e76.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eArmidale Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInitial Refugee Health Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eVitamin D\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eArmidale Medical Centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePre-Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e79.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eArmidale Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInitial Refugee Health Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e82.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eVitamin B12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eArmidale Medical Centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePre-Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e49.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e83.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eArmidale Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInitial Refugee Health Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFurther focus study was obtained from data extracted from Armidale Medical Centre refugee patients:\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAssociation between iron deficiency and\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estatus\u003c/span\u003e\u003c/p\u003e \u003cp\u003eSerum ferritin was assessed in 197 of 202 patients tested for H. pylori before treatment. Among 153 \u003cem\u003eH. pylori\u003c/em\u003e-positive patients, 53 (34.6%) were iron deficient. Among 42 \u003cem\u003eH. pylori\u003c/em\u003e-negative patients, 14 (33.3%) were iron deficient (Table\u0026nbsp;2). Two patients had equivocal results, one was iron deficient, and the other was not. Statistical analysis showed no significant relationship between \u003cem\u003eH. pylori\u003c/em\u003e status and iron deficiency (p-value\u0026thinsp;=\u0026thinsp;0.887 on chi-squared test of association and 1.00 on Fisher\u0026rsquo;s exact test).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIron deficient (on initial consult)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c11\" namest=\"c6\"\u003e \u003cp\u003eIron deficient (post-Tx)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eH. pylori\u003c/em\u003e test result\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquivocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u0026sup2; Tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.887\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFisher's exact test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter \u003cem\u003eH. pylori\u003c/em\u003e treatment, serum ferritin was assessed in 78 patients. Among 17 patients who remained \u003cem\u003eH. pylori\u003c/em\u003e positive, 7 (41.2%) had persistent iron deficiency. Among 57 patients who tested negative for \u003cem\u003eH. pylori\u003c/em\u003e post-treatment, 13 (22.8%) remained iron deficient. Four patients had equivocal results, with two being iron deficient. The association between post-treatment \u003cem\u003eH. pylori\u003c/em\u003e status and iron deficiency was not statistically significant (p-value\u0026thinsp;=\u0026thinsp;0.181 on Fisher\u0026rsquo;s exact test).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;2: \u003cem\u003eH. pylori\u003c/em\u003e Status and Iron Deficiency Before and After Treatment.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAssociation between vitamin D deficiency and\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estatus\u003c/span\u003e\u003c/p\u003e \u003cp\u003eSerum vitamin D was assessed in 190 of 202 patients before \u003cem\u003eH. pylori\u003c/em\u003e treatment. Among 148 \u003cem\u003eH. pylori\u003c/em\u003e-positive patients, 117 (79.1%) were vitamin D deficient. Of the 40 \u003cem\u003eH. pylori\u003c/em\u003e-negative patients, 32 (80%) were vitamin D deficient. Two patients had equivocal results, with one being vitamin D deficient. Statistical analysis showed no significant relationship between \u003cem\u003eH. pylori\u003c/em\u003e status and vitamin D deficiency (p-value\u0026thinsp;=\u0026thinsp;0.554) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter \u003cem\u003eH. pylori\u003c/em\u003e treatment, serum vitamin D was assessed in 76 patients. Of the 17 patients who remained \u003cem\u003eH. pylori\u003c/em\u003e positive, 13 (76.5%) were still vitamin D deficient. Among the 55 patients who tested negative for \u003cem\u003eH. pylori\u003c/em\u003e post-treatment, 37 (66.7%) remained vitamin D deficient. Four patients had equivocal results, with three being vitamin D deficient. The relationship between post-treatment \u003cem\u003eH. pylori\u003c/em\u003e status and vitamin D deficiency was not statistically significant (p-value\u0026thinsp;=\u0026thinsp;0.815) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eH. pylori\u003c/em\u003e Status and Vitamin D Deficiency Before and After Treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eVit D deficient (on initial consult)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c12\" namest=\"c7\"\u003e \u003cp\u003eVit D deficient (post-Tx)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial \u003cem\u003eH. pylori\u003c/em\u003e test result\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquivocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u0026sup2; Tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFisher's exact test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.554\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAssociation between vitamin B12 deficiency and\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estatus\u003c/span\u003e\u003c/p\u003e \u003cp\u003eSerum vitamin B12 was assessed in 190 of 202 patients before \u003cem\u003eH. pylori\u003c/em\u003e treatment. Among 147 \u003cem\u003eH. pylori\u003c/em\u003e-positive patients, 70 (47.6%) were vitamin B12 deficient. Of the 41 \u003cem\u003eH. pylori\u003c/em\u003e-negative patients, 27 (65.9%) were vitamin B12 deficient. Two patients had equivocal results, both of whom were vitamin B12 deficient. Statistical analysis revealed a significant relationship between H. pylori status and vitamin B12 deficiency (p-value\u0026thinsp;=\u0026thinsp;0.032) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter \u003cem\u003eH. pylori\u003c/em\u003e treatment, serum vitamin B12 was assessed in 74 patients. Among 16 patients who remained H. pylori positive, 1 (6.7%) remained vitamin B12 deficient, and 15 (93.3%) were not. Among 54 patients who tested negative for \u003cem\u003eH. pylori\u003c/em\u003e post-treatment, 11 (20.4%) remained vitamin B12 deficient, and 43 (79.6%) were not. Four patients had equivocal results, none of whom were vitamin B12 deficient. The relationship between vitamin B12 deficiency and \u003cem\u003eH. pylori\u003c/em\u003e status post-treatment was not statistically significant (p-value\u0026thinsp;=\u0026thinsp;0.425) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eH. pylori\u003c/em\u003e Status and Vitamin B12 Deficiency Before and After Treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eVit B12 deficient (on initial consult)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e \u003cp\u003eVit B12 deficient (post-Tx)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial \u003cem\u003eH. pylori\u003c/em\u003e test result\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquivocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u0026sup2; Tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFisher's exact test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e0.425\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePrevalence of\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInfection\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThe prevalence of \u003cem\u003eH. pylori\u003c/em\u003e infection in Ezidi refugees was 76.7%. This is significantly higher than the global rates (43.9% in adults, 35.1% in children) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and higher than the rates reported in Iraq (54.2% in adults, 37.1% in children) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This is consistent with other studies reporting \u003cem\u003eH. pylori\u003c/em\u003e prevalence between 72\u0026ndash;93% in refugees and immigrants in Western countries (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, it exceeds the 21.5% prevalence observed among newly arrived refugees in South Australia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Factors such as overcrowding, poor sanitation, large family sizes, and food sharing may explain the high rates in the Ezidi population.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIron Deficiency and\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003einfection\u003c/span\u003e\u003c/p\u003e \u003cp\u003eIron deficiency was similar in both study samples (41.9% at Armidale Hospital and 35.2% at Armidale Medical Centre). This is notably higher than the general population (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Despite this, our study found no statistically significant association between \u003cem\u003eH. pylori\u003c/em\u003e and iron deficiency as measured by serum ferritin, in contrast to several studies that report a significant association between \u003cem\u003eH. pylori\u003c/em\u003e infection and iron deficiency (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), as well as improvements in serum ferritin following \u003cem\u003eH. pylori\u003c/em\u003e eradication (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, persistent iron deficiency or anaemia has been observed for up to two years post \u003cem\u003eH. pylori\u003c/em\u003e eradication (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), raising the possibility of persisting gastritis impacting iron levels after \u003cem\u003eH pylori\u003c/em\u003e eradication.\u003c/p\u003e \u003cp\u003eKishore et al. reported higher serum ferritin levels in \u003cem\u003eH. pylori-\u003c/em\u003einfected individuals compared to the uninfected group (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A physiological immune defence mechanism, which increases iron storage and ferritin levels during infectious diseases and inflammation to limit bacterial access to needed iron for growth, may explain this (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Since we could only rely on measured serum ferritin levels to assess iron deficiency, this mechanism may explain our non-statistically significant results. It is possible that the inflammatory response caused by \u003cem\u003eH. pylori\u003c/em\u003e infection led to normal or increased serum ferritin levels in our study cohort, masking an underlying iron deficiency. Future research investigating the impact of \u003cem\u003eH. pylori\u003c/em\u003e on iron deficiency and iron deficiency anaemia should include additional parameters such as a haemoglobin concentration, mean corpuscular volume, mean corpuscular haemoglobin, total iron binding capacity, ferritin, transferrin, and transferrin saturation.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eVitamin B12 deficiency and\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003einfection\u003c/span\u003e\u003c/p\u003e \u003cp\u003eVitamin B12 deficiency was high in both samples (58% at Armidale Hospital, 50.7% at Armidale Medical Centre), exceeding the rates seen in the general Australian population (0.9\u0026ndash;2.8%) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). These rates are even higher than vulnerable populations such as the elderly (14%) and vegans (26%) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In comparison, a study that also examined refugees from a similar Middle Eastern background revealed a 16.5% prevalence rate (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterestingly, our study found that Ezidi refugees without \u003cem\u003eH. pylori\u003c/em\u003e infection were more likely to be vitamin B12 deficient than those with \u003cem\u003eH. pylori\u003c/em\u003e infection, both before and after eradication therapy. This suggests that \u003cem\u003eH. pylori\u003c/em\u003e may have a minor protective effect against vitamin B12 deficiency. These findings are inconsistent with previous studies, some of which report no association between \u003cem\u003eH. pylori\u003c/em\u003e and vitamin B12 levels (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), while others identify \u003cem\u003eH. pylor\u003c/em\u003ei infection as a significant risk factor for vitamin B12 deficiency (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eH. pylori\u003c/em\u003e is known to cause atrophic gastritis and destruction of gastric parietal cells (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), leading to impaired stomach acidification and reduced intrinsic factor secretion, both of which are required for vitamin B12 transport and absorption (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The higher rate of vitamin B12 deficiency in \u003cem\u003eH. pylori-\u003c/em\u003enegative individuals in our study is surprising, as previous research findings align more with vitamin B12 malabsorption mechanisms (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). To explore potential autoimmune causes, blood tests for intrinsic factor and parietal cell antibodies were ordered for all B12-deficient refugees, with only one patient returning a positive result for gastric parietal cell antibodies.\u003c/p\u003e \u003cp\u003eLifestyle factors and comorbid medical conditions may have influenced the vitamin B12 levels observed, but establishing an association between those components is beyond the scope of this study. Among patients who were both \u003cem\u003eH. pylori\u003c/em\u003e positive and vitamin B12 deficient, we found a rate of 47.6%, which is close to rates reported in previous studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Additionally, we observed a decrease in the prevalence of vitamin B12 deficiency from 52.1\u0026ndash;16.2% after treatment. However, there was a significant number of missing follow-up data, which does introduce some bias.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eVitamin D Deficiency and\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eH. pylori\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInfection\u003c/span\u003e\u003c/p\u003e \u003cp\u003eVitamin D deficiency was similar in both study samples (79.6% at Armidale Medical Centre, 82.6% at Armidale Hospital), closely matching a previously reported rate of 89% in Middle Eastern refugees (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Nevertheless, this is significantly higher than the approximately 23% prevalence reported in the Australian population (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The high prevalence observed in our study may attributed to factors such as the wearing of conservative clothing (scarves or hijabs) and a cultural aversion to tanning.\u003c/p\u003e \u003cp\u003eOur study found no statistically significant link between \u003cem\u003eH. pylori\u003c/em\u003e infection and vitamin D deficiency, either pre- or post-treatment. As of today, the relationship between these two factors remains unclear (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, some studies suggest that vitamin D may act as a protective factor against \u003cem\u003eH. pylori\u003c/em\u003e infection, potentially improving the success of eradication therapy (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) but further studies are required to establish a connection between \u003cem\u003eH. pylori\u003c/em\u003e infection, vitamin D deficiency, supplementation, and its impact on \u003cem\u003eH. pylori\u003c/em\u003e treatment (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSeveral limitations must be acknowledged. The small sample size of Ezidi refugees in Armidale reduces the study's statistical power. The data extraction process using Best Practice software compared to manual extraction may have introduced inconsistencies, however the data were double-checked by two collectors. The selective nature of pathology testing, based on clinical suspicion, introduces sampling bias, potentially inflating prevalence rates. Additionally, the use of multiple commercial laboratories for pathology testing may have caused minor detection bias. However, this bias is likely limited, as deficiency rates were similar between the Armidale Medical Centre and the Armidale Hospital.\u003c/p\u003e \u003cp\u003eVariable treatment durations and inconsistent follow-up times may also influence post-treatment prevalence rates due to bias. The study did not fully account for confounding factors such as age, comorbidities, and diet, which could have affected the results. For example, polyphenol-containing beverages like tea and coffee significantly reduce iron absorption, and conditions like coeliac disease are known to cause micronutrient deficiencies due to malabsorption. Finally, the retrospective nature of the study, relying on past records, may have resulted in incomplete data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eContribution to the literature:\u003c/h2\u003e \u003cp\u003eThis is the first study to assess the prevalence of \u003cem\u003eH. pylori\u003c/em\u003e, iron deficiency, vitamin B12 deficiency, and vitamin D deficiency among Ezidi refugees in Armidale, a rural Australian town selected for regional settlement through a specialised program (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). The study found no significant correlation between \u003cem\u003eH. pylori\u003c/em\u003e infection, iron and vitamin D deficiencies, but it did observe a significant association between vitamin B12 deficiency and \u003cem\u003eH. pylori\u003c/em\u003e-negative individuals. The overall relationship between \u003cem\u003eH. pylori\u003c/em\u003e infection and micronutrient deficiencies remains unclear, as previous studies have reported mixed and inconsistent results. This study emphasises the need for further research to clarify these associations and supports the potential for standardised screening protocols for Ezidi refugees.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors' contributions: S.A. acquired the data. G.N. primarily extracted the data. E.H, O.M, G.N, and N.T equally analysed the data under the joint supervision of S.A and J.C . E.H, O.M, G.N, and N.T contributed equally to the first draft of the manuscript, while S. A and J.C. revised it.This paper adheres to the STROBE Checklist: cohort, case-control, and cross-sectional studies (combined) (available upon request).\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eAcknowledgments: To Armidale Medical Centre and Armidale Rural Referral HospitalMr Ashley Young and team extracted and provided data for patients at Armidale Hospital.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eUnidentified data will be provided if needed, it is saved at Armidale Medical Centre patient confidential file.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReshetnyak VI, Burmistrov AI, Maev IV. Helicobacter pylori: Commensal, symbiont or pathogen? 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Public Health Nutr. 2021;24(14):4397\u0026thinsp;\u0026ndash;\u0026thinsp;407.10.1017/s1368980021001695.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenson J, Phillips C, Kay M, Webber MT, Ratcliff AJ, Correa-Velez I et al. Low vitamin B12 levels among newly-arrived refugees from Bhutan, Iran and Afghanistan: a multicentre Australian study. PLoS One. 2013;8(2):e57998.10.1371/journal.pone.0057998.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli U, Abbasi W, Huda N. Vitamin B12 Deficiency among Cases of Helicobacter Pylori Gastritis: A Cross Sectional Study. Journal of Health and Rehabilitation Research. 2024;4:553\u0026thinsp;\u0026ndash;\u0026thinsp;6.10.61919/jhrr.v4i2.907.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrishnegowda R, Joseph J, Thomas D. Helicobacter pylori infection and vitamin B-12 deficiency- A cross sectional study. Asian Journal of Medical Sciences. 2017;8:16.10.3126/ajms.v8i4.17280.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGowdappa HB, Mahesh M, Murthy KV, Narahari MG. Helicobacter pylori associated vitamin B12 deficiency, pernicious anaemia and subacute combined degeneration of the spinal cord. BMJ Case Rep. 2013;2013.10.1136/bcr-2013-200380.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSerin E, G\u0026uuml;m\u0026uuml;rd\u0026uuml;l\u0026uuml; Y, Ozer B, Kayasel\u0026ccedil;uk F, Yilmaz U, Ko\u0026ccedil;ak R. Impact of Helicobacter pylori on the development of vitamin B12 deficiency in the absence of gastric atrophy. Helicobacter. 2002;7(6):337\u0026thinsp;\u0026ndash;\u0026thinsp;41.10.1046/j.1523-5378.2002.00106.x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarari AS, Farraj MA, Hamoudi W, Essawi TA. Helicobacter pylori, a causative agent of vitamin B12 deficiency. J Infect Dev Ctries. 2008;2(5):346\u0026thinsp;\u0026ndash;\u0026thinsp;9.10.3855/jidc.194.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePenrose K, Hunter Adams J, Nguyen T, Cochran J, Geltman PL. Vitamin D deficiency among newly resettled refugees in Massachusetts. J Immigr Minor Health. 2012;14(6):941\u0026thinsp;\u0026ndash;\u0026thinsp;8.10.1007/s10903-012-9603-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2013 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.abs.gov.au/articles/vitamin-d\u003c/span\u003e\u003cspan address=\"https://www.abs.gov.au/articles/vitamin-d\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Shahawy MS, Hemida MH, El Metwaly I, Shady ZM. The effect of vitamin D deficiency on eradication rates of Helicobacter pylori infection. JGH Open. 2018;2(6):270\u0026thinsp;\u0026ndash;\u0026thinsp;5.10.1002/jgh3.12081.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSăsăran MO, Mărginean CO, Lupu A, Koller AM. Vitamin D and Its Association with \u003cem\u003eH. pylori\u003c/em\u003e Prevalence and Eradication: A Comprehensive Review. Nutrients. 2023;15(16).10.3390/nu15163549.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAffairs AGDoH. Humanitarian Settlement Program: Humanitarian Settlement in Regional Australia 2024 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://immi.homeaffairs.gov.au/settling-in-australia/humanitarian-settlement-program/about-the-program/humanitarian-settlement-regional-australia\u003c/span\u003e\u003cspan address=\"https://immi.homeaffairs.gov.au/settling-in-australia/humanitarian-settlement-program/about-the-program/humanitarian-settlement-regional-australia\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Helicobacter pylori, Ezidi refugees, vitamin B12 and D, iron","lastPublishedDoi":"10.21203/rs.3.rs-5469028/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5469028/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn Australia, Middle Eastern refugees, notably the Ezidi community (an ethnic and religious minority from Northern Iraq and Syria) are disproportionately affected by high rates of vitamin and iron deficiencies. These deficiencies pose significant health risks and can impact overall well-being. Recent studies have suggested a possible correlation between Helicobacter pylori \u003cem\u003e(H. pylori)\u003c/em\u003e infection and deficiencies in essential vitamins and iron, highlighting an important area of research that warrants further exploration.\u003c/p\u003e \u003cp\u003eFor several reasons, understanding the relationship between H. pylori infection and nutrient deficiencies in newly arrived Ezidi refugees is critical. First, it may provide insights into the underlying health challenges this population faces, who often arrive with pre-existing health issues. Second, establishing this association could inform current screening practices, allowing for targeted interventions that address both \u003cem\u003eH. pylori\u003c/em\u003e infection and nutritional deficiencies. Ultimately, this research aims to contribute to the development of effective health strategies that enhance the well-being of Ezidi refugees, ensuring they receive the necessary support to thrive in their new environment. By focusing on this intersection of infectious disease and nutritional health, we can better understand and mitigate the risks this vulnerable group faces.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e: A retrospective cohort study was performed using data collected from Ezidi refugees in Armidale Medical Centre and Armidale Hospital from 2018 to 2024. The data was analysed to determine the prevalence of \u003cem\u003eH. pylori\u003c/em\u003e and deficiencies in iron, vitamin B12, and vitamin D. Further analysis was done with data from Armidale Medical Center only, to study any potential association between \u003cem\u003eH. pylori\u003c/em\u003e infection and those same micronutrient deficiencies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: \u003cem\u003eH. pylori\u003c/em\u003e infection was detected in 76.7% of refugees tested. The rates of iron deficiency were 35.2% at Armidale Medical Centre and 41.9% at Armidale Hospital. Vitamin B12 deficiency was found in 50.7% and 58% of individuals, and vitamin D deficiency was present in 79.6% and 82.6%, respectively. No statistically significant associations were found between \u003cem\u003eH. pylori\u003c/em\u003e infection and iron or vitamin D deficiency. However, a statistically significant association was observed between the absence of \u003cem\u003eH. pylori\u003c/em\u003e and vitamin B12 deficiency.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: This is a significantly higher prevalence of \u003cem\u003eH. pylori\u003c/em\u003e infection, iron deficiency, vitamin B12 deficiency, and vitamin D deficiency among Ezidi refugees in Armidale. The relationship between \u003cem\u003eH. pylori\u003c/em\u003e infection and micronutrient deficiencies remains unclear. Further research is needed to clarify these associations and guide future screening protocols for Ezidi refugees.\u003c/p\u003e","manuscriptTitle":"Prevalence of Helicobacter Pylori infection, Vitamin B12, Vitamin D, and iron deficiency, and possible association of H pylori infection as a potential cause among Ezidi Refugees in rural Armidale: Findings from a Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-02 17:49:35","doi":"10.21203/rs.3.rs-5469028/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-12T19:05:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-04T05:11:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324914177092710659192553938654127570321","date":"2025-01-14T04:50:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329881148158378047988375003138073565922","date":"2025-01-13T19:46:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-08T05:44:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301550246798253533111360674946438140044","date":"2025-01-07T05:13:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-23T16:08:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-19T12:54:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-19T12:54:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Immigrant and Minority Health","date":"2024-11-17T08:50:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2dbd4636-dbc7-4831-a67d-9673beb94dd2","owner":[],"postedDate":"December 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:12:55+00:00","versionOfRecord":{"articleIdentity":"rs-5469028","link":"https://doi.org/10.1007/s10903-025-01715-9","journal":{"identity":"journal-of-immigrant-and-minority-health","isVorOnly":false,"title":"Journal of Immigrant and Minority Health"},"publishedOn":"2025-07-01 15:58:27","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2024-12-02 17:49:35","video":"","vorDoi":"10.1007/s10903-025-01715-9","vorDoiUrl":"https://doi.org/10.1007/s10903-025-01715-9","workflowStages":[]},"version":"v1","identity":"rs-5469028","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5469028","identity":"rs-5469028","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}