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Knowledge About Causes of Peptic Ulcer Disease -- United States, March-April 1997

An estimated 25 million persons in the United States have had peptic ulcer disease (PUD) during their lifetimes (1). A high proportion (at least 90%) of PUD cases are caused by infection with Helicobacter pylori -- an association first reported in 1983 (2,3). However, in 1995, most (72%) of the general public was unaware of this association (4). To increase awareness among the general public and health-care providers about the relation between H. pylori infection and PUD, CDC, in collaboration with other federal agencies, academic institutions, and partners from private industry, has developed an awareness and education campaign. The campaign is being initiated during October 19-25, 1997, in conjunction with National Infection Control Week. In preparation for the education campaign, during early 1997 a population-based survey was conducted to provide more current estimates of knowledge about the causes of PUD. This report summarizes the survey findings and describes the campaign; the findings indicate that only 27% of the general public is aware of the association between H. pylori infection and PUD.

Questions about the causes of PUD were included as part of the Health Styles Supplemental Survey, which was administered during March-April 1997 (5). Questionnaires were mailed to a representative sample of 3064 U.S. adults aged greater than or equal to 18 years; of these, 2512 (82%) persons completed the questionnaire. Respondents read statements about the causes of PUD and were asked whether they agreed or disagreed with each statement; therefore, respondents could identify more than one cause. To compensate for differential nonresponse rates in various demographic categories, data were weighted to the 1992 distribution of the U.S. population by age, sex, race/ethnicity, income level, and region.

Approximately 60% (95% confidence interval {CI}=58%-62%) of respondents believed that ulcers were caused by too much stress; 17% (95% CI=16%-18%), that eating spicy foods caused ulcers; and 27% (95% CI=25%-29%), that a bacterial infection caused ulcers. The belief that stress was the most likely cause was highest among persons aged 18-24 years (78% {95% CI=65%-81%}) and among persons with annual household incomes of less than $15,000 (65% {95% CI=60%-70%}). Similarly, the belief that spicy food was the most common cause of ulcers was highest among persons aged 18-24 years (33% {95% CI=18%-48%}) and among persons with annual household incomes of less than $15,000 (26% {95% CI=22%-30%}). The proportion of respondents who believed that PUD was caused by an infection increased with increasing age, from 12% (95% CI=2%-22%) among persons aged 18-24 years to 33% (95% CI=30%-36%) among persons aged greater than or equal to 55 years.

Reported by: Porter Novelli, Washington, DC. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: PUD is the primary reported cause of death in approximately 6500 persons in the United States each year (1). The estimated direct costs of patient care and indirect costs caused by work and productivity loss for PUD are $6 billion annually (6). Before 1983, the major causes of PUD were considered to be excess acid, diet, smoking, and stress, and most patients with recurrent PUD were treated with maintenance doses of acid-reducing medications. With the discovery of the association between H. pylori infection and PUD, appropriate antibiotic regimens can now successfully eradicate gastrointestinal infection with this organism and permanently cure ulcers in a high proportion of patients.

In 1994, a National Institutes of Health consensus development conference panel concluded that patients with ulcers caused by H. pylori infection require treatment with antimicrobial agents (7). Therapy consists of a combination of effective antibiotics for 7-14 days; cure rates for established therapies range from approximately 70% to 90%, depending on the specific regimen (8). Five H. pylori treatment regimens have been approved by the Food and Drug Administration.

The development of effective treatment has enabled a new public health approach to PUD, which was previously considered a chronic disease. Further research of this emerging infectious disease is needed, including modes of transmission and factors associated with the development of asymptomatic illness. Even though effective primary prevention strategies remain to be defined, appropriate diagnosis and antibiotic treatment can substantially reduce the burden of PUD. This secondary prevention strategy depends on awareness that PUD is caused by a curable infection.

In 1994 and 1996, national surveys of primary-care physicians and gastroenterologists about knowledge of the association between H. pylori infection and PUD indicated that approximately 90% of these physicians identified H. pylori infection as the primary cause of PUD (9,10). However, primary-care physicians reported treating approximately 50% of patients with first-time ulcer symptoms with antisecretory agents without testing for H. pylori; in comparison, gastroenterologists reported treating approximately 30% of patients with first-time ulcer symptoms with these agents (T. Breuer, Baylor College of Medicine, personal communication, 1996). These findings suggest that further education of the medical community is needed.

The findings of the survey described in this report are consistent with those of the population-based survey in 1995 (4) and confirm limited awareness among the general population about H. pylori infection as a treatable cause of PUD. CDC, in collaboration with partner organizations, has developed a national campaign to increase awareness among and educate the general public and the medical community about the association between H. pylori infection and PUD. This month, public service announcements for television and radio are being released in both English and Spanish. In addition, consumer education brochures and information about treatment strategies are being mailed to health-care providers. These materials also are available from CDC, telephone (888) 698-5237 ({888} MY-ULCER).


  1. Sonnenberg A. Peptic ulcer. In: Everhart JE, ed. Digestive diseases in the United States: epidemiology and impact. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1994:359-408; NIH publication no. 94-1447.

  2. Marshall B, Warren JR. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1983;1:1273-5.

  3. Borody TJ, Brandl S, Andrews P, Jankiewicz E, Ostapowicz N. Helicobacter pylori-negative gastric ulcer. Am J Gastroenterol 1992;87:1403-6.

  4. American Digestive Health Foundation and Opinion Research Corporation. Familiarity with H. pylori among adults with digestive disorders and their views toward diagnostic and treatment options. Bethesda, Maryland: American Digestive Health Foundation and Opinion Research Corporation, 1995.

  5. Maibach E, Maxfield A, Ladin K, Slater M. Translating health psychology into effective health communication: the American Health Styles Audience Segmentation Project. Journal of Health Psychology 1996;1:261-7.

  6. Sonnenberg A, Everhart JE. Health impact of peptic ulcer in the United States. Am J Gastroenterol 1997;92:614-20.

  7. NIH Consensus Conference. Helicobacter pylori in peptic ulcer disease: NIH Consensus Development Panel on Helicobacter pylori in peptic ulcer disease. JAMA 1994;272:65-9.

  8. van der Hulst RW, Keller JJ, Rauws EA, Tytgat GNJ. Treatment of Helicobacter pylori infection in humans: a review of the world literature. Helicobacter 1996;1:6-19.

  9. Fendrick AM, Hirth RA, Chernew ME. Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease. Am J Gastroenterol 1996;91:1544-8.

  10. Breuer T, Malaty HM, Goodman K, Sudhop T, Graham DY. Has the scientific evidence about Helicobacter pylori infection in gastrointestinal diseases reached the practicing physicians in the U.S.? Am J Gastroenterol 1996;91:1905.

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