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The clinical associations and correlations with other virulence factors such as  cag  pathogenicity island (PAI) of the Integrating Conjugative Elements  Helicobacter pylori  TFSS (ICE Hptfs ), a new type IV secretion system (TFSS) in  H. pylori  has not been described. Among 103 studied strains from Indonesia, almost all strains (99.0%) contained  cag  PAI with more than half (55.8%) were intact  cag  PAI. Patients infected with intact  cag  PAI strains showed significantly higher antral activity, inflammation and atrophy as well as corporal inflammation than those with non-intact  cag  PAI strains, confirming the virulence of  cag  PAI. Over half of strains (53.8%) contained ICE Hptfs , predominantly consisted of ICE Hptfs3 - tfs4a  (42.8%) and ICE Hptfs3  (16.3%). Although patients infected with ICE Hptfs -positive strains had lower  H. pylori  density, those with the complete ICE Hptfs4b  strains tended to have higher antral activity than the negative one. In combination, patients infected with combination of intact  cag  PAI-ICE Hptfs -positive strains had more severe inflammation than those with non-intact  cag  PAI-ICE Hptfs -negative, suggesting a possibility of a mutual correlation between these TFSS(s).

Distribution and clinical associations of integrating conjugative elements and cag pathogenicity islands of Helicobacter pylori in Indonesia