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Background  The cytotoxin-associated gene A ( cagA ) is one of the most important virulence factors of  Helicobacter pylori  ( H. pylori ). There is a highly polymorphic Glu-Pro-Ile-Tyr-Ala (EPIYA) repeat region in the C-terminal of CagA protein. This repeat region is thought to play an important role in the pathogenesis of gastrointestinal diseases. The aim of this study was to investigate the diversity of  cagA  3′ variable region and the amino acid polymorphisms in the EPIYA segments of the CagA C-terminal region of  H. pylori , and their association with gastroduodenal diseases.    Methods  A total of 515  H. pylori  strains from patients in 14 different geographical regions of China were collected. The genomic DNA from each strain was extracted and the  cagA  3′ variable region was amplified by polymerase chain reaction (PCR). The PCR products were sequenced and analyzed using MEGA 7.0 software.    Results  A total of 503 (97.7%)  H. pylori  strains were  cagA -positive and 1,587 EPIYA motifs were identified, including 12 types of EPIYA or EPIYA-like sequences. In addition to the four reported major segments, several rare segments (e.g., B′, B″ and D′) were defined and 20 different sequence types (e.g., ABD, ABC) were found in our study. A total of 481 (95.6%) strains carried the East Asian type CagA, and the ABD subtypes were most prevalent (82.1%). Only 22 strains carried the Western type CagA, which included AC, ABC, ABCC and ABCCCC subtypes. The CagA-ABD subtype had statistical difference in different geographical regions (P = 0.006). There were seven amino acid polymorphisms in the sequences surrounding the EPIYA motifs, among which amino acids 893 and 894 had a statistical difference with gastric cancer (P = 0.004).    Conclusions  In this study, 503 CagA sequences were studied and analyzed in depth. In Chinese population, most  H. pylori  strains were of the CagA-ABD subtype and its presence was associated with gastroduodenal diseases. Amino acid polymorphisms at residues 893 and 894 flanking the EPIYA motifs had a statistically significant association with gastric cancer.

Diversity of 3′ variable region of cagA gene in Helicobacter pylori strains isolated from Chinese population