| Summary: | Background: The prevalence of gastric cancer in Mongolia, in East Asia, remains the highest in the world. However, most <i>Helicobacter pylori</i> strains in Mongolia have a less virulent Western-type CagA. We aimed to determine how <i>H. pylori</i> genomic variation affected gastric diseases, especially gastric cancer, based on comprehensive genome analysis. Methods: We identified a set of 274 virulence-associated genes in <i>H. pylori</i>, including virulence factor and outer membrane protein (OMP) genes, the type four secretion system gene cluster, and 13 well-known virulence gene genotypes in 223 <i>H. pylori</i> strains and their associations with gastric cancer and other gastric diseases. We conducted a genome-wide association study on 158 <i>H. pylori</i> strains (15 gastric cancer and 143 non-gastric cancer strains). Results: Out of 274 genes, we found 13 genes were variable depending on disease outcome, especially iron regulating OMP genes. <i>H. pylori</i> strains from Mongolia were divided into two main subgroups: subgroup (Sg1) with high risk and Sg2 with low risk for gastric cancer. The general characteristics of Sg1 strains are that they possess more virulence genotype genes. We found nine non-synonymous single nucleotide polymorphisms in seven genes that are linked with gastric cancer strains. Conclusions: Highly virulent <i>H. pylori</i> strains may adapt through host-influenced genomic variations, potentially impacting gastric carcinogenesis.
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