Volume 167 Issue 6

Reported general practitioner vaccination procedures, 1994 and 1996 Ana Herceg, Monica B Johns and Helen M Longbottom For editorial comment, see Kable & Harris Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - - ©MJA1997 Abstract Objective: To determine general practitioner (GP) vaccination procedures during the first two years of implementation of the National Childhood Immunisation Program. Design: Two cross-sectional self-completion mail surveys of Australian GPs, in October/November 1994 (Survey 1) and April/May 1996 (Survey 2). Participants: 1417 systematically selected (Survey 1) and 1482 randomly selected (Survey 2) GPs. Intervention: Mailing of a package of publications on immunisation to all GPs, a community education campaign, and the introduction of the Australian Childhood Immunisation Register. State and Territory and local initiatives on immunisation, changes in vaccine distribution and funding, and media coverage of vaccination issues may also have affected GPs' procedures. Main outcome measures: Reported vaccination procedures consistent with National Health and Medical Research Council (NHMRC) recommendations. Results: Response rates were 77% (Survey 1) and 78% (Survey 2). There were statistically significant rises in the proportions of GPs who reported vaccination procedures consistent with NHMRC recommendations for simultaneous administration of vaccines, injection site, vaccination of children taking antibiotics or those with mild upper respiratory tract infection, and vaccine storage. There was a reduction in reported opportunistic vaccination, and no change in reported procedures regarding pertussis vaccination. Conclusions: Many factors may have contributed to these changes in GP vaccination procedures. While the changes mostly show an improvement in adherence to NHMRC guidelines, further progress needs to be made, particularly in the areas of opportunistic vaccination, pertussis vaccination and vaccine storage. The best method of informing GPs of current vaccination recommendations needs to be explored. MJA 1997; 167: 299-302 Introduction Vaccine-preventable diseases of childhood continue to occur in Australia, with large outbreaks of measles, pertussis and rubella occurring in 1993 and 1994.1 Vaccination coverage rates in Australia are still not high enough to prevent these outbreaks, with reported coverage varying from 60% for pertussis to 92% for measles.2 More than 60% of childhood vaccinations in Australia are given by general practitioners (GPs),2 and vaccination guidelines are published by the National Health and Medical Research Council (NHMRC) in The Australian immunisation handbook, which is updated regularly.3-5 Studies in the United States have shown that health care systems and immunisation provider services contain major barriers to childhood vaccination, including inaccessibility, insufficient staff, insufficient clinic hours, missed opportunities to vaccinate (i.e., not vaccinating children who present for another reason and are due or overdue for vaccination), and misconceptions about true and false contraindications to vaccination.6 The existence or otherwise of these barriers to childhood vaccination in Australian health care has not been well researched, but one study showed that many immunisation providers in Victoria were unaware of the NHMRC recommendations for diphtheria-tetanus-pertussis (DTP) vaccine and combined diphtheria-tetanus (CDT) vaccine.7 Other studies found that GPs frequently do not follow the NHMRC recommendations for site of injection of vaccines and vaccine storage.8,9 The National Childhood Immunisation Program was devised to address the problem of low vaccination cover - age through a coordinated national approach. The Program, which commenced in July 1994, involved Commonwealth, State and Territory health authorities, as well as professional and consumer bodies. Aspects of the Program included improving surveillance and reporting for vaccine-preventable diseases and vaccination coverage; improving vaccine purchasing, distribution and delivery; and educating parents, the general public and vaccination providers about vaccination. We conducted two national surveys of GPs to estimate changes in vaccination procedures during the first two years of the National Childhood Immunisation Program. Methods Sample selection and survey method Providers were systematically (Survey 1) and randomly (Survey 2) selected from GPs registered with the Health Insurance Commission who had lodged more than 50 services in the preceding quarter. A 10% sample was selected from each group, comprising 1843 GPs in Survey 1 and 1888 GPs in Survey 2. The sample for Survey 1 was created by selecting every tenth GP on the list; a modified classic synchronised sampling method was used for random selection for Survey 2.10 Both surveys were anonymous self-completion mail surveys. For each survey, an initial questionnaire and covering letter was sent to each GP, followed a week later by a reminder letter and a duplicate questionnaire. Practitioners were asked to ignore the reminder if they had already completed the questionnaire, and to return only one blank questionnaire if they did not wish to participate in the survey. The two surveys contained identical questions about GPs and their practices, vaccine storage methods and vaccination procedures. Questions on vaccination procedures and vaccine refrigeration were based on the NHMRC recommendations in the fifth edition of The Australian immunisation procedures handbook (1994). No identifying information was collected. Interventions Survey 1 was conducted in October/November 1994, one month before the National Childhood Immunisation Program sent a package of publications to all vaccination providers, including all GPs. The package included The Australian immunisation procedures handbook (fifth edition) and other publications on vaccine provision and storage. Survey 2 was conducted in April/May 1996, after the National Childhood Immunisation Program had been in place for almost two years. Activities of the Program during that time included distribution of the publications mentioned above (November 1994), a community education campaign (April to November 1995), and the introduction of the Australian Childhood Immunisation Register (January 1996). During the period between the two surveys, other activities which may have affected GP immunisation practices included State and Territory initiatives to inform immunisation providers about vaccination procedures, changes in vaccine distribution and funding systems, the development of school-entry vaccination record requirements in some jurisdictions, media coverage, and local promotion of vaccination issues through Divisions of General Practice and other agencies. Statistical analysis Data entry and analysis were done with Epi Info version 6. 11 The chi-squared test for independence in 2 x 2 tables was used to compare the results of the two surveys. Analyses were based on the number of respondents who completed each question rather than the total number of respondents. Results Response rates After exclusion of respondents who indicated they did not provide childhood vaccinations, response rates were 77% for Survey 1 and 78% for Survey 2. Ninety-eight per cent of respondents worked in general practice. The two samples did not differ significantly in type of practice or age groups, but, for number of vaccines given per week, significantly more respondents in Survey 2 gave between one and nine (Box 1, below). Vaccine administration procedures Reported vaccine administration procedures consistent with the NHMRC recommendations are compared in Box 2. The proportion of practitioners who would always opportunistically vaccinate fell from 32% to 28%, although an additional 47% of GPs in 1996 said they would frequently vaccinate children opportunistically. Simultaneous administration of DTP, oral polio vaccine and Haemophilus influenzae type b (Hib) vaccine increased from 49% to 68%. Recording of vaccine batch number and use of recommended injection sites also increased. There were statistically significant rises from 1994 to 1996 in reported willingness of GPs to vaccinate children with mild upper respiratory tract infections or who were taking antibiotics (Box 3), and there was a fall from 94% to 90% in the proportion of GPs who would not vaccinate a febrile child. There was no change between the two surveys regarding when CDT should be used to replace DTP, or vaccination for a child taking inhaled or topical steroids. Reported storage of vaccines according to NHMRC recommendations improved between the two surveys, including use of a maximum/minimum thermometer, storing vaccines only on the top and middle shelves of the refrigerator and not storing food or specimens in the same refrigerator (Box 4). Although reported daily checking of the vaccine refrigerator temperature increased, in 1996 only 27% of GPs reported that this was done. A further 30% reported that the refrigerator temperature was checked weekly. In November 1994, 15% of respondents reported their practices had immunisation recall/reminder systems functioning. In April 1996, 78% of GPs reported always contributing to the Australian Childhood Immunisation Register. Discussion Our study has a number of limitations, including the sampling methods, the number of non-respondents and the fact that it was based on self-reported behaviour. While the sampling methods for the two surveys were not identical, the two groups were demographically comparable, and we believe both samples are representative of the GP population. It is estimated that around 170 GPs would have received both surveys; however, as the surveys were conducted anonymously we have no record of this overlap. Thus, it is possible that a small proportion of the reported change in behaviour was because of this previously surveyed group who would have been more aware of the issues. Finally, self-reported behaviour does not necessarily correlate with actual behaviour. Hence, these surveys probably provide a conservative estimate of behaviour contrary to NHMRC guidelines. Our study showed a significant improvement in several reported GP vaccination procedures between 1994 and 1996. The reasons for these changes are probably multiple, and include the information provided through the National Childhood Immunisation Program, State and Territory immunisation provider information and other professional education sources, as well as community and media interest in the topic. The degree to which each of these sources may have influenced the change cannot be assessed from our study. However, the coordination and information dissemination role of the National Childhood Immunisation Program meant that the information conveyed from health authorities and professional organisations to GPs between the two surveys was consistently based on NHMRC recommendations. Our results indicate, however, that more progress needs to be made in some areas. Opportunistic vaccination, including in hospital emergency departments, has frequently been identified as a way of improving immunisation coverage.12 In 1996, many GPs potentially missed opportunities to vaccinate by infrequently or never checking children's immunisation status when they presented for another reason. The high use of the parent-held Personal Health Record identified in our survey was also found by Bailey et al.13 Recording of batch number on the Record and/or in practice records improved between the two surveys; this is recommended by the NHMRC to ensure that children potentially at risk of illness can be found if a faulty batch of vaccine is identified. Misconceptions about true and false contraindications to vaccination have previously been recognised as barriers to full vaccination; this especially applies to when it is appropriate to replace DTP with CDT.6,7 The NHMRC guidelines have previously not been clear about pertussis vaccination, and this is likely to have contributed to the confusion. Most GPs in our study would replace DTP with CDT if a child had a febrile convulsion or persistent screaming after the last dose of DTP. These are situations which were previously classed by the NHMRC as contraindications to DTP and which, in the 1994 recommendations, "may preclude" another dose of DTP. The 1997 sixth edition of The Australian immunisation handbook provides new, clear guidelines on pertussis vaccination.5 GPs need to be aware of these changes; following the new recommendations should increase pertussis vaccination rates and prevent more disease. Vaccine storage procedures have been previously shown in New South Wales to be inadequate in many immunisation provider practices.9,14 Although there were improvements between our two surveys, in 1996 only 27% of practices checked and recorded the refrigerator temperature daily. Correct vaccine storage is essential to maintain vaccine potency. Our study looked only at private vaccination providers. We currently have no information about immunisation procedures of public providers, who administer around 40% of vaccines, and further studies are needed to assess procedures in this sector. While many GPs have kept abreast of changing recommendations, further improvements are possible. In addition, because of the impending availability of new vaccines and combinations of vaccines, further changes to the vaccination schedule and recommendations are likely in the coming years. Our study has not identified the best way to inform GPs of changes in recommendations, and this must be determined. The 78% participation rate of GPs in the Australian Childhood Immunisation Register five months after its commencement shows that good communication channels with GPs are available. Further improvements in vaccination provider practices will result in more children receiving the correct, efficacious vaccines safely and on time. References Herceg A, Oliver G, Myint H, Andrews G, et al. Annual report of the National Notifiable Diseases Surveillance System, 1995. Commun Dis Intell 1996; 21: 440-464. Australian Bureau of Statistics. Children's immunisation, Australia. Canberra: ABS, April 1995. (Catalogue No. 4352.0.) National Health and Medical Research Council. Immunisation procedures. 4th ed. Canberra: AGPS, 1991. National Health and Medical Research Council. The Australian immunisation procedures handbook. 5th ed. Canberra: AGPS, 1994. National Health and Medical Research Council. The Australian immunisation handbook. 6th ed. Canberra: AGPS, 1997. Cutts FT, Orenstein WA, Bernier RH. Causes of low preschool immunisation coverage in the United States. Annu Rev Publ Health 1992; 13: 385-398. McIntyre CR, Nolan T. Attitudes of Victorian vaccine providers to pertussis vaccine. Med J Aust 1994; 161: 295-299. Rixon G, March L, Holt DA. Immunisation practices of general practitioners in metropolitan Sydney. Aust J Public Health 1994; 18: 258-260. Liddle JLM, Harris MF. How general practitioners store vaccines. A survey in south-western Sydney. Med J Aust 1995; 162: 366-368. Calcino G. Sampling from the HIC data set. Proceedings of the General Practice Evaluation Program 1993 work-in-progress conference, Canberra; 20-22 May 1993. Canberra: Department of Health, Housing, Local Government and Community Services, 1993. Dean AG, Dean JA, Couombier D, Brendel KA, et al. Epi Info, Version 6: a word processing, database, and statistics program for epidemiology on microcomputers. Atlanta, Ga: Centers for Disease Control and Prevention, 1994. Jones K, Fasher B, Hanson R, Burgess M, et al. Immunization status of casualty attenders: risk factors for non-compliance and attitudes to "on the spot" immunization. J Paediatr Child Health 1992; 28: 451-454. Bailey FK, Nossar V, Jeffs DA, et al. An evaluation of the NSW Personal Health Record. Sydney: NSW Health, 1992. Miles T. The integrity of the vaccine cold chain in the Hunter area of New South Wales. Aust J Public Health 1993; 17: 169-171. (Received 19 Sep 1996; accepted 21 Jul 1997) Authors' details National Centre for Disease Control, Department of Health and Family Services, ACT. Ana Herceg, MPH, MAppEpid, Medical Epidemiologist, Surveillance and Management Section. Monica B Johns, BAppSc; formerly, Senior Project Officer, National Childhood Immunisation Program. Helen M Longbottom, MPH, FAFPHM; formerly, Director, Surveillance and Epidemiology Section. Reprints will not be available from the authors. Correspondence: Ana Herceg, Surveillance and Management Section, National Centre for Disease Control, MDP 6, Department of Health and Family Services, GPO Box 9848, ACT 2601. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Ana Herceg · Monica B Johns · Helen M Longbottom

Helicobacter pylori infection in an Australian regional city: prevalence and risk factors Hedley G Peach, Dora C Pearce and Stephen J Farish Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objective: To investigate the prevalence of Helicobacter pylori infection and potential risk factors for infection in an adult Australian population. Design: Cross-sectional study. Setting: Ballarat, a major regional city in Victoria (population, 78 000; 92% born in Australia), November 1994 to July 1995. Participants: 217 adults randomly selected from the electoral roll. Main outcome measures: H. pylori IgG antibody status by enzyme immunoassay; amount of dental plaque; sociodemographic and other potential risk factors; odds ratios for risk factors determined by logistic regression analysis. Results: Age-standardised prevalence of H. pylori infection was 30.6%. After adjustment for age, sex and socioeconomic index, positive H. pylori status was significantly associated with increasing number of tooth surfaces with a high plaque score (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.7), increasing number of years in a job with public contact (OR, 1.7; 95% CI, 1.3-2.3), blood group B antigen (OR, 3.1; 95% CI, 1.1-9.1), and having lived in a household with more than six members during childhood (OR, 2.5; 95% CI, 1.1-5.5). Negative H. pylori status was significantly associated with increasing education, having ever lived on a farm, and having teeth scaled less than once a year. Conclusions: H. pylori infection is common. Dental plaque may be a reservoir for H. pylori, which is probably transmitted by person-to-person contact, and blood group B antigen may predispose to infection. Community education about effective oral hygiene and adoption of good hygiene practices by those with regular public contact may be important to prevent acquisition and transmission of H. pylori . MJA 1997; 167: 310-313 Introduction The presence of Helicobacter pylori in humans is now recognised as a chronic infection which in most cases persists indefinitely and is involved in the development of several serious diseases, including peptic ulcer, gastric cancer, and possibly cardiovascular disease.1 It is uncertain from where and how H. pylori is acquired, but most investigators seem to favour person-to-person transmission.1 In developed countries, including Australia, the prevalence of H. pylori infection increases with age at the rate of about 1% per annum, to reach 40% or more at age 60 years.2 In contrast, in developing countries prevalence is 40% or more at age 10 years.2 Seroconversion in childhood also seems more likely in particular populations in developed countries; it was found to occur among people of lower socioeconomic background in Northern Ireland3 and England 4 and in a rural town in Western Australia.5 Suspected childhood risk factors for H. pylori infection in developed countries include having a single parent, lower parental social class, greater housing density or proportion of rented housing in school catchment area, overcrowding, bed-sharing, and absence of a fixed hot water supply.6 In adults, previously investigated risk factors include race-ethnicity, socioeconomic status, education, dental prosthesis and irregular dental treatment, public contact, working with animals, smoking status, alcohol consumption, homosexuality, sexually transmitted diseases, and having an infected child or partner.1,2,7-10 To assess the importance of these and other risk factors for H. pylori infection in Australia, we investigated the H. pylori status and risk factors of a sample of adults in Ballarat, a regional city in Victoria. Methods Setting and population Ballarat is a major regional city in Victoria (population, 78 000; with 92% of residents born in Australia according to the 1991 census).11 The study population was drawn from the population sample used in a 1992 survey of cardiovascular disease risk factors. This survey used the procedures of the National Heart Foundation for its surveys of Australian capital cities.12 A sample of 501 adults randomly selected from the electoral roll was invited to attend a screening clinic; 338 (68%) attended and gave informed consent. Between November 1994 and July 1995, 217 of the 262 participants who were still contactable (83%) participated in our study of risk factors for H. pylori infection, after again giving informed consent. The study was approved by the Ballarat Base Hospital Ethics Committee. Investigations Plasma samples were tested for H. pylori IgG antibodies with the Pyloriset EIA-G Kit (Pyloriset, Orion Corporation, Orion Diagnostica, Espoo, Finland). This kit uses one of the two original Marshall and Warren strains of H. pylori13 for antigen preparation. A cut-off antibody titre of 500 was used to classify subjects as positive or negative, as recommended by the manufacturer (sensitivity, 92.5%; specificity, 84.3%).14 Dental plaque was also assessed for the 156 dentate subjects. The mouth was rinsed with water before and after fluorescein application, and plaque score was recorded on a modified Dental Health Services of Victoria treatment chart.15 Research personnel were blind to the H. pylori status of each subject. A high plaque score (≥2) was defined as a clear line of plaque along the gingival margin or a larger coverage of the tooth surface with plaque.15 After examination, the subject was given toothpaste and a toothbrush to remove residual fluorescein. A questionnaire on socio demographic and potential risk factors was administered by one of three trained research personnel. Job title and duties were used to classify jobs held over a subject's lifetime, without knowledge of his or her H. pylori status, as mainly involving contact with the general public or otherwise. Subjects identified the 1991 Census Collector's District in which they lived from a map of Ballarat; this was classified according to socioeconomic index.16 Blood group was determined if unknown. Statistical analyses The sample-based estimate of the prevalence of H. pylori infection was standardised to the age distribution of Ballarat's population.12 This accounted for any imbalances between respondents and the general population caused by under-representation of younger or more mobile residents in the electoral rolls or differential response rate by age. Odds ratios (ORs) and 95% confidence intervals (CIs) for suspected risk factors for H. pylori infection were produced by logistic regression analyses. Collinearity was first assessed through a series of multiple linear regression analyses, using each predictor variable in turn as the dependent variable and all others as independent variables. Dependent variables with an R2 greater than 0.95 were excluded. All remaining variables were entered into the logistic regression model, and then excluded manually in a stepwise manner if they were not significantly associated with H. pylori status and had an OR in the range 0.95-1.05. Edentate subjects were assigned the mean plaque score of subjects with teeth, as recommended by Thompson.17 This avoided having to analyse edentate and dentate subjects separately, with the inevitable loss in precision when estimating risk associated with other variables. The effect of response to the study on ORs was assessed by the method of Criqui.18 The associations found using H. pylori status as a dichotomous variable, based on a cut-off antibody titre of 500, were confirmed using H. pylori antibody titres (logarithmically transformed) as a continuous variable in a multiple linear regression model. Results The prevalence of H. pylori infection in Ballarat was estimated as 30.6% after standardising to the age distribution of the city's population. The proportion of subjects who were H. pylori-negative in the H. pylori study (66.8%) was similar to that in the original cardiovascular study (69.6%). H. pylori-positive subjects in the H. pylori study had similar age, sex distribution, education and median antibody titres to those in the original cardiovascular study. H. pylori-negative subjects in the two populations were also similar for these variables. Therefore, the ORs for suspected risk factors were unlikely to be affected by the response rate.18 The association between positive H. pylori antibody status and possible risk factors in the final logistic regression model is shown in the Box. In the final model, which adjusted for age, sex and socioeconomic index of residence, the following were significantly associated with positive H. pylori status: increasing number of buccal and lingual tooth surfaces with a plaque score ≥2 (adjusting for the absence of natural teeth and number of teeth), increasing years in a job with public contact, presence of blood group B antigen, and having lived in a household of six or more people during the first 16 years of life. Washing of hands only sometimes or rarely after using the toilet and visiting a dentist less than once a year had a large but not statistically significant association with positive H. pylori status. Negative H. pylori status was significantly associated with increasing education, having ever lived on a farm, and having teeth scaled less than once a year. Univariate analysis showed that dentate subjects who visited a dentist at least annually had a significantly lower prevalence of H. pylori infection if they had their teeth scaled less than once a year (three out of 25) compared with more often (20 out of 56) (chi-squared = 4.78; P = 0.03; 1 degree of freedom). In addition, among those who had their teeth scaled less than once a year, visiting a dentist at least annually was protective (three infected out of 25) compared with visiting a dentist less often (27 infected out of 78) (chi-squared = 4.69; P = 0.03; 1 degree of freedom). The following variables were initially included in the logistic regression model, but excluded from the final model because of lack of a significant association with H. pylori status: dentures, history of gum infections, frequency of sharing toothbrush or cup, travel to high prevalence countries, smoking status, lifetime alcohol consumption, vegetarian diet, eating unwashed home-grown vegetables, washing hands before eating, years with occupational or recreational contact with animals, having visited farms, marital status, height, weight, and variation between interviewer/oral health observers. The results of multiple regression analysis confirmed those of the logistic regression analysis for all variables except increasing education, which was negatively, but not significantly, associated with H. pylori titre. Discussion To our knowledge, this is the first time in Australia that the prevalence of H. pylori infection has been determined in a random sample of the adult population. Our crude age-specific prevalences were among the lowest of such figures published for European countries and white Americans.19 Nevertheless, the considerable proportions of gastroduodenal ulcers, peptic ulcer bleeds and gastric cancers attributable to H. pylori make an infection rate of 30.6% an important public health issue.20 The cost-benefit ratio for eradicating H. pylori infection with antibiotics in asymptomatic adults will not be known for some time.20 It is therefore important to identify factors associated with the acquisition and transmission of H. pylori. This is the first time that Public contact through employment; Moderate or heavy accumulation of dental plaque; Frequent scaling of teeth; Only rarely or sometimes washing hands after using the toilet; and Having blood group B antigen have been found to be positively associated with H. pylori infection. Further, it is the first time that having lived on a farm, as a third of our sample had done, has been identified to be protective against H. pylori infection. We confirmed that living in an overcrowded household during childhood and visiting a dentist less than once a year are positively associated with H. pylori infection in Australia, although the latter association was not significant. The association between H. pylori infection and public contact through employment was not surprising, as overcrowding in childhood has led to speculation that close personal contact may promote transmission of the organism.7 The protective effect of having lived on a farm in our study may be a consequence of low population density in rural areas. Rural China has a significantly lower prevalence of H. pylori infection, despite poorer standards of hygiene, compared with urban China.2,21 There is other evidence to corroborate our finding that moderate or heavy accumulation of dental plaque is significantly associated with H. pylori infection. H. pylori has been cultured from dental plaque, and identical H. pylori ribotypes were found in the mouth and gastric antrum of ulcer patients.22,23 Moreover, H. pylori has been detected by reverse transcription polymerase chain reaction in only moderate to heavy accumulations of plaque.22 Our finding that visiting the dentist less than once a year increased the risk of H. pylori infection is consistent with the protective effect of regular dental treatment found by Gasbarrini et al.10 If H. pylori inhabits plaque, scaling may lead to ingestion of the organism and inoculation of the stomach. A decreased risk of H. pylori infection from having teeth scaled less than once a year is therefore plausible. In agreement with other studies, we found no significant association between H. pylori infection and alcohol consumption. We also found no significant association with smoking, although 52% of our sample were current or ex-smokers. Others have found significantly more smokers among patients with no abnormalities on endoscopy who had H. pylori infection,8 and the difference could be caused by confounding by oral hygiene. Smokers have poor oral hygiene and visit their dentist and brush their teeth less often than non-smokers.24 Further, in our study, dentate subjects who had ever smoked had a significantly larger mean number of tooth surfaces with a high plaque score than non-smokers, after adjusting for number of teeth (P = 0.02). Although the risk of H. pylori infection was increased for people who washed their hands only sometimes or never after using the toilet, because of the small number of these subjects the odds ratio had a wide confidence interval and the association was not significant. Faecal-oral spread of the organism is known to occur, but our data imply that it is relatively uncommon between adults, as others have suggested.1 Nevertheless, this result underlines the importance of good hygiene practices and the provision of handwashing facilities both indoors and out-of-doors. Eating from communal bowls has been postulated as a mechanism of H. pylori transmission in China.21 Our study found that sharing of cups and cooking utensils was not common in Ballarat and not a risk factor. Genetic effects have been found to influence the acquisition of H. pylori.1 However, the importance of the association we found between the presence of blood group B antigen and H. pylori infection must await further research into the mechanisms of genetic susceptibility to H. pylori infection. Our results imply that good hygiene practices are essential for those in frequent contact with the public to prevent H. pylori transmission. As moderate to heavy dental plaque emerged as a clear risk factor, reducing plaque may have an important role in preventing acquisition of H. pylori. This is another reason for educating the public, adults and children about effective tooth-brushing and other oral hygiene techniques. Regular dental treatment may need to be encouraged, while avoiding the ingestion of plaque debris which could occur during tooth scaling. In view of these potentially important public health implications, confirmatory evidence of our results should be sought. Acknowledgements We thank Mrs Wendy Ross and Mrs Cheryl Potter for assistance with the interviews and oral examinations, Dr John Williams for advice on the examinations, Mr Christopher Pearce (Dorevitch Pathology, Ballarat Base Hospital) for technical assistance, State Data Centre, Ballarat, for mapping the Census Collector's Districts, Colgate for toothbrushes and toothpaste, and Chiron Diagnostics for serological advice. The study was funded by the Shepherd Foundation, Melbourne, VIC. References Hunt RH. Helicobacter pylori : from theory to practice. Am J Med 1996; 100: 1S-64S. Taylor DN, Blaser MJ. The epidemiology of Helicobacter pylori infection. Epidemiol Rev 1991; 13: 42-59. McCallion WA, Ardill JES, Bamford KB, et al. Age dependent hypergastrinaemia in children with Helicobacter pylori gastritis -- evidence of early acquisition of infection. Gut 1995; 37: 35-38. Banatvala N, Mayo K, Megraud F, et al. The cohort effect and Helicobacter pylori . J Infect Dis 1993; 168: 219-221. Cullen DJE, Collins BJ, Christiansen KJ, et al. When is Helicobacter pylori infection acquired? Gut 1993; 34: 1681-1682. Patel P, Mendall MA, Khulusi S, et al. Helicobacter pylori infection in childhood: risk factors and effect on growth. BMJ 1994; 309: 1119-1123. Whitaker CJ, Dubiel AJ, Galpin OP. Social and geographical risk factors in Helicobacter pylori infection. Epidemiol Infect 1993; 111: 63-70. Bateson MC. Cigarette smoking and Helicobacter pylori infection. Postgrad Med J 1993; 69: 41-44. Aceti A, Attanasio R, Pennica A, et al. Campylobacter pylori infection in homosexuals. Lancet 1987; 2: 154-155. Gasbarrini G, Pretolani S, Bonvicini F, et al. A population based study of Helicobacter pylori infection in a European country: the San Marino Study. Relations with gastrointestinal diseases. Gut 1995; 36: 838-844. HealthWIZ [computer file]: national social health database. Canberra: Department of Health and Family Services. National Heart Foundation. Risk factor prevalence survey. Canberra: National Heart Foundation, 1989: 133-136. Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet 1984; 1: 1311-1314. Pearce DC, Peach HG, Farish SJ. Helicobacter pylori antibody titres in serum, plasma and successively thawed specimens: implications for epidemiological and clinical studies. J Clin Pathol 1996; 49: 1017-1019. Muhlemann HR. Introduction to oral preventive medicine. Carol Stream, Ill: Quintessance Publishing Company, 1976: 124. Ross R, Farish S, Plunkett M. Indicators of socio-economic disadvantage for Australian schools. Geelong: Deakin Institute for Studies in Education, 1988. Thompson WD. Statistical analysis of case-control studies. Epidemiol Rev 1994; 16: 33-50. Criqui MH. Response bias and risk ratios in epidemiologic studies. Am J Epidemiol 1979; 109: 394-399. Goodman KJ, Correa P. The transmission of Helicobacter pylori . A critical review of the evidence. Int J Epidemiol 1995; 24: 875-887. Axon A, Forman D. Helicobacter gastroduodenitis: a serious infectious disease. BMJ 1997; 314: 1430-1431. Mitchell HM, Li YY, Hu PJ, et al. Epidemiology of Helicobacter pylori in Southern China: identification of early childhood as the critical period for acquisition. J Infect Dis 1992; 166: 149-153. Nguyen A-MH, Engstrand L, Genta RM, et al. Detection of Helicobacter pylori in dental plaque by reverse transcription-polymerase chain reaction. J Clin Microbiol 1993; 31: 783-787. Khandaker K, Palmer KR, Eastwood MA. DNA fingerprints of Helicobacter pylori from mouth and antrum of patients with chronic ulcer dyspepsia. Lancet 1993; 342: 751. Hardo PG, Tugnait A, Hassan F, et al. Helicobacter pylori infection and dental care. Gut 1995; 37: 44-46. (Received 18 Feb, accepted 21 Jul, 1997) Authors' details Department of Public Health and Community Medicine, University of Melbourne, Ballarat Health Services Base Hospital, Ballarat, VIC. Hedley G Peach, PhD, FFPHM, Professor; Dora C Pearce, BAppSc(Biol), Research Fellow. Epidemiology and Biostatistics Unit, Department of Public Health and Community Medicine, University of Melbourne, VIC. Stephen J Farish, MEd, Senior Lecturer. Reprints: Professor H G Peach, Department of Public Health and Community Medicine, University of Melbourne, Ballarat Health Services Base Hospital, PO Box 577, Ballarat, VIC 3353. E-mail: a.temperley AT phcm.unimelb.edu.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Hedley G Peach · Dora C Pearce · Stephen J Farish

Women's satisfaction with medical abortion with RU486 Pam M Mamers, Anna L Lavelle, Amanda J Evans, Sandra M Bell, Jen R Rusden and David L Healy The combination of RU486 (mifepristone) and prostaglandin analogues has been used for medical abortion in several European centres. We surveyed 41 Australian women who successfully used this method of abortion in a World Health Organization-sponsored trial. Overall, the women were satisfied with the method and found the associated pain level acceptable. (MJA 1997; 167: 316-317) For editorial comment, see Henshaw Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Introduction - Clinical record - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Introduction A safe, reliable, non-invasive, but effective, method of fertility control has been sought for many years. The combination of the progesterone antagonist mifepristone (RU486) and prostaglandin E1 analogues has been used in several European countries for medical abortion, and its efficacy has been extensively studied for human fertility control. RU486 has been approved for use in the United Kingdom, Sweden, China and France, and it is estimated that over a million women have received RU486 in these countries since 1988 (Dr P Van Look, Associate Director, Special Program of Research, Development and Research Training, World Health Organization, personal communication). Following approval from the Therapeutic Goods Administration in March 1994, the World Health Organization selected Monash University and Family Planning Victoria to participate in an international multicentre, double-blind, randomised controlled trial to test the efficacy and side effects of two doses of mifepristone (600 mg or 200 mg) followed by 400 mg of misoprostol 48 hours later for the termination of early pregnancy. Ethical approval to conduct the trial was obtained from the ethics committee of Family Planning Victoria. We thought it would be useful to know if the Australian women who participated in this WHO trial considered medical abortion an acceptable primary treatment and if their level of pain was acceptable. For women who had had a previous surgical termination, we were interested in how they felt the methods compared. Clinical record Fifty patients seeking legal abortion were admitted to the study on satisfying the criteria of the WHO protocol, which were: women seeking legal abortion, in good general health, over the age of consent, with a menstrual delay of up 35 days, with uterine size equal to that expected for the estimated duration of pregnancy, having had a positive pregnancy test, and who gave informed consent. Each woman received extensive counselling by the nurse coordinator (P M M) and the investigator (D L H) before entering the trial. Women were advised that further counselling would be available at any time. According to the trial protocol, participants attended the clinic to receive mifepristone and returned after 48 hours to receive misoprostol. Women were offered paracetamol (500 mg) for mild to moderate pain or pethidine (50 mg intramuscularly) for severe pain. Analgesic preparations known to interfere with prostaglandin metabolism, such as salicylates and mefenamic acid, were not dispensed and women were advised not to take these. Patients returned for follow-up two weeks and six weeks after abortion. Five women were withdrawn from the trial because they needed surgical intervention. Four women who had a successful termination of pregnancy failed to attend for assessment at six weeks and were lost to follow-up. Thirty-eight of the remaining 41 women who completed the protocol agreed to complete a self-administered questionnaire to assess their satisfaction with medical abortion. The questionnaire included two visual analogue scales on which: All women were asked to score their degree of satisfaction with the medical abortion (Box 1a); and Women who had previously had a surgical abortion were asked to compare medical abortion with the surgical procedure (Box 1b). Further, the questionnaire included questions about cost, avoidance of anaesthesia, whether the procedure was considered more natural, and whether the pain and discomfort were acceptable. Women were also invited to make personal comments about why they chose a medical abortion and how they rated their experience. Results The demographic variables for the 38 women who completed the questionnaire are shown in Box 2. The mean score for satisfaction with medical termination of pregnancy was 4.5 (range, 1-5). The 15 women who had previously had a surgical abortion found the medical approach more acceptable (mean score, 4.5; range, 3-5). The level of pain and discomfort was regarded as acceptable by 34 participants; 19 women experienced only mild discomfort, while one woman was pain free. Seventeen of these 20 women did not require analgesia. Only one patient required pethidine for severe pelvic cramping. The remaining women who required analgesia were satisfied with paracetamol. Cost was an important factor in the choice for seven of the 38 participants. There were no costs involved for trial patients. As public hospitals in Victoria are able to service only a small number of patients, most women seeking termination must attend private abortion clinics, so that cost becomes a factor in their choice of provider. The wish to avoid anaesthesia was important for 19 women, while 25 regarded medical abortion as more natural. Other factors in women's decisions to choose medical termination included preferring a less clinical atmosphere and finding research staff to be very supportive at a stressful time (nine women), considering a medical termination to be more emotionally acceptable (nine women), and fear of surgical operation (six women). Other factors included more autonomy (expressed as "a need to be in control of the situation") and the desire for a less invasive procedure. One woman stated: "I was much more able to cope with my decision to have a medical termination as I was conscious the whole time and did not feel that my body was invaded." Six women reported that the associated pain and the duration of bleeding was a drawback for medical abortion, but all six rated the procedure as acceptable. Discussion We acknowledge that our sample was biased, as the 38 women who completed questionnaires sought out medical termination of pregnancy. However, in terms of many demographic variables, our participants were similar to a large sample of women who sought surgical terminations in New South Wales surveyed by Adelson et al.1 Over half the women in both groups were single, most were 25 years or under and they were generally well educated. Satisfaction with medical termination of pregnancy among the 38 women was evident. The factors involved in their choice of medical abortion were complex. Overall, medical abortion provided women with a more active role in the process, thus allowing them to achieve a certain degree of autonomy. Most of the women surveyed described the medical approach as more natural, and two women likened the procedure to having a miscarriage. The requirements for a medical abortion differ in many respects from those for a surgical abortion. In particular, partners, friends or family could be present at any time, and patients were not required to fast during the three hours they remained in the clinic after being given misoprostol. Many of the women who participated in the trial commented on the friendly, non-clinical approach, which they considered psychologically beneficial at a time when anxiety levels were increased. Similar psychological benefits of medical abortion have been noted by Henshaw and colleagues.2 Medical abortion as an alterative to surgical abortion has gained acceptance in countries in which it has become available. In a British study of 363 women undergoing first-trimester abortion, 20% of women chose medical abortion, 26% chose the surgical technique, and the remainder agreed to be randomised to either method.3 This finding concurs with earlier studies in France where one-fifth of women chose medical abortion.4 In a Chinese study, women who were likely to accept medical abortion were single, young, nulliparous and employed; these women were reportedly fearful of "trauma to the body" from surgical abortion.5 Significantly, all women who answered the questionnaire in that study said that they would choose medical termination again.5 As Baird6 has suggested, more studies are needed to establish the acceptability of mifepristone (RU486) for termination of pregnancy in different countries and different cultures. A further follow-up study in Australia with a larger sample of women would be useful in this regard. Acknowledgements We thank our patients as well as Family Planning Victoria for their support and recruitment of women for this study. References Adelson PL, Frommer MS, Weisberg E. A survey of women seeking termination of pregnancy in New South Wales. Med J Aust 1995; 163: 419-422. Henshaw RC, Naji SA, Russell IT, Templeton AA. Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration. Acta Obstet Gynecol Scand 1994; 73: 812-818. Henshaw RC, Naji SA, Russel IT, Templeton AA. Comparison of medical abortion with surgical vacuum aspiration: women's preferences and acceptability of treatment. BMJ 1993; 307: 714-717. Bachelot A, Cludy L, Spira A. Conditions for choosing between drug-induced and surgical abortions. Contraception 1992; 45: 547-559. Tang GW, Lau OW. Further acceptability evaluation of RU486 and ONO 802 as abortifacient agents in a Chinese population. Contraception 1993; 48: 267-276. Baird DT. Clinical use of mifepristone (RU486). Ann Med 1993; 25: 65-69. (Received 17 Dec 1996, accepted 27 Jun, 1997) Authors' details Monash University Department of Obstetrics and Gynaecology, Monash Medical Centre, Melbourne, VIC. Pam M Mamers, RN, BA, Clinical Research Nurse; Amanda J Evans, FRACGP, CertFPA, Medical Director Family Planning, and Honorary Senior Lecturer; David L Healy, FRACOG, PhD, Chairman. Family Planning Victoria, Melbourne, VIC. Anna L Lavelle, BSc(Hons), PhD, Executive Director; Sandra M Bell, RN, RM, Research Nurse and Pregnancy Counsellor; Jen R Rusden, RN, Research Nurse and Pregnancy Counsellor. Reprints will not be available from the authors. Correspondence: Ms P M Mamers, Monash University Department of Obstetrics and Gynaecology, Level 5, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Pam M Mamers · Anna L Lavelle · Amanda J Evans · Sandra M Bell · Jen R Rusden · David L Healy