Volume 172 Issue 3

Research Complementary therapies: have they become accepted in general practice? Marie V Pirotta, Marc M Cohen, Vicki Kotsirilos and Stephen J Farish MJA 2000; 172: 105-109 For related articles see Lewith and Newell Abstract - Methods - Results - Discussion - Acknowledgements - Disclosure - Authors' details - - More articles on complementary medicine Abstract Objectives: To describe Victorian general practitioners' attitudes towards and use of a range of complementary therapies. Design: A self-administered postal survey sent to a random sample of 800 general practitioners (GPs) in Victoria in July 1997. Participants: 488 GPs (response rate, 64%). Main outcome measures: GPs' knowledge; opinions about harmfulness and effectiveness; appropriateness for GPs to practise; perceived patient demand; need for undergraduate education; referral rates to complementary practitioners; and training in and practice of each therapy. Results: Acupuncture, hypnosis and meditation are well accepted by the surveyed GPs, as over 80% have referred patients to practitioners of these therapies and nearly half have considered using them. General practitioners have trained in various therapies -- meditation (34%), acupuncture (23%), vitamin and mineral therapy (23%), hypnosis (20%), herbal medicine (12%), chiropractic (8%), naturopathy (6%), homoeopathy (5%), spiritual healing (5%), osteopathy (4%), aromatherapy (4%), and reflexology (2%). A quarter to a third were interested in training in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. General practitioners appear to underestimate their patients' use of complementary therapies. Conclusions: There is evidence in Australia of widespread acceptance of acupuncture, meditation, hypnosis and chiropractic by GPs and lesser acceptance of the other therapies. These findings generate an urgent need for evidence of these therapies' effectiveness. The past decade has seen a dramatic increase in the reported use of non-orthodox or complementary therapies by the public.1-4 In one year in Australia, almost half of a representative sample had used at least one non-medically prescribed complementary remedy and at least one in five had attended a non-medically trained complementary therapist.1 Further, Australians consume as much non-traditional medicine, vitamin and mineral supplements as prescription drugs.5There is evidence that the increasing public use of complementary medicine is paralleled by acceptance among family doctors. In one region of the United Kingdom in one week, 25% of general practitioners (GPs) referred patients for complementary therapies,6 while in Canada half7 to two-thirds8 of family doctors had at some time referred patients to alternative practitioners; these studies did not explore reasons for such referral. However, patient pressure is an acknowledged factor in medical referrals,9 so willingness of family doctors to refer their patients for these therapies may not be a good measure of their acceptance of them. Interest by GPs in training in and practising complementary therapies may give a better indication. In New Zealand, 54% of GPs were interested in further training in non-orthodox therapies,10 while in Israel 88% wanted training and 16% had trained.11 Estimates of practice of complementary therapies by GPs vary from around 16% in Canada8 and the UK,6,12 to 30% in New Zealand,10,13 47% in Holland (mainly homoeopathy)14 and up to 85% in Germany (mainly herbal medicine).15 Despite this degree of interest in and use of complementary therapies by family doctors, in the United States it has been estimated that 70% of people who attend non-medically trained complementary therapists do not inform their family doctor.3 The corresponding situation in Australia is largely unknown. At least 15% of Australian GPs practise acupuncture,16 the only non-orthodox therapy that attracts specific funding from Medicare. In this study, we describe Victorian GPs' attitudes towards and use of a range of complementary therapies. Methods We obtained a random sample of 800 Victorian GPs who had each seen at least 1500 patients in 1996 from the Health Insurance Commission, which administers the national health insurance scheme (Medicare). We designed an 11-page survey to investigate various aspects of GPs' interactions with the following complementary therapies: acupuncture, aromatherapy, chiropractic, herbal medicine, homoeopathy, hypnosis, meditation, naturopathy, osteopathy, reflexology, spiritual healing (eg, Reiki) and vitamin and mineral therapy. We developed the survey from the existing literature17 and by using a focus group of local GPs. After pilot testing, the survey was mailed to the 800 GPs with a reply paid envelope in July 1997. Non-responders were sent a reminder postcard and then a follow-up survey if necessary. Doctors who had left their clinic leaving no forwarding address, taken extended leave, were seriously ill, or had moved overseas, retired or died were excluded. The study received ethical approval from both the University of Melbourne and Monash University. The statistical analysis was performed using SAS.18 Responses were analysed to search for groupings of common levels of use/acceptance. (In all instances, for these data the 95% confidence intervals for percentages never exceed ± 4.5%.) Qualitative data from space left for comments were coded and classified by themes. Results Thirty-six GPs were excluded according to the exclusion criteria, leaving 764 GPs. Questionnaires were returned by 488, giving a response rate of 64%. The sample was representative of Australian GPs19,20 in terms of sex, age distribution, metropolitan or rural practice location and number of patients seen per week up to 199; doctors seeing more than 200 patients per week, however, were underrepresented. There was no significant difference in age or sex between responders and non-responders. Knowledge of complementary therapies At least 80% of GPs reported that they knew something of acupuncture, hypnosis, meditation and chiropractic; about half knew something of herbal medicine, naturopathy and vitamin and mineral therapy; while 60%-70% had only heard of osteopathy, homoeopathy, spiritual healing, reflexology and aromatherapy. Opinions on the harmfulness and effectiveness of complementary therapies Most GPs agreed that the well-known therapies (acupuncture, meditation, hypnosis and chiropractic) were moderately to highly effective (see Box 1); three-quarters also agreed that chiropractic was occasionally harmful. When given the opportunity to write comments, many doctors expressed concern that complementary therapies could be harmful if a diagnosis is delayed or missed or if a proven (orthodox) therapy is neglected. Complementary therapies were considered to have a strong placebo effect. Some respondents commented that, while some therapies were effective in certain conditions, one could not generalise and effectiveness may depend upon the training and competence of the therapist. General practitioners frequently differentiated between medical and non-medical practitioners and expressed greater confidence in medically trained colleagues who practised these therapies. Opinions on the appropriateness of GPs to practise complementary therapies and eligibility for Medicare subsidy Box 2 shows responses to the question of whether it is appropriate for general practitioners to practise these therapies. Although chiropractic was considered occasionally harmful by 75% of general practitioners surveyed, 55% considered it appropriate for trained GPs to practise. Doctors who agreed that it was appropriate to practise a therapy were asked whether GPs should be eligible for Medicare funding when practising these therapies. Nearly all GPs agreed that acupuncture should be funded. There was also strong support for specific funding for GPs practising hypnosis (91%), meditation (77%) and chiropractic (69%). Even the relatively unknown therapies had support from approximately a quarter of GPs for specific Medicare funding. Teaching in undergraduate curricula Most respondents (93%) agreed that there should be some education on complementary therapies in core medical undergraduate curricula. However, doctors were evenly divided over a five-point scale about the importance of this education for students. Patient demand Fifty-nine per cent of GPs reported that patient demand for complementary therapies was increasing, 29% reported demand was static, and 10% were unsure. A third of doctors estimated that less than 10% of their patients used complementary therapies and another third thought that 11%-30% did. Nearly half of the GPs reported that less than 5% of their patients had asked them about complementary therapies in the past month. Referrals for complementary therapies Box 3 summarises GPs' responses on referrals to complementary therapists, from how they would respond if a patient suggested consulting a complementary therapist to how often they themselves refer patients to these therapists. The question did not specify whether the therapists were medically trained. Most GPs (93%) had referred at least once and 82% had referred at least a few times a year for a complementary therapy. Just under half of the sample referred at least a few times per year for the best-known therapies -- acupuncture, meditation, hypnosis and chiropractic. While approximately two-thirds of the general practitioners would encourage a patient who suggested consulting a practitioner of acupuncture, meditation or hypnosis, only 29% would do so for chiropractic. In the remaining therapies, GPs were twice as likely to have actually referred a patient for these therapies than to endorse a patient's suggestion to consult a practitioner. Training and use of complementary therapies Box 4 shows that half of the GPs expressed an interest in training in acupuncture, meditation and hypnosis and a quarter to a third in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. Nearly 20% of GPs practised one of the therapies, 8% used two therapies, 6% three, and 3% of general practitioners practised between 4 and 11 of these complementary therapies. For most of the complementary therapies, 80% or more of the GPs who trained in them practised them to some degree; exceptions were meditation (50%), hypnosis (56%), herbal medicine (62%) and vitamin and mineral therapy (64%). The practice of some complementary therapies, notably homoeopathy, vitamin and mineral therapy, naturopathy and herbal medicine, represented more than half of the clinical work for a small number of Victorian GPs. Discussion Our survey provides the first comprehensive description of the use of complementary therapies by GPs in Victoria. As the large sample is, in nearly all characteristics, similar to Australian GPs as a whole, our findings about GP attitudes and use of complementary therapies are likely to reflect the situation across the country. Nearly 20% of GPs had used acupuncture, meditation or hypnosis, and almost half had considered practising these therapies. Over 80% of GPs had referred patients to practitioners of these therapies. A quarter to a third were interested in training in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. Further, around 5% of doctors use therapies, such as osteopathy, homoeopathy, aromatherapy and spiritual healing, which are relatively unknown to most of their colleagues. It is interesting to speculate on the discrepancy between the number of GPs who trained in meditation, hypnosis, herbal medicine and vitamin and mineral therapy and the number who actually practise these therapies (Box 4). Possible reasons may include GP or patient dissatisfaction with outcomes, poor acceptance by patients, lack of financial reward, or difficulty accommodating more time-consuming therapies in a busy clinic. The GPs we surveyed estimated a lower use of complementary therapies by their patients than indicated by population-based research. This may be because the portion of the population who do not attend GPs for their primary health care may attend complementary therapists, and because those who do attend GPs may be less likely to use complementary therapies. The interpretation of our findings is limited by several possible sources of bias. We have no information on non-responders, and the 64% who did respond may have been more likely to participate because they had particularly strong positive or negative views. The effects of self-report and recall bias are also unknown. Further, we did not define the therapies listed in the questionnaire and GPs may have different interpretations of the terms used, particularly vitamin and mineral therapy. Reviewing studies of various designs shows that Victorian doctors have similar levels of interest in training in, and of referral of patients for, complementary therapies as their colleagues in other Western countries, with the exceptions of Holland and Germany.6-8,10,12-15 However, the popularity of therapies varies. For example, the most popular therapy practised in Victoria was acupuncture, with 23% of respondents having trained, whereas only 8% of GPs in Canada8 and 4% in the UK12 had had acupuncture training. By contrast, homoeopathy, which has an established role in Europe,4 was the most popular complementary therapy practised by British GPs,6,12 but one of the least popular therapies in Victoria. Complementary therapies may well have something to offer, but it is of concern that therapies of unproven effectiveness are apparently being accepted in mainstream general practice. Many editorials, while acknowledging that randomised controlled trial evidence is lacking for many aspects of orthodox Western medical practice, have called for quality trials in complementary therapies.21,22 The Cochrane Library is coordinating a search for randomised controlled trials of complementary therapies and is undertaking systematic reviews of therapies for specific conditions.23 Meanwhile, other reviews have found some evidence of efficacy, for example St John's wort in treating mild to moderate depression,24 acupuncture for antiemesis,25 and also an overall greater than placebo effect for homoeopathy in a meta-analysis of trials for various conditions.26 There are diverse reasons for the lack of evidence for complementary therapies. Many therapies have not been challenged before because of their long history, "natural" origins or patients' or doctors' anecdotal reports of success. In this era of evidence-based medicine, there are difficulties applying the gold standard of randomised controlled trials to therapies which are based on different and varied paradigms of health and illness. Funding for trials in "natural" therapies is also lacking. Freely available herbs cannot be patented, so there is little incentive for research, particularly if the public is buying them regardless of evidence. Lewith et al suggest that lack of structure to enhance research in complementary therapies is a barrier in Britain.27 Our experience would suggest a similar situation in Victoria. Our findings show that general practitioners are actively using complementary therapies. Therefore, whatever the profession's attitude towards these therapies, well-designed trials, disseminated and accessible results and education are urgently needed to inform GPs' decision-making. Further research is also required into why GPs decide to practise these therapies and why they are less likely to endorse a patient's suggestion to consult a complementary therapist than to refer themselves. The problems of compliance with and interactions between orthodox and complementary therapies are also areas where much research is needed. As our findings support those of Eisenberg et al3 that GPs may not communicate sufficiently with their patients and are not aware of their widespread use of complementary therapies, the issues of communication between doctors and complementary therapists, as well as between doctors and their patients, also need to be addressed. Conclusions Acupuncture, meditation, hypnosis and, possibly, chiropractic may be considered to be well-accepted therapies in Victorian general practice, while herbal medicine, naturopathy, vitamin and mineral therapy, osteopathy and homoeopathy are accepted by a sizable minority of doctors. Doctors underestimate their patients' use of these therapies, which may contribute to compliance and medication interaction problems. There is an urgent need for well-designed trials to search for evidence of the effectiveness of these non-orthodox therapies, to inform doctors' and patients' use of them. Acknowledgements We thank Dr Jane Gunn and Dr Ngaire Kerse for advice, and Eleni Sita and Sue Vallance for assistance with data collection. Dr I Brighthope, Blackmores Ltd, Aveda, Nutrition Care Pharmaceuticals and the Australian Integrative Medicine Association contributed funding for this research. Disclosure Those who funded this trial had no input into its design, analysis, conclusions, writing of the manuscript or the decision to submit it for publication. References MacLennan A, Wilson D, Taylor A. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Lloyd P, Lupton D, Wiesner D, Hasleton S. Choosing alternative therapy: an exploratory study of sociodemographic characteristics and motives of patients resident in Sydney. Aust J Public Health 1993; 17: 135-144. Eisenberg D, Davis R, Ettner S, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998; 280: 1569-1575. Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994; 309: 107-111. Australian Bureau of Statistics. Australian social trends 1998. Canberra: ABS, 1998. (Catalogue No. 4102.0). White A, Resch K, Ernst E. Complementary medicine: use and attitudes among general practitioners. Fam Pract 1997; 14: 302-306. Verhoef M, Sutherland L. Alternative medicine and general practitioners. Can Fam Physician 1995; 41: 1005-1011. Goldszmidt M, Levitt C, Duarte-Franco E, Kaczorowski J. Complementary health care services: a survey of general practitioners' views. Can Med Assoc J 1995; 153: 29-35. De Marco P, Dain C, Lockwood T, Roland M. How valuable is feedback of information on hospital referral patterns? BMJ 1993; 307: 1465-1466. Hadley C. Complementary medicine and the general practitioner: a survey of general practitioners in the Wellington area. N Z J Med 1988; 101: 766-768. Schachter L, Weingarten M, Kahan E. Attitudes of family physicians to nonconventional therapies. Arch Fam Med 1993; 2: 1268-1270. Perkin M, Pearcy R, Fraser J. A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine. J R Soc Med 1994; 87: 523-525. Marshall R, Gee R, Israel M, et al. The use of alternative therapies by Auckland general practitioners. N Z J Med 1990; 103: 213-215. Visser G, Peters L. Alternative medicine and general practitioners in the Netherlands: towards acceptance and integration. Fam Pract 1990; 7: 227-232. Himmel W, Schulte M, Kochen M. Complementary medicine: are patients' expectations being met by their general practitioners? Br J Gen Pract 1993; 43: 232-235. Easthope G, Beilby J, Gill G, Tranter B. Acupuncture in Australian general practice: practitioner characteristics. Med J Aust 1998; 169: 197-200. Hopper I, Cohen M. Complementary medicine and the medical profession: a survey of medical students attitudes. Altern Ther Health Med 1998; 3(4): 68-73. SAS [computer program], version 6.12. Cary, NC: SAS Institute Inc, 1996. Australian Institute of Health and Welfare. Medical labour force 1995. Canberra: AIHW 1997. Commonwealth Department of Health and Family Services. General practice in Australia: 1996. Canberra: AGPS, 1996. Hensley M, Gibson P. Promoting evidence-based alternative medicine. Med J Aust 1998; 169: 573-574. Kerr D. In search of truth. J R Coll Physicians Lond 1996; 30: 405. The Cochrane Library Complementary Medicine Field. Oxford: Update Software, 1998. Linde K, Ramirez G, Mulrow C, et al. St John's wort for depression -- an overview and meta-analysis of the randomised clinical trials. BMJ 1996; 313: 253-258. Vickers A. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J R Soc Med 1996; 89: 303-311. Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834-843. Lewith G, Kenyon J, Lewis P. Complementary medicine: an integrative approach. New York: Oxford University Press. 1996. (Received 13 May, accepted 5 Oct,1999) Authors' details Department of General Practice and Public Health, University of Melbourne, Carlton, VIC. Marie V Pirotta, MMed, FRACGP, Senior Lecturer. Stephen J Farish, BSc(Hons), MEd, Biostatistician and Senior Lecturer. Complementary Medicine Research Unit, Monash University, Melbourne, VIC. Marc M Cohen, PhD, MB BS(Hons), Senior Lecturer. Clayton, VIC. Vicki Kotsirilos, MB BS, General Practitioner. Reprints will not be available from the authors. Correspondence: Dr M V Pirotta, Department of General Practice and Public Health, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053. m.pirottaATgpph.unimelb.edu.au Make a comment 1: Attitudes among the 488 general practitioners on the harmfulness and effectiveness of complementary therapies* Harmful Effective FrequentlyOccasionallySeldomHighlyModeratelySeldomAcupuncture1 (0)76 (16%)395 (82%)93 (21%)294 (67%)41 (9%)Chiropractic32 (7%)362 (75%)82 (17%)48 (11%)306 (70%)61 (14%)Hypnosis1 (0) 141 (29%)305 (63%) 77 (18%)260 (60%)61 (14%)Meditation0 10 (2%)436 (90%)124 (29%)230 (53%)41 (10%)Osteopathy12 (3%)180 (37%)141 (29%)31 (7%)138 (32%)114 (26%)Herbal medicine20 (4%)262 (54%)144 (30%)14 (3%)128 (30%)199 (46%)Naturopathy16 (3%)200 (42%)165 (34%)19 (4%)125 (29%)191 (44%)Vitamin and mineral therapy11 (2%)214 (45%)182 (38%)22 (5%)94 (22%)224 (52%)Spiritual healing (Reiki)8 (2%)57 (12%)199 (41%)12 (3%)83 (19%)123 (28%)Homoeopathy13 (3%)143 (30%)188 (39%)10 (2%)72 (17%)217 (50%)Aromatherapy3 (1%)22 (5%)313 (65%)5 (1%)67 (16%)215 (50%)Reflexology12 (3%)47 (10%)198 (41%)4 (1%)31 (7%)207 (48%)*Many GPs offered no opinion, resulting in some missing values. Back to text 2: Opinions among general practitioners about the appropriateness of GPs to practise and charge Medicare for complementary therapies Appropriate for trained GPs to practise Should be eligible for Medicare rebates*Acupuncture97% (419/434)91% (384/422)Hypnosis92% (396/430)91% (364/399)Meditation80% (342/428)77% (282/367)Chiropractic55% (238/432)69% (207/301)Vitamin and mineral therapy44% (184/423)54% (137/254)Herbal medicine43% (183/427)53% (138/263)Naturopathy28% (117/424)42% (93/224)Osteopathy27% (113/423)44% (94/216)Homoeopathy23% (98/424)36% (77/213)Spiritual healing (Reiki)18% (74/422)27% (50/189)Aromatherapy17% (73/428)24% (47/197)Reflexology11% (48/426)22% (38/174)*Follow-on question answered only if the therapy was considered appropriate to practise. Back to text 3: Referral of patients for complementary therapies among general practitioners Those who ever referred patients Frequency of referrals Encourage a patient's suggestion to attend% (No.)RarelyFew times a yearAt least monthlyAt least weeklyMeditation74% (374/470)80% (379/476)31% (118)40% (153)20% (76)9% (32)Acupuncture71% (332/470)90% (424/473)24% (100)47% (199)19% (82)10% (43)Hypnosis62% (292/470)82% (386/473)44% (168)46% (179)10% (37)1% (2)Chiropractic29% (137/470)69% (326/476)37% (122)41% (135)17% (54)5% (15)Vitamin and mineral therapy17% (79/469)33% (157/472)57% (90)30% (47)8% (12)5% (8)Osteopathy16% (75/467)30% (141/476)55% (78)30% (42)11% (15)4% (6)Spiritual healing (Reiki)14% (66/469)20% (93/476)74% (69)20% (19)4% (4)1% (1)Naturopathy13% (62/470)30% (141/474)56% (79)26% (37)13% (18)5% (7)Herbal medicine12% (56/469)29% (138/474)63% (87)24% (33)9% (13)4% (5)Homoeopathy9% (43/470)20% (91/473)73% (66)18% (16)8% (7)2% (2)Aromatherapy9% (42/471)18% (83/475)70% (58)23% (19)6% (5)1% (1)Reflexology7% (22/470)10% (48/476)77% (37)17% (8)6% (3)0 Back to text 4: Training in and practice of complementary therapies among general practitioners Those who practise the therapy % Who practise Interest in trainingHave trained*No.5%6%-24%25%-50%>50%Meditation59% (283/477)34% (151/441)7567% (50)27% (20)5% (4)1% (1)Hypnosis52% (246/478)20% (89/442)5078% (39)20% (10)02% (1)Acupuncture49% (235/477)23% (102/441)9958% (59)34% (33)4% (4)3% (3)Herbal medicine36% (169/474)12% (53/438)3361% (20)27% (9)3% (1)9% (3)Vitamin and mineral therapy34% (160/470)23% (98/434)6346% (29)38% (24)3% (2)13% (8)Naturopathy25% (117/476)6% (26/439)2556% (14)24% (6)8% (2)12% (3)Chiropractic24% (112/475)8% (34/437)2976% (22)21% (6)3% (1)0Aromatherapy17% (83/477)4% (19/438)1883% (15)16% (3)00Homoeopathy16% (75/477)5% (23/440)2167% (14)19% (4)014% (3)Osteopathy13% (61/475)4% (17/437)†22†68% (15)18% (4)9% (2)5% (1)Spiritual healing (Reiki)12% (57/473)5% (21/439)1771% (12)24% (4)06% (1)Reflexology7% (33/475)2% (9/438)†12†100% (12)000*Includes self-taught. †These figures, which show that more doctors use osteopathy and reflexology than have actually trained in it, reflect inconsistencies in individual responses. Back to text

Marie V Pirotta · Marc M Cohen · Vicki Kotsirilos · Stephen J Farish

Abstract Objective: To assess Australian radiation and medical oncologists' self-reported knowledge about and attitudes towards a range of non-traditional therapies used by people with cancer. Design: Postal survey during May and June 1997 of all 265 radiation and medical oncologists practising in Australia. Participants: 161 oncologists returned surveys (61% response rate). Main outcome measures: Oncologists' own level of knowledge, and, for each known therapy, their perceptions of its likely harm or benefit in patients being treated curatively and palliatively, and of the prevalence of use among their patients. Results: Oncologists reported knowing most about acupuncture, antioxidant therapy and meditation and least about cellular therapy, magnetotherapy and psychic surgery. The therapies most likely to be considered helpful were meditation, acupuncture and hypnotherapy. Those most likely to be considered harmful were coffee enemas, psychic surgery, Iscador therapy and diet therapies. Perceptions of patients' use of most therapies varied widely, with herbal therapies, antioxidant therapy and meditation considered the most commonly used. Conclusions: These results indicate self-identified gaps in oncologists' knowledge about non-traditional therapies their patients may use; they suggest a need to consider including education about these therapies in oncologists' training. Introduction Recent studies have confirmed the popularity of non-traditional therapies among Australian cancer patients: 22%-52% of medical oncology patients,1,2 40% of those being treated palliatively3 and 46% of children with cancer4 report using at least one non-traditional therapy. Many of the most popular non-traditional therapies are psychosocial (eg, relaxation, meditation and visual imagery) and are unlikely to pose threats to patients' health.1-4 However, other popular therapies include dietary therapies, antioxidants, high dose vitamins and herbal therapies,1-4 many of which are poorly evaluated and could pose physical threats to patients, either directly, or by interfering with traditional therapies. Despite the lack of scientific evidence, 25%-73% of patients using non-traditional therapies expect them to cure their cancer or to prolong their lives,1-4 and 74%-86% expect them to assist their traditional therapies.2 Despite fairly high reported levels of satisfaction and perceived benefit with non-traditional therapies,1,2 17% of patients in one study reported negative side effects,4 10%-36% of patients reported no perceived benefit or feeling worse,1,2 and around 20% reported they would not take the therapy again or recommend it to other patients.2 Even if not harmful, many non-traditional therapies are expensive,1,2 and only 64% of patients felt the non-traditional therapies provided value for money.1 Recent guidelines highlight the need for oncologists to be aware of non-traditional therapies being used or considered by their patients, and to encourage patients to discuss them.5 This would require oncologists having at least a basic understanding of these therapies. We were able to identify only two relevant studies in this area -- a quantitative survey of 106 Italian oncologists6 and a qualitative study of 18 Canadian oncologists.7 They found limited knowledge about non-traditional therapies,6,7 relatively positive attitudes towards psychological therapies,6,7 more negative attitudes towards more invasive therapies,7 negative attitudes towards non-traditional therapy practitioners6 and more positive attitudes towards the use of non-traditional therapies by palliative patients.7 As there is a lack of data in this field, we explored Australian medical and radiation oncologists' knowledge of and attitudes to non-traditional therapies, and their perceptions of the frequency with which their patients used them. Given the increased tolerance among overseas oncologists of palliative patients using non-traditional therapies,7 we assessed attitudes to palliative and curative patients separately. We use the term "non-traditional therapies" to describe all therapies other than surgery, radiotherapy, chemotherapy and hormone therapy. Methods In May and June 1997, 273 questionnaires about 19 non-traditional therapies covering a wide range of psychosocial and physical therapies commonly discussed in the literature and media were mailed to all oncologists who practise in Australia. Non-responders received a written reminder after four weeks and a telephone reminder after six weeks. Ethical approval for this study was granted by the University of Newcastle's Human Research Ethics Committee. Sample identification We identified all medical and radiation oncologists practising in Australia through the Clinical Oncological Society of Australasia (COSA) and the Royal Australasian College of Radiologists' (RACR) Faculty of Radiation Oncology. The list of all the individuals registered with the Medical and Radiation Oncology Groups of COSA in late April 1997 comprised 155 Australian-based medical oncologists and 62 radiation oncologists. As the Medical Oncology Group of Australia advised they were aware of only 165 practising Australian-based medical oncologists, we considered the COSA list comprehensive for medical oncologists. However, the RACR advised they had 123 members currently practising in Australia, and, in line with its policy of not releasing members' contact details, they agreed to mail surveys to any of their members not on the COSA list -- an additional 56 radiation oncologists. The final sample of 273 thus comprised 155 medical and 118 radiation oncologists. The survey We designed a brief survey whereby oncologists rated, on a four-point scale ("none/never heard of it", "very little", "some" or "lots"), their own levels of knowledge about each of 19 non-traditional therapies; we provided no additional information about these therapies. Oncologists were also asked to rate each therapy they knew (also on a four-point scale: "very", "fairly", "neither" or "don't know"), according to how harmful or helpful they considered it for patients being treated palliatively and curatively. Finally, they were asked to estimate the proportion of their palliative and curative patients they believed were using, or had used, each known therapy. Copies of the survey may be obtained from the authors. Statistical analysis We report descriptive statistics on oncologists' knowledge and attitudes, including 95% confidence intervals around the proportion of oncologists knowing "lots" about each therapy. All analyses were conducted with the SAS statistical package;10 95% confidence intervals were calculated using Microsft Excel,11 based on the standard binomial approximation formula.12Results Of the 273 oncologists identified, four medical and two radiation oncologists were no longer practising and two radiation oncologists received surveys through both the COSA and RACR lists, leaving 265 eligible oncologists. Completed surveys were returned by 161 (61%) -- 60 radiation oncologists, 64 medical oncologists and 37 who could not be classified because they had destroyed the identifying number that allowed us to make this differentiation. Knowledge about non-traditional therapies Box 1 shows that meditation, relaxation and visual imagery were the therapies that most oncologists (about a quarter) reported knowing a lot about. Approximately a fifth of the oncologists surveyed also reported knowing a lot about antioxidant therapy and microwave, or Tronado, therapy. The least-known therapies were cellular therapy, magnetotherapy and psychic surgery. Perceptions of each therapy's potential harmfulness or helpfulness Box 2 shows that oncologists tended to consider the psychosocial therapies helpful for patients being treated both palliatively and curatively. Acupuncture was also considered helpful, especially for palliative patients. Many therapies were considered more likely to help palliative patients and, conversely, more harmful for curative patients. Not surprisingly, the less familiar, more physical or invasive therapies dominated those considered likely to be harmful. Perceptions of their patients' use of each therapy Box 3 compares the median proportion of their curative and palliative patients that oncologists believed were using or had used each non-traditional therapy with levels of use reported by Australian cancer patients.1-4 The oncologists showed a consistent trend to estimate higher use among palliative patients. The oncologists' estimates were within the ranges reported by Australian cancer patients for acupuncture, antioxidants, faith healing, hypnotherapy, iridology and meditation, relaxation and visual imagery. However, the oncologists overestimated patients' use of aromatherapy, coffee enemas, herbal therapies, naturopathy, homoeopathy, magnetotherapy and shark cartilage therapy. No patient data were available to compare cellular, mistletoe, microwave and ozone therapies or psychic surgery, and estimates for diet therapy were difficult to compare because of variation in the definitions used. Discussion As in the overseas studies,6,7 we found that oncologists identified gaps in their knowledge about many non-traditional therapies. It is interesting to note, however, that the therapies most patients reported using (meditation, relaxation and visual imagery and antioxidants) were also the therapies that most oncologists -- although still only up to a quarter -- reported knowing a lot about. Also consistent with the overseas studies,6,7 psychosocial therapies were viewed positively, and non-traditional therapies were considered more likely to be potentially helpful to patients being treated palliatively and potentially harmful to those being treated curatively. The more positive attitudes towards psychosocial therapies may reflect oncologists' awareness of some evidence of proven benefits from these therapies.8,9 Although our respondents tended to accurately estimate their patients' use of more commonly used non-traditional therapies, they tended to overestimate patients' use of more radical therapies, especially those with higher media profiles, such as coffee enemas and shark cartilage therapy. While the oncologists' and patients' estimates come from different surveys of different populations collected at different points in time, making some degree of variation inevitable, such variation is unlikely to explain the reasonably large differences for many of the lesser-used therapies. The trend for oncologists to estimate higher use of non-traditional therapies among palliative than curative patients is consistent with Australian and international data suggesting that patients with more advanced cancers are more likely to use non-traditional therapies.2,13-15 Our study has some other limitations. Firstly, for brevity, we sought no demographic information, thus prohibiting any assessment of the respondents' representativeness of Australian oncologists. However, as we targeted all Australian oncologists, and received responses from over 60% of the population, covering the full range of responses, we are confident that our data provide the first quantitative, reasonably representative overview of Australian oncologists' knowledge of and attitudes to non-traditional therapies. Secondly, we used self-report rather than an objective assessment of oncologists' actual knowledge about non-traditional therapies. As the oncologists are unlikely to have deliberately underestimated their knowledge levels, these estimates of how much they know should probably be interpreted as best-case scenarios. Also, we provided no definitions of "helpful" or "harmful", leaving individual oncologists to decide what constituted a harm or a help. This was done intentionally, as patients seek a range of benefits from non-traditional therapies, including physical, psychosocial and spiritual ones. Finally, while our results represent the first quantitative data on oncologists' knowledge and attitudes in this area, they cannot be generalised to other clinicians who treat people with cancer, such as surgeons, haematologists and general practitioners. Sceptics may question the need for oncologists to increase their knowledge about non-traditional therapies when the benefit of most remains unproven. However, without some basic knowledge of what is involved in each therapy, and of any demonstrated benefits or adverse reactions, oncologists may be unable to give adequate advice to patients. As outlined in the National Health and Medical Research Council guidelines, overly heavy-handed and dismissive attitudes are less likely to succeed in discouraging patients from using potentially harmful non-traditional therapies than more rational and considered discussions.5 Conclusions Research is needed to facilitate the production of evidence-based information summaries for oncologists in the area of non-traditional therapies, to compare oncologists' perceptions of use with their own patients' reported use of such therapies, and to establish the knowledge and attitudes of other clinicians treating cancer patients. Acknowledgements This research was funded by the NSW Cancer Council's Cancer Education Research Program. The views expressed are not necessarily those of the Cancer Council, which had no direct role in the design and/or analyses of this study or in the decision about publication of the results. We gratefully acknowledge the assistance of the Clinical Oncological Society of Australasia and the Royal Australasian College of Radiologists' (RACR) Faculty of Radiation Oncology for their assistance with identifying eligible oncologists, and the oncologists who completed the surveys. References Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. Med J Aust 1996; 165: 545-548. Miller M, Boyer MJ, Butow PN, et al. The use of unproven methods of treatment by cancer patients: frequency, expectations and cost. Supportive Care Cancer 1998; 6: 337-347. Yates PM, Beadle G, Clavarino A, et al. Patients with terminal cancer who use alternative therapies: their beliefs and practices. Sociol Health Illness 1993; 15: 199-216. Sawyer MG, Gannoni AF, Toogood IR, et al. The use of alternative therapies by children with cancer. Med J Aust 1994; 160: 320-322. National Health and Medical Research Council. Clinical practice guidelines: the management of early breast cancer. Sydney: The Stone Press; 1995. Crocetti E, Crotti N, Montella M, Musso M. Complementary medicine and oncologists' attitudes: A survey in Italy. Tumori 1996; 82: 539-542. Bourgeault IL. Physicians attitudes toward patients' use of alternative cancer therapies. Can Med Assoc J 1996; 155: 1679-1685. Meyer TJ, Mark MM. Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 1995; 14: 101-108. Devine EC, Westlake SK. The effects of psychoeducational care provided to adults with cancer: meta-analysis of 116 studies. Oncol Nurs Forum 1995; 22: 1369-1381. SAS [computer program], version 6.12. Cary, NC: SAS Institute Inc, 1998. Microsoft Excel [computer program], version 97. Seattle: Microsoft Corporation, 1997. Dobson AJ. Calculating sample size. Trans Menzies Found 1984; 7: 75-79. Risberg T, Lund E, Wist E. Use of non-proven therapies. Differences in attitudes between Norwegian patients with non-malignant disease and patients suffering from cancer. Acta Oncologica 1995; 34: 893-898. Sollner W, Zingg-Schir M, Rumpold G, Fritsch P. Attitude toward alternative therapy, compliance with standard treatment, and need for emotional support in patients with melanoma. Arch Dermatol 1997; 133: 316-321. Risberg T, Lund E, Wist E, et al. The use of non-proven therapy among patients treated in Norwegian oncological departments. A cross-sectional national multicentre study. Eur J Cancer 1995; 31A: 1785-1789. (Received 5 Jul, accepted 5 Nov, 1999) Authors' details NSW Cancer Council Cancer Education Research Program (CERP). Sallie Newell, PhD Research Academic (also Conjoint Lecturer, Discipline of Behavioural Science in Medicine, Faculty of Medicine and Health Sciences, University of Newcastle; currently Epidemiologist (Health Promotion Evaluation, Northern Rivers Institute for Health and Research, Lismore, NSW). Rob W Sanson-Fisher, PhD, Director (also Professor, Discipline of Behavioural Science in Medicine, Faculty of Medicine and Health Sciences, University of Newcastle; currently Dean of Faculty). Reprints will not be available from the authors. Correspondence: The Secretary, NSW Cancer Council Cancer Education Research Program, Locked Bag 10, Wallsend, NSW 2287. cherylmATmail.newcastle.edu.au Make a comment Back to text 2: Percentage of the 161 oncologists believing non-traditional therapies about which they reported at least some knowledge ("very little" or more) to be helpful or harmful Curative patients Palliative patients TherapyNo. reporting some knowledge of therapy*HelpfulHarmfulHelpfulHarmfulAcupuncture16025%1% 58%1%Antioxidants/high-dose vitamin C1605% 30%5%23%Aromatherapy1569%2% 21%1%Cellular therapy57029% 026%Coffee enemas1511%71% 1%70%Diet therapy (Gerson/macrobiotic)1422% 49%4%48%Faith healing/spiritualism15212%24% 23%15%Herbal therapies/naturopathy1598% 22%13%15%Homoeopathy1504%12% 8%6%Hypnotherapy15631%4% 46%3%Immune-enhancing therapy1313%27% 5%22%Iridology144 1%15%1%8%Iscador/mistletoe therapy1032%55% 2%45%Magnetotherapy695%8% 8%6%Meditation/relaxation/visual imagery15969% 3%82%2%Microwave/Tronado therapy1207%45% 7%37%Ozone therapy961%46% 2%37%Psychic surgery872%57% 2%56%Shark cartilage therapy1501%23% 1%17% *The remaining response options were "neither helpful nor harmful" and "don't know" - the balance of the oncologists with some knowledge of the therapy selected one of these options. Back to text 3: Perceptions among the 161 oncologists of their patients' use of non-traditional therapies compared with that reported by Australian cancer patients Oncologists' perceptions TherapyNo. reporting some knowledge of therapyMedian curative patientsMedian palliative patientsAcupuncture1606%10%Antioxidants/high-dose vitamin C16015%20%Aromatherapy1565%10%Cellular therapy573%3%Coffee enemas1513%5%Diet therapy (Gerson/macrobiotic)*14210%10%Faith healing/spiritualism1525%10%Herbal therapies/naturopathy15920%25%Homoeopathy15010%15%Hypnotherapy1565%5%Immune-enhancing therapy1315%8%Iridology1443%5%Iscador/mistletoe therapy1032%3%Magnetotherapy692%3%Meditation/relaxation/visual imagery15920%20%Microwave/Tronado therapy1201%1%Ozone therapy963%5%Psychic surgery871%1%Shark cartilage therapy1505%10% Reported use Therapy% Paediatric patients (n=48)4% Palliative patients (n=151)3% Medical oncology patients (n=319) 1% Medical oncology patients (n=156)2Acupuncture- 7%3%5%Antioxidants/high-dose vitamin C8%24%12%12%-16%Aromatherapy- --0.5%Cellular therapy----Coffee enemas---1%Diet therapy (Gerson/macrobiotic)*8%18%13%30%(diet therapy)(special foods)(diet therapy)(changed diet) 0.5% (Gerson)Faith healing/spiritualism6%9%7%3%Herbal therapies/naturopathy8%3%-8%6%5%-10%Homoeopathy2% 5%3%2%Hypnotherapy15%--3%Immune-enhancing therapy-3%4% -Iridology- --3%Iscador/mistletoe therapy----Magnetotherapy--- 0.5%Meditation/relaxtion/visual imagery4%-17%19%10%-13%12%-28%Microwave/Tornado therapy----Ozone therapy----Psychic surgery----Shark cartlilage therapy---4% *As diet therapies included those ranging from basic dietary changes through to very restricted diets (eg, Gerson diet), the actual wording used in each of the studies is included. Back to text

Sallie Newell · Rob W Sanson-Fisher

Public Health Enhanced measles surveillance during an interepidemic period in Victoria Stephen B Lambert, Heath A Kelly, Ross M Andrews, Mike C Catton, Pauline A Lynch, Jennie A Leydon, Debbie K Gercovich, Geoffrey G Hogg, Melissa L Morgan and Rosemary A Lester MJA 2000; 172: 114-118 For related article see McIntyre et al Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Infectious diseases and parasitology Abstract Objective: To describe results of the first two years of enhanced measles surveillance in Victoria. Design: Case series identified through enhanced measles surveillance. Participants and setting: All measles cases notified to the Disease Control Section, Department of Human Services, Victoria, in 1997 and 1998. Main outcome measures: Proportion of notified cases laboratory confirmed as measles, rubella, or human parvovirus infection; identification of clusters (two or more linked cases of measles); and utility of the National Health and Medical Research Council clinical case definition for suspected measles. Results: Rates of laboratory testing of notified cases improved after introduction of a paediatric phlebotomy service in July 1997, from 21 of 90 notified patients (23%) in the preceding six months, to 258 of 317 notified patients (81%) between July 1997 and December 1998. Of the 317, only 19 (6%) were laboratory confirmed with measles, while a further 26 (8%) were laboratory confirmed with human parvovirus infection (18) or rubella (8). Three clusters of measles, involving 11 cases, were identified during 1998. Use of the NHMRC case definition did not greatly improve the positive predictive value for diagnosis of measles above that of notification alone (14% versus 8%). Conclusions: Circulation of measles virus in Victoria in 1997 and 1998 appeared minimal. In this interepidemic period most notified cases of measles were not measles; to identify true cases, surveillance during an interepidemic period must include laboratory testing of notified cases. Cases of classical measles are uncommon in countries with successful measles control programs, making clincal diagnosis less reliable. To ensure the validity of clinical notifications, it is increasingly important to confirm the diagnosis in every sporadic case of measles and in at least one case in every chain of transmission in such countries.1 Australia suffered a nationwide outbreak of measles in 1993-1994.2 Since 1994, a two-dose measles-mumps-rubella (MMR) vaccination program has been implemented,3 and in 1998 a national campaign targeting primary school-aged children was conducted.4 The country was free of any substantial outbreak until early 1999, when importation of the disease from Bali resulted in measles cases, mainly among young adults in Victoria.5 To monitor the success of the measles control program, the State of Victoria began a state-based enhanced surveillance program in 1997. This program concentrates on confirming the diagnosis of measles for all notifications received by the Disease Control Section of the Victorian Department of Human Services.6 We report the results of the first two (interepidemic) years of this enhanced measles surveillance program and make recommendations for the investigation of notified cases of measles. Methods The enhanced measles surveillance strategy adopted by Victoria has been reported elsewhere.6 In brief, all notifications to the Department of Human Services in 1997 and 1998 were followed up by a structured telephone interview with the patient or, if the patient was a child, with the parent or guardian. Demographic data, clinical symptoms, and measles vaccination history were recorded. The parent/guardian was asked to read the date of vaccination from the personal vaccination record when available. We attempted to identify a possible source of infection, as well as contacts who required advice about immunoglobulin or MMR vaccination. Suspected preceding or subsequent cases were followed up in a similar manner to identify clusters of infection (defined as two or more epidemiologically linked cases7). A sporadic case was one that could not be linked to another case. Serological testing A serum specimen was sought from each notified patient for laboratory confirmation of the clinical diagnosis. From July 1997, this specimen was obtained by a paediatric phlebotomist in the patient's home. Some patients provided a combined throat and nose swab and a urine specimen for viral culture or isolation of genetic material by polymerase chain reaction, and subsequent virus genotyping.8Sera were tested for measles IgM and IgG at the Victorian Infectious Diseases Reference Laboratory (VIDRL) or, if original testing was performed elsewhere, the testing laboratory was asked to forward remaining sera from measles IgM-positive specimens to VIDRL for confirmatory testing. Testing at VIDRL used a commercial enzyme immunoassay (Dade Behring Enzygnost, Marburg, Germany). The manufacturer reports the measles IgM assay as having a sensitivity of 100% and specificity of 98%. Sera that were negative for measles IgM at VIDRL were assayed for human parvovirus IgM and IgG (Biotrin Parvovirus B19 Enzyme Immunoassay, Dublin, Ireland), rubella IgM (DiaSorin ETI-RUBEK-M reverse PLUS, Saluggia, Italy) and rubella IgG (Panbio Rubella IgG ELISA Test, Brisbane, Australia). Analyses Using a defined algorithm,6 each notified case was classified as confirmed measles or otherwise according to the criteria in Box 1. These included serological and other results, as well as concordance with the clinical case definition for suspected measles11 recommended by the National Health and Medical Research Council (NHMRC) -- morbilliform rash, fever present at rash onset, and cough.12Analysis was performed using Epi Info version 6.04.13 Significance of differences between categorical data was tested by the Fisher's exact or χ2 test. Results In the first six months of surveillance (January to June 1997), sera were collected from 21 of 90 notified patients (23%). After employment of a paediatric phlebotomist to collect samples in the patient's home, collection rates improved progressively -- sera were collected from 258 of 317 notified patients (81%) between July 1997 and December 1998, including from 107/120 (89%) in the second half of 1998.6Because of the lower rate of specimen collection in the first six months of surveillance, we analysed data for July 1997 to December 1998 only. In this period, only 19/317 notifications (6%) were classified as laboratory confirmed (Box 2). The remainder were laboratory rejected (229; 72%), clinically compatible (12; 4%), not clinically compatible (41; 13%) and not classifiable (16; 5%). All epidemiologically linked cases were able to be laboratory confirmed. Of the 229 cases that were laboratory rejected as measles, 18 had human parvovirus infection (8%), and eight had rubella (3%). Box 3 shows serological results by age group. Serum collection rates did not differ significantly between age groups (P = 0.4), but laboratory confirmation was significantly more likely among patients aged 10 years or over than among younger children (P = 0.0002). Clusters of measles Three clusters of measles, involving 11 patients, were identified, all in 1998. The first, involving four people, began in January 1998. A 19-year-old man from New South Wales visited Melbourne soon after illness onset on 10 January. Three other people were infected: his 22-year-old brother (onset, 18 January), six-month-old nephew (onset, 1 February), and a 23-year-old male household contact (onset, 3 February). None of the Victorian patients in this cluster reported previous measles vaccination; all required hospital admission. In the second cluster, the index patient was a two-year-old girl (onset, 1 February). Although she lived within a kilometre of the household of the first cluster, no clear epidemiological link could be established with any of the earlier cases. Three other children, aged 10 months to three years, and an 18-year-old woman were infected (onset, 12 February-13 March); all attended the same small church group as the index patient. The index patient's parent reported she had been vaccinated against measles in New Zealand at the age of one year, but did not have a record to confirm this. No other patients in the cluster had been vaccinated against measles. In the third cluster, the index patient was an 18-year-old woman who had returned from Bali on 4 December and became ill seven days later. Her brother developed prodromal symptoms 12 days later. Neither had been vaccinated against measles. Measles vaccination history Vaccination histories of the 317 notified patients are shown in Box 4. More than half those notified (55%) reported having been vaccinated, more than half of whom provided a vaccination date from a personal vaccination record. Reported measles vaccination status was compared with the presence of measles IgG for those with serological results available. Only 7% of those who reported prior vaccination lacked measles IgG. In contrast, 67% of patients who were aged over one year (and therefore eligible for vaccination) and did not report being vaccinated lacked measles IgG (P < 0.001). Among patients who reported vaccination, those who provided a vaccination date were no more likely to have measles IgG detected than those who did not provide a date (P = 0.76). Prior measles vaccination was reported by 141 patients (62%) who were classified as laboratory rejected, compared with six (32%) who were classified as laboratory confirmed (P = 0.01). Among patients with laboratory-confirmed measles, sporadic cases were more likely to give a history of vaccination (5/8) than those who were part of a cluster (1/11) (Fisher's exact test, P = 0.04). Reference laboratory testing Of the 19 patients classified with laboratory-confirmed measles, 16 were positive for measles IgM on testing at VIDRL, two after initial positive results elsewhere. The 16 comprised all 11 cluster cases and five sporadic cases. Another three sporadic cases were positive for measles IgM on testing at other laboratories but had insufficient serum available for retesting at VIDRL. These cases were still classified as "laboratory confirmed". A further three patients were positive for measles IgM on testing at other laboratories but were negative on retesting at VIDRL and were classified as "laboratory rejected". Evaluation of NHMRC clinical case definition for suspected measles There was sufficient clinical information to classify 275 notified patients (87%) according to the NHMRC clinical case definition for suspected measles: 92 (33%) met the definition, and 183 (67%) did not. To examine the utility of the NHMRC case definition, we analysed cases that were able to be classified both in this way and according to serological results -- either laboratory confirmed (18) or rejected (202) as measles. Results are shown in Box 5. Sensitivity of the NHMRC case definition was 61% and specificity was 66%, while positive and negative predictive values were 14% and 95%, respectively. When non-index cases from clusters were excluded (to test the utility of the definition in identifying cases with no epidemiological link to a confirmed measles case), sensitivity and positive predictive value fell to 40% and 5%, respectively, while specificity and negative predictive value remained almost unchanged. Cases from clusters were more likely than sporadic cases to satisfy the NHMRC case definition (10/11 [91%] versus 1/7 [14%]; Fisher's exact test, P = 0.002). The relationship between notification and laboratory measles diagnosis was also examined: the positive predictive value of notification was 8% (18/220), dropping to 5% (10/212) when non-index cases were excluded. Discussion We found that, during the interepidemic period of July 1997 to December 1998 in Victoria, a clinical diagnosis of measles had a low positive predictive value. Despite an 81% rate of serological testing, only 6% of all measles notifications were laboratory confirmed (8% of those that could be classified on the basis of serological results). Laboratory diagnoses of human parvovirus or rubella infections accounted for a further 8% of measles notifications, similar to experience in other countries that have conducted enhanced surveillance.14These results highlight the critical importance of laboratory confirmation as part of enhanced measles surveillance. They also highlight the low utility of the NHMRC clinical case definition for suspected measles. As only 33% of notified cases met this definition, it does not seem widely used as the basis for notification. Furthermore, it was neither sensitive (40%) nor highly predictive of true measles (5%) during this interepidemic period. Therefore, rather than the NHMRC clinical case definition for suspected measles, we advocate a definition similar to that used by the Pan American Health Organization of all cases in which a health worker suspects measles.15 Our findings do not mean that those responsible for measles surveillance, investigation and control can ignore measles notifications. The Disease Control Section now relies on urgent serological testing performed by VIDRL to inform public health action and improve the quality of the surveillance dataset. In Victoria, clinical specimens can often be collected within 24 hours of notification, with a laboratory result available on the next testing day.6 During the interepidemic period, when measles was rare, if public health action were to involve excluding contacts of a notified case from a school or childcare centre, we attempted to arrange urgent serological testing. No action was taken until the result was available. If serological testing was not possible, we treated the case as though it were measles regardless of whether it met the NHMRC case definition. Based on our experience, and drawing on elements from the National Measles Surveillance Strategy,7 we have refined recommendations for follow-up of measles notifications in a region with good disease control during an interepidemic period (Box 6). We believe these recommendations will allow identification of clusters of disease and minimise unnecessary public health action. We have maximised the sensitivity of the passive surveillance system by following up notifications from any source. By using laboratory testing to identify cases that are not measles, we have minimised the likelihood that our surveillance dataset will consist largely of false-positive notifications. Because no IgM antibody test is 100% specific, even laboratory-confirmed cases may not be measles. We found that three of five laboratory diagnoses of measles made in non-reference laboratories could not be confirmed at VIDRL. Sporadic cases were less likely to be confirmed at VIDRL than cluster cases and were also less likely to meet the NHMRC case definition, but were more likely to report prior measles vaccination. As prior measles vaccination correlates well with measles immunity, we believe that at least some of the sporadic cases classified as laboratory confirmed were not true measles. This reinforces the important role of reference laboratories as we approach national measles elimination and global eradication.7 We suggest that local transmission of measles within Victoria during this interepidemic period was minimal. We base this belief on the small number of sporadic cases identified, along with the possibility that some of these cases were not true measles, and the fact that identified clusters of infection involved few people and were self-limiting. Specimen collection for genotyping is already under way and will provide further evidence of the interruption of indigenous transmission in Victoria.16,17 The findings of the enhanced surveillance program, along with those from investigation of the 1999 measles outbreak in Victoria,5 lead us to believe that the two-dose MMR vaccination policy and the 1998 measles control campaign have dramatically reduced circulation of measles virus in the targeted age groups. We have demonstrated that, when measles is rare, enhanced surveillance relying on laboratory confirmation is essential to identify true cases of measles promptly and to ensure that surveillance datasets do not largely comprise false positive notifications. Acknowledgements The Victorian Enhanced Measles Surveillance Working Party appreciates the cooperation of the patients who agreed to be interviewed and provided serum samples for enhanced surveillance. We also gratefully acknowledge the nursing staff, clinicians, and pathology collection centres who collected serum specimens during the study period. Enhanced surveillance and public health intervention would not be possible without notification of cases by clinicians and laboratories. References World Health Organization. Expanded programme on immunization (EPI). Meeting on advances in measles elimination: conclusions and recommendations. Wkly Epidemiol Rec 1996; 71: 305-309. Lambert S. Measles in Victoria 1992 to 1996: the importance of laboratory confirmation. Comm Dis Intell 1998; 22: 17-22. National Health and Medical Research Council. The Australian immunisation handbook. Canberra: AGPS, 1997. National Centre for Disease Control. Immunise Australia program: measles control campaign. Comm Dis Intell 1998; 22: 156. Lambert S, Lynch P, Morgan M, et al. Measles outbreak -- young adults at high risk. Victorian Infectious Diseases Bulletin 1999; 2: 21-22. The Enhanced Measles Surveillance Working Party. Implementing a system of enhanced surveillance for measles in Victoria. Commun Dis Intell 1999; 23: 51-54. Heath T, Burgess M, McIntyre P, Catton M. A national measles surveillance strategy. Commun Dis Intell 1999; 23: 41-49. Jenkin GA, Chibo D, Kelly HA, et al. What is the cause of a rash after measles-mumps-rubella vaccination? Med J Aust 1999; 171: 194-195. Centers for Disease Control and Prevention. Measles, mumps, and rubella -- vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunisation Practices (ACIP). MMWR Morb Mortal Wkly Rep 1998; 47 (RR-8): 1-58. Helfand R, Heath J, Anderson L, et al. Diagnosis of measles with an IgM capture EIA: the optimal timing of specimen collection after rash onset. J Infect Dis 1997; 175: 195-199. Ferson M, Young L, Robertson P, Whybin L. Difficulties in clinical diagnosis of measles: proposal for modified clinical case definition. Med J Aust 1995; 163: 364-366. National Health and Medical Research Council. Measles: guidelines for the control of outbreaks in Australia. Canberra: AGPS, 1996. Dean A, Dean J, Coulombier D, et al. Epi Info, version 6: a word processing database, and statistics program for public health on IBM-compatible microcomputers. Atlanta, Ga: Centers for Disease Control and Prevention, 1995. Brown D, Ramsay M, Richards A, Miller E. Salivary diagnosis of measles: a study of notified cases in the United Kingdom, 1991-3. BMJ 1994; 308: 1015-1017. Centers for Disease Control and Prevention. Measles eradication: recommendations from a meeting cosponsored by the World Health Organization, the Pan American Health Organization, and CDC. MMWR Morb Mortal Wkly Rep 1997; 46 (RR-11): 1-20. Rota JS, Heath JL, Rota PA, et al. Molecular epidemiology of measles virus: identification of pathways of transmission and implications for measles elimination. J Infect Dis 1996; 173: 32-37. Chibo D, Birch C, Rota P, Catton M. Genetic characterisation of measles viruses isolated in Victoria, Australia 1973-1998. Immunisation beyond 2000. 6th National Public Health Association Immunisation Conference; 1998 Nov 4-5; Melbourne. Canberra: Public Health Association of Australia, 1998. (Received 30 Jun, accepted 27 Oct, 1999) Authors' details Department of Human Services, Melbourne, VIC Stephen B Lambert, FAFPHM, Public Health Physician; Ross M Andrews, MPH, MAppEpid, Epidemiologist; Pauline A Lynch, Public Health Nurse; Debbie K Gercovich, Paediatric Phlebotomist; Melissa A Morgan, MB BS, Immunisation Coordinator; Rosemary A Lester, FAFPHM, Public Health Physician. Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC Heath A Kelly, FAFPHM, Head, Epidemiology Division; Mike C Catton, FRCPA, Head, Virology Division; Jennie A Leydon, BAppSci, Senior Scientist. Microbiological Diagnostic Unit, University of Melbourne, Melbourne, VIC. Geoffrey G Hogg, FRACP, FRCPA, Director. Reprints will not be available from the authors. Correspondence: Dr H A Kelly, Victorian Infectious Diseases Reference Laboratory, Locked Bag 815, Carlton South, VIC 3053. heath.kellyATnwhcn.org.au Make a comment 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>". <URL: http://www.mja.com.au/> 1: Classification of notified measles cases by the Victorian Enhanced Measles Surveillance Program 1. Laboratory confirmed Serum is positive for measles IgM,* and patient had not received the first dose of a measles vaccine within 45 days of specimen collection9 OR Diagnostic rise in measles antibody titres in paired sera OR Wild-type measles virus isolated from a clinical specimen OR A clinical specimen is PCR-positive for wild-type measles virus 2. Laboratory rejected Serum is negative for measles IgM with sample collected at least three days after rash onset10 OR Serum is negative for measles IgM but positive for measles IgG OR Serum is positive for rubella IgM OR Serum is positive for human parvovirus IgM 3. Epidemiologically linked to a laboratory-confirmed case Neither 1 nor 2 above AND An epidemiologic link to a laboratory-confirmed case has been established7 4. Clinically compatible Neither 1, 2 nor 3 AND The case satisfies the NHMRC clinical case definition † for suspected measles 5. Not clinically compatible Neither 1, 2 nor 3 AND The case does not satisfy the NHMRC clinical case definition for suspected measles 6. Not classifiable Neither 1, 2 nor 3 AND There are insufficient clinical data available to allow classification as clinically compatible (4) or not clinically compatible (5). NHMRC=National Health and Medical Research Council. PCR=polymerase chain reaction. *Sera that gave IgM-positive results at laboratories other than the Victorian Infectious Diseases Reference Laboratory (VIDRL) were retested at VIDRL and classified accordingly. If serum was not available for retesting, then the case was classified as laboratory confirmed to maximise sensitivity, rather than positive predictive value, of the system. †Morbilliform rash, fever present at rash onset, and cough. Back to text Back to text 3: Serological results for patients notified with measles in Victoria, July 1997 to December 1998 Age group (years)Number (% of notifications) Serologically tested (% of age group) Serologically confirmed (% of tested)<190 (28%)69 (77%)2 (3%)1-4122 (38%)100 (82%)7 (7%)5-963 (20%)55 (87%)010-1927 (9%)22 (81%)5 (23%)>2015 (5%)12 (80%)5 (42%)Total317258 (81%)19 (7%) Back to text 4: Measles vaccination and immunity for 317 notified cases in Victoria, July 1997 to December 1998 Reported vaccination statusNumber (% of notifications)Serologically tested (% of vaccination group)IgG-negative (% of tested)Vaccinated174 (55%)152 (87%)11 (7%)Date provided9987 (88%)7 (8%)No date provided7565 (87%)4 (6%)Not vaccinated124 (39%)92 (74%)83 (90%)Age <1 year9068 (76%)67 (99%)Age ≥1 year3424 (71%)16 (67%)No information19 (6%)14 (74%)2 (14%) Back to text 5: Utility of the National Health and Medical Research Council clinical case definition for suspected measles in Victoria, July 1997 to December 1998 Predictive value SensitivitySpecificityPositiveNegativeAll cases11/18 (61%)133/202 (66%)11/80 (14%)133/140 (95%)Excluding non-index cases4/10 (40%)133/202 (66%)4/73 (5%)133/139 (96%)Back to text 6: Recommendations for follow-up of measles notifications in an interepidemic period Cases of measles should be notified on suspicion, regardless of whether they satisfy the NHMRC clinical case definition for suspected measles. A serum specimen should be obtained for all sporadic notified cases of measles, and from at least two cases in an outbreak. All IgM positive serological results should be confirmed at a reference laboratory. If public health action during an interepidemic period is to involve excluding contacts, this action should be postponed if rapid serological testing is available. If a serum specimen cannot be obtained from a notified case, or rapid serological testing is not available, it should be assumed the case is measles, regardless of whether the case meets the NHMRC clinical case definition for suspected measles, and public health action should be taken immediately. Back to text

Stephen B Lambert · Heath A Kelly · Ross M Andrews · Mike C Catton · Pauline A Lynch · Jennie A Leydon · Debbie K Gercovich · Geoffrey G Hogg · Melissa L Morgan · Rosemary A Lester