Research

Funding Australia's health and medical research A commitment to improving health through high quality research MJA 1997; 167: 608-609 In 1996, the National Health and Medical Research Council's research expenditure was approximately $142 million.1 According to official estimates, this is about a quarter of Australia's total outlay on health research.2 With this level of expenditure, it is reasonable to ask what we gain from this investment. In this issue of the Journal, Bourke and Butler show that in 1995 Australian research provided about 2.5% of new knowledge in medicine and the health sciences (Australian research produced 18390 publications, which were cited over 88000 times), a contribution that has strengthened in recent years.3 This is tangible evidence of our commitment to improving the health of people not only in Australia but in other countries. In one sense, this health research commitment is similar to our other international commitments, such as preserving world heritage areas or reducing emissions of gases causing ozone depletion. Apart from this international contribution to knowledge and new discoveries to improve health, research also benefits Australia itself. For example, health care practitioners with research training are of key importance in ensuring that Australian clinical practice is effective and of high quality because they can access, sift and digest new research findings here and elsewhere. Researchers active in public health are needed to provide informed advice on the benefits and costs of proposed public health measures; for example, the detection and prevention of cancer and cardiovascular disease. The strong base of Australian medical research is also helping to build our biotechnology industry. Finally, and less tangibly, Australians derive satisfaction and pride through the achievements of their health researchers, just as they are proud of high achievers in sport and the arts. The NHMRC now provides research funds across the spectrum of health and medical science via a single Research Committee formed in 1997 by a merger of the Medical Research Committee and the Public Health Research and Development Committee. As the largest single provider of peer-reviewed health research funds for the public good, the NHMRC has the responsibility of ensuring that Australia's health research effort is of high quality: the Research Committee provides funds on the basis of excellence (as judged by peer review), strives for fair, open and competitive processes, considers funding applications in all areas relevant to health, and attempts to ensure that research findings are translated into better health and health care delivery. Health research is conducted mainly in universities, hospitals and medical research institutes (Box 1, above). About 30% of total NHMRC research support is provided to medical research institutes, about half of which is via block funding to five institutes. Box 2 shows the support won by institutes receiving over $1 million, those which are block funded, and the proportion of institute funding going to each State (for institutes receiving over $100 000). NHMRC funding to the major universities is shown in Box 3. The Government provides additional support for hospital and university research via salaries for researchers doing academic or clinical research as part of their teaching and clinical duties, but this does not occur for all research institutes. The institutes also play a valuable role in gaining additional support for health research from private corporations and individuals. The report by Bourke and Butler3 shows that the medical research institutes produce some of our most highly regarded research. Ten of the 12 most cited Australian biomedical research articles are associated with institutes, and the overall citation rate for publications from institutes is impressively high: medical research institutes publish about 13% of all Australian health research articles, and these account for about 21% of the total citations of Australian health research. Underfunding the institutes would jeopardise this high quality output. Bourke and Butler comment that their results raise issues of the efficacy of block funding,3 but stress that conclusions about funding methods require further bibliometric studies. The NHMRC's Research Committee is actively reviewing all aspects of research support, including issues in block funding, such as how best to review institutes and how to increase competition between institutes. Some will argue that the data of Bourke and Butler show that substantial, longer term research support (e.g., block funding) is required in order to achieve the highest impact research. Others will point to examples such as St Vincent's Institute for Medical Research in Melbourne to argue that institutes can achieve outstanding publication results without block funding. The NHMRC supports a pluralistic system because the aims of health research extend well beyond quality research publication. It currently supports three-year project grants (about 48% of the current total NHMRC funding), and five-year program grants (9% of total NHMRC funding) and block grants (13% of total NHMRC funding) to provide for longer term research commitments. New researchers are supported via scholarships and postdoctoral awards (about 9% of funding), and outstanding individuals are supported by Fellowships (11% of funding, exclusive of Fellows on Programs and at block-funded institutes). Nothing in science or medicine is immune to change. The NHMRC's research support system must accord with the ways in which research is currently conducted and be relevant to contemporary health needs. One exciting plan for the triennium 1997-1999 is the introduction of multidisciplinary Health Research Networks in important health areas. This scheme will involve researchers at different locations working collaboratively on research in areas of major health importance. Part of the aim is to capitalise on the merger of the Medical Research Committee and the Public Health Research and Development Committee by creating teams of biomedical, clinical and public health researchers. The Networks will focus on effective delivery of health care or prevention. They will thus be integrated research teams (as in the NHMRC Program Grants Scheme), but multisite and multidisciplinary. Interestingly, Bourke and Butler's article3 shows that research collaborations, both local and international, are growing strongly. The NHMRC-sponsored Networks scheme acknowledges this trend and will help to build new collaborations. Bibliometric data are important for monitoring Australian research. We also need better indicators of the other outcomes of research (such as discoveries which benefit health or reduce health costs, better-informed medical and public health decision making, a vibrant biotechnology industry, and new generations of trained researchers in all areas) so that we can assure the Australian community that its financial investment in health and medical research is well placed. Warwick P Anderson Professor and Chairman, Research Committee (Public Health and Medical) National Health and Medical Research Council, Canberra, ACT National Health and Medical Research Council. 1996 Annual Report. Canberra: AGPS, 1997. Australian Institute of Health and Welfare. Health Expenditure Bulletin No 13, July 1997. Bourke PF, Butler L. Mapping Australia's basic research in the medical and health sciences. Med J Aust 1997; 167: 610-613. - ©MJA 1997 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>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Warwick P Anderson

Mapping Australia's basic research in the medical and health sciences Paul F Bourke and Linda Butler The Institute for Scientific Information indexes most of the major international basic research journals in science in the Science Citation Index (SCI). Australia's presence in the medical and health sciences journals in the SCI and the citations its published research receives in these journals show that Australia's basic medical research has high international "visibility". Mapping the source of the most highly "visible" Australian medical research articles shows high impact research coming from several different sectors (research institutes, universities, hospitals, etc.), but with a concentration in the member institutions of the Australian Association of Medical Research Institutes (AAMRI). Published research from the AAMRI is cited at a rate two-thirds higher than the Australian average for medical and health sciences. (MJA 1997; 167: 610-613) Introduction - Data source - To what extent is Australian basic research in the medical and health sciences covered by the REPP database? - Where is the research being conducted? - Are patterns of medical authorship changing? - How "visible" is Australian medical research? - Where is Australia's most "visible" medical research being conducted? - Where are Australia's most highly cited medical articles produced? - Discussion - References - Authors' details - - - ©MJA1997 Introduction A very high proportion of the articles reporting the results of basic research in the medical and health sciences are in the journals indexed by the Institute for Scientific Information (ISI) in the Science Citation Index (SCI). The SCI is therefore an excellent tool for identifying the sources of Australian published research in this field, while the citations received by (or references to) these articles can also be used to identify the source of the most-cited research. We have focused on Australia's basic research output, not its applied research. Data source The Research Evaluation and Policy Project (REPP) at the Australian National University (ANU) has constructed a database of all Australian research published in ISI-indexed journals for the period 1981-1995. This database has been well documented in several of our published studies, and a description is available on the Internet.1,2 Our analysis of this database is based on the addresses shown on the publications, which we have "cleaned" down to the level of university department. This has been done by ensuring all variants of a departmental, faculty or institutional address (sometimes running into hundreds) are grouped together and given the same "standard" address. The database also contains details of the citations in ISI journals received by these Australian research articles; that is, the number of times Australian articles are in the reference list of other ISI journal articles. We also code the sector -- universities, hospitals, medical research institutes, government institutions, and "other" -- of each address. The medical research institutes sector comprises the 25 members of the Australian Association of Medical Research Institutes (AAMRI). Medical research in the Government sector comes primarily from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) and the State and Federal departments of health. The "other" sector includes industry and non-profit organisations. We acknowledge "grey areas" at the margins of these assignments to sectors. For example, where a research group based in a hospital with a university connection lists the university in the address, we consistently assign the publication to the university. Another example is the John Curtin School of Medical Research (JCSMR), a full-time medical research institute (though not a member of AAMRI), which is also a research school of the ANU funded from that university's operating grant. Its publications are assigned to the ANU and hence fall within the universities sector. Most publications can be unambiguously assigned, but some addresses are not precise guides to the source where the research was conducted. This arises particularly for researchers who hold conjoint or adjunct appointments in two institutions. If such an author nominates a single institution, we accept that this is the location of the research leading to that publication. If an author specifies two separate addresses, two records are created for that publication showing the two institutions (double-counting created by this procedure is removed for sectoral and national analysis, but remains when the individual institution is the focus of the analysis). If the address itself has multiple components, the publication can not be split into multiple records and has to be assigned to the apparent primary institution. Very few publications fall into this latter category, and their existence has little effect on the map of national, sectoral or institutional sites of research. We have used the standard bibliometric practice of ascribing an article to a particular field of research on the basis of the classification of the journal in which it appears. This procedure is not without problems, particularly in the case of analysis at the subfield level, but experience from our other studies has shown that the results are accurate if the data are being used to map research in a large field.3 To what extent is Australian basic research in the medical and health sciences covered by the REPP database? In this field, at least 70% of published research output from universities and medical research institutes is in the form of journal articles, and, of these, at least 70% appear in SCI journals.4,5 We therefore estimate that, as a minimum, the REPP database covers 50% of the published output in these two sectors. SCI coverage of research from the sectors hospitals and government institutions may be less complete in terms of their total research output, but their contributions to basic research will be well represented. In this article, we are using the REPP database to answer questions about the map of medical research in Australia, concentrating primarily on publications from 1990 onwards, but also introducing some time-series analysis. Where is the research being conducted? The sectoral distribution (Figure 1) shows that the bulk of Australia's basic medical research is located in universities and hospitals. Most of the research articles from the universities sector (75%) come from the 10 teaching medical schools and the JCSMR at the ANU. Our data also show that little has changed in the sectoral location of research over the past 15 years: the share of publications from the hospitals sector has remained constant, there has been a small drop in the universities share, and there has been a corresponding increase in the share from the medical research institutes. Are patterns of medical authorship changing? The REPP database enables us to distinguish publications by type of authorship, viz: Single author -- one author only (i.e., no collaboration); Group -- more than one author but sharing the same departmental address; Institutional -- more than one author from different departments/faculties; National -- more than one author from different institutions in Australia; and International -- more than one country listed in the author addresses. Figure 2 shows how the type of authorship of medical research articles has changed in the past 15 years. The two authorship types showing marked decline are "single author" articles, and "group" articles. Medical and health sciences in Australia appeared slow to exhibit the "internationalisation" of research apparent in other fields since the early 1980s, but the period since 1987 has seen a dramatic change. The proportion of publications involving international collaboration nearly doubled between 1987 and 1995. Collaboration with other Australian institutions has also become more common, increasing from 19% to 26% over the 15-year period. (A detailed analysis of Australia's international collaboration in basic research may be found in a monograph we prepared for the Australian Research Council.6 ) How "visible" is Australian medical research? We assess "visibility" by the number of research articles published and the citations those articles receive. Figure 3 plots Australia's share of "world" publications (i.e., of the total in the SCI) in the medical and health sciences and its share of all citations in SCI journals. The chart also plots Australia's Relative Citation Impact (RCI), which is calculated by dividing its share of "world" citations by its share of "world" publications. The most notable feature of this Figure is that Australia's share of publications in SCI medical journals increased by 25% between 1986 and 1995. The average RCI for the whole period was 1, indicating that Australian publications are attracting appropriate notice. Australia's RCI has not changed significantly over time, but remained at or marginally above 1. This is a strong performance as citation rates are influenced principally by publications from the major research centres of America and Europe. Where is Australia's most "visible" medical research being conducted? A standard measure used to compare the visibility of research in different sectors is the average number of citations received per publication (cpp). In Box 1 (below) we relate the number of publications produced by each sector in the period 1991-1995 to the number of citations those publications attracted in the same period. The leading position of the institutes making up the AAMRI is consistent with Richard Smith's impression of Australia's research institutes.7 Some of the differences in cpp rates can be attributed to the varied research profiles of different institutions. Data supplied by ISI enable us to quantify this, as we can calculate cpp rates for sets of journals. For example, articles in immunology journals for the same period attracted citations at the average rate of 6.21, while those in clinical sciences journals averaged 3.81. We would therefore expect hospitals, with their strong clinical focus, to have a lower cpp rate than those AAMRI establishments with a strong presence in immunology. However, the difference in cpp rates apparent in Box 1 (above) cannot be explained fully by differences in field concentrations; we calculate that differing citation rates across fields account for only a third of the gap in cpp rates between the AAMRI institutions and other sectors. The remainder is a measure of the differing visibility and impact of the research. Not all institutions within a given sector have similar visibility. In Box 2 we list the top five institutions (in terms of cpp rates) in each of the four sectors active in medical research. In the universities sector, we looked specifically at the teaching medical schools and for this reason have excluded JCSMR. The institutions in Box 2 are those with more than 100 SCI publications in the period. In this instance, we count publications in multidisciplinary journals such as Nature, Science and Proceedings of the National Academy of Sciences together with publications in medical and health sciences journals, on the assumption that for the listed institutions and faculties these articles would almost certainly relate to medical research. Sorting the institutions in Box 2 by cpp rates within sectors has the effect of allowing volume of publications to be moderated by impact. The consequences of the choice of the measure on which to rank institutions can be seen by a closer examination of the medical research institutes. While the Walter and Eliza Hall Institute of Medical Research has the largest number of publications and citations, and would be ranked first if these were the measures used, the Ludwig Institute for Cancer Research is top-ranked on the basis of average cpp rates. All three are measures of impact and visibility, but cpp rates take institutional size into account. We looked at the research focus of institutions to determine if the higher cpp rates of some institutions resulted from differing fields of concentration. Again, we found that while an institution's cpp rate was affected by the relative impact of the fields in which it was active, this accounted at most for only 30% of the variation in cpp rates between institutions in any given sector. Where are Australia's most highly cited medical articles produced? We identified a very small group of 12 articles, published since 1990, which have attracted more than 200 citations (Box 3). This Box does much to explain the ranking of the AAMRI institutes in Box 2. The Ludwig Institute for Cancer Research had only 135 publications satisfying our criteria of publication date and journal, yet three of these have attracted more than 200 citations. St Vincent's Institute of Medical Research had even fewer publications (130), but claimed authorship of the most highly cited publication for the period, with 551 citations, and another article with 256 citations. Seven of the listed articles, including the most highly cited publication, were "wholly" Australian; the other five articles involved international collaboration. Discussion Studying ISI journals in isolation does not permit conclusions to be drawn about quality. However, an analysis of citations can provide a guide to the source of Australia's most visible research, and there is a well established positive association8 between high visibility in ISI-indexed journals and research judged on other grounds, such as via peer evaluation and esteem measures, to be of high quality. The limitations of bibliometric analysis are well documented.9 Publications can attract large numbers of citations because they contain error, or because they report a new technique with wide application. Citation data are also highly skewed. Many publications attract no citations at all, and most of those that do receive only one or two. These and other problems are of little consequence when the focus is at the national or sectoral level, involving large numbers of publications.10 Our data provide only one approach to constructing a profile of Australian medical research. However, bibliometric or literature-based analysis cannot stand in isolation from historical and other kinds of evaluative judgements, and should not be used in a policy setting apart from those perspectives. That said, we believe that the information reviewed here does allow some interesting points to be made. The most encouraging inference we draw from our study is that, using the measure of Relative Citation Impact, Australian medical research stands relatively high in terms of international visibility. As Box 3 makes clear, Australian-based researchers publish in international journals and have well established links to collaborative projects in the major centres of work in the field.6 The bulk of Australia's basic research in the medical and health sciences comes from the universities and hospitals, but Australia's medical research institutes, the members of AAMRI, have the highest international profiles. Research from these institutions has had a major impact on the international community. However, high visibility is not confined to the AAMRI institutions, and, as we have shown, research achieving very high impact also comes from hospitals and universities. One of the most interesting policy issues which these data raise is the efficacy of block funding by comparison with direct project funding of research. Medical research in Australia is undertaken in a pluralist system, with major contributions from hospitals, universities, AAMRI and government institutions. While at first glance our data may appear to argue for block funding through the prominence of several AAMRI institutions funded in this way, the situation is more complex. Many of the AAMRI institutions are block-funded, but in some instances this accounts for as little as 35% of their total income. Any conclusions about funding await the completion of detailed bibliometric studies of the relative performance of medical research, in which we will attempt to identify the output of research supported by the varying modes of research funding. References Bourke P, Butler L. A Crisis for Australian science? Canberra: Performance Indicators Project, Australian National University, 1993. (Monograph Series No. 1.) < http://coombs.anu.edu.au/Depts/RSSS/REPP/repp.htm > Butler L, Bourke P, Biglia B. CSIRO: profile of basic research. Canberra: Research Evaluation and Policy Project, Australian National University, 1997. (Monograph Series No. 4.) National Board of Employment Education and Training (NBEET). Quantitative indicators of Australian academic research. Canberra: AGPS, 1994. (Commissioned Report No. 27.) Bourke P, Butler L. Monitoring research in the periphery. Canberra: Research Evaluation and Policy Project, Australian National University, 1996. (Monograph Series No. 3.) National Board of Employment Education and Training. International links in higher education research. Canberra: AGPS, 1995. (Commissioned Report No. 37.) Smith R. Top of the pile: the institutes. BMJ 1991; 302: 1006-1010. Narin F. Evaluative bibliometrics. Cherry Hill, NJ: Computer Horizons Inc, 1976. Van Raan AFJ, editor. Handbook of quantitative studies of science and technology. Amsterdam: Elsevier Science Publishers, 1988. Garfield E. In: Evered D, Harnett S, editors. Ciba Foundation Conference: the evaluation of scientific research. Chichester (UK): John Wiley & Sons, 1989. (Received 6 Jun, accepted 29 Sep, 1997) Authors' details Research Evaluation and Policy Project, Research School of Social Sciences, Australian National University, Canberra, ACT. Paul F Bourke, PhD, FASSA, Head of Research Evaluation and Policy Project; and Professor of History. Linda Butler, BEcon, Research Officer. Reprints: Professor P F Bourke, Research Evaluation and Policy Project, Research School of Social Sciences, Australian National University, ACT 0200. E-mail: paulb AT coombs.anu.edu.au - ©MJA 1997 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>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Paul F Bourke · Linda Butler

The Institute of Medical and Veterinary Science Brendon J Kearney Situated in the grounds of South Australia's principal teaching hospital, the IMVS provides a unique blend of statewide pathology services with comprehensive basic and clinical research programs. MJA 1997; 167: 614-617 Introduction - Growth of the IMVS - Core pathology services - Research at IMVS - The Hanson Centre for Cancer Research - The future of IMVS - References - Authors' details - - - ©MJA1997 Introduction The Institute of Medical and Veterinary Science (IMVS), in Adelaide, South Australia, began in 1938 as a development from the Royal Adelaide Hospital (RAH) laboratories largely because Sir Trent Champion de Crespigny, an eminent physician, Medical Superintendent of the RAH and Dean of Medicine from 1929 to 1947, had a vision for an institute which combined laboratory services, teaching and research.1,2 In this respect, the IMVS differs from pure research institutes and has continued to emphasise an integration of service, teaching and research in clinical medicine. Growth of the IMVS The steady development of the IMVS was interrupted in the late 1970s by a series of enquiries into management efficiency, services provided and internal policies, as well as a critical review of the care and control of animals used in scientific experiments. The result was a major redefinition of core services: the Division of Forensic Pathology and the Division of Biology became the Forensic Science Centre (and relocated elsewhere in Adelaide) and the Division of Veterinary Pathology was transferred to the South Australian Department of Agriculture. In July 1982, a new Act (with a new Council) defined and strengthened the relationships of the IMVS with the RAH and the University of Adelaide, allowing it to concentrate on the mainstream areas of medical pathology and their application to research, teaching and service. In 1986, an internal report (Review of Research) on the IMVS/RAH campus by Professors David Penington and Gustav Fraenkel outlined a framework for the development of research. The integration of service, teaching and research with the outcome of high quality care provided by clinicians actively engaged in research was endorsed in the report, but they also suggested the creation of separate basic science laboratories to support research and avoid disparate but duplicated facilities on the campus. They recommended that this development should be part of the IMVS/RAH campus because the benefits of a separate research centre would be diminished by the separation of research activities from service functions. The IMVS and RAH accepted the challenge, and by 1990 funds had been raised and the Hanson Centre (now the Hanson Centre for Cancer Research) had been established. Over the past decade, the IMVS has organised itself along business lines and become reliant on its ability to provide high quality patient services, attract grants and contract for service and research. About 80% of its $55 million expenditure annually is derived from contracts or grants (for public and private pathology services on a fee-for-service basis); the remaining 20% is derived from direct grants from the South Australian Government for statewide or specific pathology services. Therefore, the IMVS differs from pure research institutes that rely on government grants, research grants and donations. While this adds a complexity to its management, it is also a strength, ensuring that the IMVS remains competitive, efficient and relevant to the services for which it contracts. The strength of the IMVS is its collocation on the RAH and University of Adelaide medical school campus. This allows easy collaboration, integration and coordination with both the hospital and University, which has a symbiotic effect on achievement. This integration between hospital, university, service and research is exemplified by the organisational structure of the IMVS. Core pathology services The provision of a high quality general medical pathology service to the RAH remains the core service of the IMVS, and The Queen Elizabeth Hospital laboratories recently joined the IMVS. The IMVS also provides pathology services to metropolitan and rural areas in South Australia through a network of 12 country and regional laboratories. These comprehensive, regionally based laboratory facilities have ensured that a high quality pathology service is available to most communities in South Australia. In addition, services are provided to the Northern Territory and some areas in Victoria. The integration of the IMVS with a teaching hospital and university medical school has allowed the IMVS to develop a comprehensive teaching and training program in pathology and to become involved in education and training in collaboration with clinical disciplines. Research at IMVS Examples of the symbiotic relationship between pathology services, clinical services and research are illustrated by the research endeavours occurring within the Divisions of the IMVS. Division of Tissue Pathology The Division of Tissue Pathology, developed by Professor Barrie Vernon-Roberts, is one of the largest in Australia, with specialists in tissue pathology subspecialising and with the Division integrated into the University of Adelaide and RAH. The Adelaide Head Injury Group incorporates neuropathology from the IMVS, neurosurgery from the RAH and bio mechanical engineering from the University of Adelaide's Road Accident Research Unit. Together, they form a unique combination collaborating in basic laboratory and clinical research into the effects of head injury caused by road trauma. The research objective of the Adelaide Head Injury Group is to reduce the severity of brain injury from accidents by prevention and early intervention. Until recently, brain injury was believed to be instantaneous and irreversible. Work undertaken by the group suggests that axonal damage evolves over hours and may be modified by early interventions. They have developed techniques to identify the pathological changes occurring within an hour of a head injury. The increased production of an amyloid precursor protein is a sensitive indicator of brain injury and can be used to measure the effectiveness of treatments aimed at reducing axonal damage. The Spinal Research Group has won several national and international awards, including the prestigious Volvo Prize (twice), the International Society for Biomechanics Prize, the Amrad Award, and the Smith and Nephew Spine Research Award (twice). It is supported by the specialised bone and histoquantification laboratories of Dr Robert Moore and Dr Nicola Fazzalari. The group collaborates closely with the RAH Spinal Services and RAH Department of Orthopaedics and Trauma. They used a sheep model to reproduce the pathology of human disc lesions and showed how investigational studies of discs can inadvertently introduce bacteria, causing damage to the disc and adjacent bone,3 and the beneficial effect of prophylactic antibiotics to prevent this common complication.4 Other studies have analysed the damage to the disc resulting from cumulative wear and tear to the spine, and have defined the biomechanical and biochemical characteristics of this degeneration. The researchers are currently examining the vascularisation of the disc during ageing, the potential for allograft disc replacement, and the use of cultured osteogenic precursor cells in surgical fusion of the spine. The Bone and Joint Group, in collaboration with the RAH Department of Orthopaedics and Trauma, studies bone structure and remodelling, with an emphasis on osteoarthritis and osteoporosis, using computerised analysis and modelling.5 The findings are relevant to development of preventive treatment for osteoporotic fractures and osteoarthritis.6 The group has also shown that loosening of artificial joints is caused by particles of metal or plastic released from the articulating surfaces.7 Division of Medical Microbiology and Virology The Division of Medical Microbiology and Virology has a long and distinguished reputation. Dr J E McCartney, Medical Bacteriologist at the IMVS in the early 1950s, was a close colleague of Alexander Fleming (the discoverer of penicillin), who gave him some of the original Penicillium mould. Professor Barrie Marmion, Professor of Virology at the IMVS during the 1980s, worked on developing an effective Q fever vaccine and on hepatitis B. Professor Christopher Burrell, the current Head, is acclaimed for his cloning of the hepatitis B genome.8 This Division is the core of the South Australian Infectious Diseases Service. It provides statewide services in food and environmental testing, monitoring of viral diseases and food- borne microbial diseases as well as the State HIV/AIDS Reference Laboratory and national Salmonella Reference Laboratory. A first for the microbiology laboratories was recognition of the association between commercial potting soils and Legionella longbeachae infections.9 They have played a leading role in developing diagnostic procedures for Legionella spp., as well as researching virulence mechanisms and their source and role in infections in the community. The expertise of the Division in applying research into service was shown during the 1995 outbreak of haemolytic- uraemic syndrome in South Australia.10 Three days after receipt of the first specimen, the laboratories had implemented a gene amplification test to detect toxin in food and clinical specimens, identified the toxigenic Escherichia coli strain and traced its source. The tracing of the source of E. coli within days contrasts to the weeks and months needed in outbreaks in Japan and the United States and was significant in rapidly controlling its spread. Infectious diseases research programs. The Division also maintains programs of basic research related to infectious diseases, largely funded by the National Health and Medical Research Council. AIDS Research Laboratory is one of the component units of the National Centre for HIV Virology. Its goal is to define the early molecular events in the replication of HIV in the infected cell.11 This has led to clarification of the events in cell-to-cell transmission of the virus. A related area of research is the use of antisense molecules as a form of gene therapy to inhibit HIV replication. Hepatitis Research Laboratory is studying the mechanism of infection with hepatitis B and related viruses, including patterns of spread within the body, regulation of the carrier state and ways to interrupt it, and the mechanism of protection by vaccines and ways to improve it.12 Herpes simplex research on the pathogenesis of herpes simplex, with emphasis on latent infections within the nervous system and how the host response reacts to infection, is being directed by Dr Tony Simmons. Papillomavirus research into the replication of papillomavirus, the patterns the virus expresses during infection of epithelial surfaces and the factors controlling the different outcomes of the infection (e.g., warts, cancer) is being directed by Dr Geoff Higgins. Adelaide Infectious Diseases Centre. The Division of Medical Microbiology and Virology provides a continuum from patient diagnostic testing, reference test development and public health to basic research. To maximise synergy between these activities, the Adelaide Infectious Diseases Centre has been established, combining the IMVS Division of Medical Microbiology and Virology, the University of Adelaide Department of Microbiology and the infectious diseases services of the RAH and The Queen Elizabeth Hospital. This group is pre-eminent in South Australia in infectious disease surveillance, reference testing, epidemiological studies and disease outbreak investigation. Division of Clinical Biochemistry Bone research group. Professor Christopher Nordin, Associate Professor Allan Need and Associate Professor Howard Morris are addressing bone loss at the menopause, which, together with age-related bone loss, eventually leads to osteoporosis. Studies have established that increased urinary calcium excretion at menopause contributes significantly to bone loss.13 Increased dietary protein and salt exacerbate the urinary calcium "leak" and its effect on bone loss, while dietary restriction of these helps stabilise bone loss. Studies are being undertaken into the changes in the intestinal absorption of dietary calcium at menopause.14 Studies on new therapies for osteoporosis and on the most effective way of monitoring treatment are continuing. A longitudinal study of osteoporosis in men has found that bone loss commences at age 50 and that the pattern and causes of bone loss are different from those found in women.15 The effects of diet, physical activity, hormone and growth factor levels are being evaluated for their effect on the rate of bone loss. A sophisticated rat model of postmenopausal osteoporosis has allowed investigation of the influences on bone at the molecular level. Local factors have been identified which protect bone from the increased cellular activity induced by oestrogen deficiency.16 The Detectacol bowel screening program was one of the earliest Australian voluntary bowel screening programs using an immunologically based test to detect faecal occult blood.17 It has been running for 15 years and has been endorsed through randomised controlled trials showing a reduction in mortality from colorectal cancer as a result of such screening techniques.18 Bone metastasis research. In collaboration with the Department of Surgery of the University of Adelaide, the Division is using a rat tumour model to study how metastatic tumours develop at incision sites after laparoscopic surgery. They will investigate changes in the immune state of the peritoneum and the effect of the different gases used to expand the peritoneum during laparoscopy. Division of Haematology Bone marrow transplantation. Haemopoiesis research began in the early 1980s, led by Dr Chris Juttner and Dr Bik To. They pioneered blood stem cell mobilisation and transplantation, which has now almost replaced autologous bone marrow transplantation.19 The group is currently seeking to define the role of integrin and bone resorption in mobilisation. Work continues on using haemopoietic stem cells purified using immunomagnetic techniques to refine the application in allogeneic and autologous transplantation in leukaemia, lymphoma and myeloma. Ex-vivo expansion is another project for which the Division has a pioneering role as a way of improving the safety of transplantation.20 Dr Tim Hughes is leading a study of chronic myeloid leukaemia and has established a SCID-NOD model for characterising leukaemic stem cells.21 The group is currently involved in 12 clinical trials in transplantation for leukaemia and lymphoma. Research continues into mesenchymal stem cell and cellular therapies, cell death differentiation and oncogenesis and cellular interactions. The stromal group, led by Dr Paul Simmons, has made a major contribution on STRO-1-positive marrow stromal cell percursor and its role in bone formation, haemopoietic regulation and cellular therapies using marrow stromal tissue. Dr Sharad Kumar's group is studying apo ptosis, including the role, activation and regulation of caspases, the function of homologue(s) of C elegans CED-4 and the identification of CED-4M. The group is studying how integrins may modulate cytokine response and function of tetraspan and GPI-linked molecules. The Hanson Centre for Cancer Research The RAH Board and the IMVS Council have strongly supported the development of the Hanson Centre. Through fundraising, the RAH has provided $7.5 million over the past decade for the construction of buildings and provision of equipment for the Centre. The IMVS provides infrastructure funds from its operations and through its commercial company, Medvet Science Pty Ltd, created by the IMVS Council to commercialise the intellectual property and other biomedical activities of the IMVS/RAH campus, and has contributed in excess of $2 million in research grants and infrastructure funding to the Centre. When the Centre began, in 1991, the core research groups were the RAH Division of Human Immunology and the Division of Haematology, but other groups have since joined, including the University of Adelaide Department of Cardiology and the RAH Departments of Gastroenterology, Rheumatology and Thoracic Medicine. These groups have their research support within the Hanson Centre, but are integrated into the service and teaching activities of the IMVS, RAH and the University of Adelaide. Professor Mathew Vadas, appointed 10 years ago to head the Division of Human Immunology, has developed strong basic research groups of excellence which have become known as the Hanson Centre for Cancer Research. This Centre is now the jewel in the research crown of the IMVS. Professor Vadas's research is focused on vascular biology.22,23 Other groups, led by Dr Shannon and Dr Cockerill, have had success in gene regulation,24 and Dr Gonda's laboratory is working on oncogene research.25 The Lipid Research Laboratory has succeeded in understanding the structural principles that govern the assembly of high density lipoprotein.26,27 It was known from epidemiological studies that the human blood high density lipoprotein fraction was protective against atherosclerosis, but the structural and functional basis for this protection was largely unknown. In collaboration with the Vascular Biology Laboratory, they discovered a novel and likely vital function for this particle that directly regulates the function of the vessel wall, and hence the propensity for atherosclerosis.23 Significant progress has been made in understanding cell death. The orderly and timely death of cells is essential in giving shape to the body and renewing its worn parts. A disorder in this process leads to abnormal growth that is a component of cancer. Work in the Molecular Regulation Laboratory, headed by Dr Sharad Kumar, and the Cytokine Laboratory of Dr Angel Lopez has provided novel insights into this process.28 The signals that are involved in "sentencing" and "execution" leading to cell death have been elaborated, and a new therapeutic agent based on an actual growth factor has been discovered that induces this process in blood cells. It is likely that the clinical implications of these discoveries will be considerable. The future of IMVS The IMVS will maintain a business-like approach to the management of operations and to the continued development of Medvet Science. A recent external review of research on the IMVS/RAH/University of Adelaide campus, led by Professor Lawrie Powell, has commented on the excellent productivity of research on the campus. The IMVS intends to further enhance research through expansion of laboratories for basic research while maintaining the strong integration of teaching, patient services and clinical research. New areas of research are being developed in the neurosciences and in molecular pathology, with an emphasis on cancer genetics. References The Institute of Medical and Veterinary Science. Annual Report 1952. Adelaide, IMVS: 1952: 5. The Institute of Medical and Veterinary Science. 50th Anniversary Review 1938-88. Nicholson B, editor. Adelaide, IMVS: 1988: 33-34. Fraser RD, Osti OL, Vernon-Roberts B. Discitis following chemonucleolysis -- an experimental study. Spine 1986; 11: 679-687. Fraser RD, Osti OL, Vernon-Roberts B. Iatrogenic discitis -- the role of intravenous antibiotics in prevention and treatment. An experimental study. Spine 1989; 14: 1025-1032. Fazzalari NL, Crisp DJ, Vernon-Roberts B. Mathematical modelling of trabecular bone structure; the evaluation of analytical and quantified surface to volume relationships in the femur and iliac crest. J Biomech 1989; 22: 901-910. Moore RJ, Durbridge TC, McNeil PJ, et al. Trabecular spacing in postmenopausal Australian women with and without vertebral fractures. Aust N Z J Med 1992; 22: 269-273. Howie DW, Cornish BL, Vernon-Roberts B. Resurfacing hip arthroplasty classification of loosening and the role of prosthesis wear particles. Clin Orthop 1990; 255: 144-159. Burrell CJ, Mackay P, Greenaway PJ, Hofschneider MK. Expression in Escherichia coli of hepatitis B virus DNA sequences cloned in plasmid pBR322. Nature 1979; 279: 43-47. Steele P W, Lanser JA, Sangster N. Isolation of Legionella longbeachae serogroup I from potting mixes. Appl Environ Microbiol 1990; 56: 49-53. Paton AW, Ratcliff RM, Doyle RM, et al. Molecular microbiological investigation of an outbreak of hemolytic-uremic syndrome caused by dry fermented sausage contained within Shiga-like toxin-producing Escherichia coli . J Clin Microbiol 1996; 34: 1622-1627. Li P, Stephenson AJ, Kuiper LJ, Burrell CJ. Double-stranded strong-stop DNA and the second template switch in human immunodeficiency virus (HIV) DNA synthesis. Virology 1993; 194: 82-88. Triyatni M, Jilbert AR, Qiao M, et al. Protective efficacy of DNA vaccines against duck hepatitis B virus infection. J Virol. In press. Morris HA, Cleghorn DB, Need AG, et al. The 5-year reproducibility of calcium-related biochemical variables in postmenopausal women. Scand J Clin Lab Invest 1995; 55: 383-389. Nordin BEC, Morris HA, Need AG, et al. Dietary calcium and osteoporosis. In: Pietinen P, Nishida C, Khaltaev N, editors. Proceedings of the 2nd World Health Organization Symposium on Health Issues for the 21st Century: nutrition and quality of life. Kobe, Japan, 1993. Geneva: WHO, 1996: 181-198. Need AG, Horowitz M, Stiliano A, et al. Vitamin D receptor genotypes are related to bone size and bone density in men. Eur J Clin Invest 1996; 26: 793-796. Morris HA, Porter SJ, Durbridge TC, et al. Effects of oophorectomy on biochemical and bone variables in the rat. Bone Mineral 1992; 18: 133-142. Bone HA, Roder D, McCaul K, Milliken L. Epidemiology of cancer in South Australia. Adelaide: South Australian Cancer Registry, 1993: 57-63. Weller D, Thomas D, Hiller J, et al. Screening for colorectal cancer using an immunochemical test for faecal occult blood: results of the first 2 years of a South Australian programme. Aust N Z J Surg 1994; 64: 464-469. To LB, Haylock DN, Simmons PJ, Juttner CA. The biology and clinical uses of blood stem cells. Blood 1997; 89: 2233-2259. Haylock DN, To LB, Dowse TL, et al. Ex vivo expansion and maturation of peripheral blood CD34 + cells into the myeloid lineage. Blood 1992; 80: 1405-1412. Hughes T, Iverson PO, Lewis ID, et al. A second generation GM-CSF analogue that prevents dissemination and induces remission of human juvenile myelomonocytic leukaemia in engrafted immunodeficient mice. Blood. In press. Korpelainen EI, Gamble JR, Vadas MA, Lopez AF. IL-3 receptor expression, regulation and function in cells of the vasculature. Immunol Cell Biol 1996; 74: 1-7. Cockerill GW, Rye KA, Gamble JR, et al. High density lipoproteins inhibit cytokine-induced expression of endothelial cell adhesion molecules. Arterioscler Thromb Vasc Biol 1995; 15: 1987-1994. Cockerill PN, Osborne CS, Bert AG, Grotto JRM. Regulation of GM-CSF gene transcription by core-binding factor. Cell Growth Differ 1996; 7: 917-922. Gonda TJ, Favier D, Ferrao D, et al. The c-Myb negative regulatory domain. In: Wolff L, Perkins AS, editors. Molecular aspects of myeloid stem cell development. Curr Top Microbiol Immunol 1996; 211: 99-107. Rye KA, Hime N, Barter PJ. The influence of sphingomyelin on the structure and function of reconstituted high density lipoproteins. J Biol Chem 1996; 271: 4243-4250. Rye KA, Hime N, Barter PJ. Evidence that cholesteryl ester transfer protein-mediated reductions in reconstituted high density lipoprotein size involve particle fusion. J Biol Chem 1997; 272: 3953-3960. Kumar S, Kinoshita M, Noda M. Characterization of a mammalian cell death gene Nedd2. Leukemia 1997; 11 Supp 3: S385-S386. Authors' details The Institute of Medical and Veterinary Science, Adelaide, SA. Brendan J Kearney, FRACP, FRACMA, Director. Reprints: Professor B J Kearney, Director, Institute of Medical and Veterinary Science, PO Box 14, Rundle Mall, SA 5000. - ©MJA 1997 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>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Brendon J Kearney

Mammographic screening: results from the 1996 National Breast Health Survey Alexandra L Barratt, Jill Cockburn, Sally Redman, Christine Paul and Janice Perkins For editorial comment, see Glasziou & Irwig This article has been cited in Rodger A, Kavanagh AM, Outcome measures of an Australian breast-screening program, MJA 1998; 169: 179-180 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 establish the extent of women's knowledge of mammographic screening, particularly in relation to the national screening program, BreastScreen Australia, and to estimate the proportion of women who are participating in screening both within and outside BreastScreen Australia. Design and setting: Validated prospective telephone survey of women aged 30-69 years selected at random from across Australia. Participants: 2935 women with no previous breast cancer diagnosis. Results: The adjusted response rate was 64%. Almost 90% of women had heard of the national program; only 1% correctly stated that screening is for asymptomatic women. 60% correctly identified the current recommended age of starting screening is about 50 years of age; 26% thought screening should begin at about 40 years of age. Approximately 60% correctly reported that the recommended screening interval is every two years; 27% thought screening should be done annually. 55% reported ever having had a mammogram, and 37% reported having had at least one screening mammogram. Among women in the target age group (50-69 years) about 70% reported ever having had a screening mammogram, and about 50% reported having had a screening mammogram within the national program in the last two years. Among women aged 40-49 years, 29% reported ever having had a screening mammogram, and 22% reported having been screened in the last two years. Conclusions: Awareness of the national screening program is high, but some women do not know the purpose of screening, the target age group and the recommended screening interval. Compliance with screening is good among women in the target age group; many women in their 40s are also participating in screening. MJA 1997; 167: 521-524 Introduction Breast cancer is the most common cause of cancer death in Australian women, with approximately 7000 new cases and over 2500 deaths annually.1 Evidence from randomised controlled trials shows that mammographic screening can substantially reduce mortality from breast cancer among women aged 50-69 years,2,3 but high rates of compliance with screening are necessary to achieve these benefits. Since 1991 the Commonwealth and State governments have funded a national program of mammographic screening, BreastScreen Australia, which provides free mammographic screening for women aged 40-79 years, but specifically targets women aged 50-69 years. Clearly, if women are to participate, they need to know about mammographic screening generally, and about the service provided by the national program in particular. In 1996, we undertook a national survey on behalf of the National Health and Medical Research Council National Breast Cancer Centre (NBCC) to establish baseline information about women's knowledge of, and participation in, screening mammography. Limited data about participation within the national program are available from the national program's own evaluation reports. Little is known about participation in screening outside the national program. Our aims were, firstly, to determine Australian women's knowledge of mammographic screening and the national program, and whether knowledge differs by area of residence or education. Secondly, we aimed to estimate the proportion of women who are participating in screening both within and outside BreastScreen Australia. Methods The survey was conducted by telephone by a market research company on behalf of the NBCC in April 1996. The questionnaire was developed and pilot-tested by the NBCC; test-retest reliability was assessed by administering the questionnaire twice to a random sample of 100 women at a one-week interval, with good agreement for key items ( k = 0.89-1.00). Telephone numbers were chosen at random from the electronic white pages telephone directory. Up to five callbacks were made to contact eligible women (those aged 30-69 years whose English was sufficient to complete a telephone interview). The sampling frame was stratified to ensure participation by women in all States and Territories, and in urban and rural areas.4 The outcome of every phone call was recorded. Ethical approval for this study was obtained from the NSW Cancer Council Ethics Committee in March 1996. Validation A random sample of 150 women who reported having been screened by BreastScreen Australia were asked for consent to check their questionnaire answers against BreastScreen Australia records. For those who consented, identifying data and the estimated date of last screen within the program were forwarded to BreastScreen Australia for confirmation. To assess selection bias, one survey question (Have you ever had a mammogram?) was placed in the February 1996 Australian Bureau of Statistics (ABS) Population Survey Monitor, which is conducted quarterly by household interview. The question was asked only of women 30-69 years in the ABS sample, and the results were weighted as for our survey (described below) to give a comparable estimate. Statistical analysis Our data were weighted for area of residence and age based on ABS projected population estimates. As all percentages reported in this paper are weighted results, sample sizes are not routinely given in the results. Significance testing was done by chi-squared tests based on the sample size of the survey; P values of less than 0.05 were considered statistically significant. Ninety-five per cent confidence intervals were calculated from the standard error of the proportion, again based on the sample size of the survey. Education was coded according to ABS categories and collapsed to those with post-school qualifications and those without post-school qualifications.5 Age was classified as younger (30-49 years) and older (50-69 years) to differentiate women within and outside the target age range of the national program. Results The raw response rate was 70.2% (calculated as completed interviews [3014] over contacted eligible women [4291]). After inflating the denominator by the estimated number of eligible women among those who could not be contacted (n = 389), the response rate was 64.4%. Seventy-nine women who had previously been diagnosed with breast cancer were excluded. The demographic characteristics of the remaining women are shown in Box 1. Of the 150 women asked, 127 (85%) consented to having their screening records checked. Of 126 women who reported having been screened within BreastScreen Australia within the last two years, attendance was confirmed for 121 (96%). Twenty-six per cent of women were able to recall the mammogram date accurately to the day, and a further 38% accurately recalled the month. Ninety-two per cent of women reported the mammogram date accurately to within 12 months. The weighted ABS estimate for the question Have you ever had a mammogram? was 50% (95% CI, 46.9-53.2). Responses to specific questions Do you know any ways to detect breast cancer in the early stages? -- 63.2% of respondents nominated mammography without prompting. Those more likely to nominate mammography were older women (chi-squared = 14.99; P < 0.01) and women with post-school qualifications (chi-squared = 12.05; P< 0.01). The Commonwealth and State governments fund a mammographic screening program in Australia known as the National Program for the Early Detection of Breast Cancer. In [respondent's State] it is known as [program name in respondent's State] . Have you heard of this Program? -- 88.7% of women responded that they had heard of the national program. More women in rural areas than in urban areas had heard of the program (92.9% v. 87.0%; chi-squared = 14.82; P< 0.001). More older than younger women had heard of the program (93.1% v. 86.2%; chi-squared = 42.09; P< 0.001). There was no difference in the proportion who had heard of the program by educational level. Which women do you think should attend for mammographic screening; only women who have no symptoms of breast cancer ; only women who have symptoms of breast cancer ; or it doesn't matter whether women have symptoms or not? -- only 1.3% of women correctly replied that screening was for women without symptoms, 2.9% replied that it was for women with symptoms, and 94.8% replied that it didn't matter. Slightly more younger women than older women thought screening was for women with symptoms (3.6% v. 2.0%; chi-squared = 11.70; P< 0.009). There were no differences between women living in urban and rural areas or according to educational level. When does the government program recommend women should start (stop) having mammograms? -- 60.3% of women correctly reported that the recommended commencement age was 50-59 years; 26.0% reported it was 40-49 years (see Box 2). More younger women than older women reported that the recommended commencement age was 40-49 years (28.1% v. 22.5%; chi-squared = 58.73; P= 0.001). Again, there were no differences in these proportions between women living in urban and rural areas or according to educational level. Most women (55.5%) thought screening should never cease, and 19.5% of women were unable to say when screening should stop (Box 2). How often does the government screening program suggest women should have a screening mammogram? -- 58.7% correctly reported that the government program suggests screening should be done every two years, but 26.7% reported that annual screening is recommended. More younger women than older women reported that annual screening is recommended (32.1% v. 17.4%; chi-squared = 178.76; P< 0.001). Referral and access to the government program Of respondents in the target age group (50-69 years), 34.7% reported that their GP had suggested they have a mammogram as part of the government program. This proportion did not vary by area of residence or by education level. Among all respondents, almost all women (95.8%) reported having visited a GP within the last two years. Among women in the target age group, 84.0% knew that a screening mammogram within the national program was free. More women with post-school qualifications knew this (87.9% v. 80.9%; chi-squared = 9.30; P= 0.01), but the proportions did not vary according to area of residence. Most women in the target age group (65.8%) reported being very confident of knowing how to make an appointment for a mammogram within the program, and this proportion did not differ according to area of residence or educational level. Participation in screening mammography A series of questions was used to determine whether women had had a mammogram within or outside the national program. To determine whether it had been a screening mammogram, they were then asked, When you had [that mammogram] was it because you already thought you had some problems with your breasts?. Overall, 55.0% of all women reported ever having had a mammogram (Box 3). The frequency of having had a mammogram rose steeply with age, peaking in the 50-59 years age group at 86.5%. Overall, 36.6% of women reported having had at least one screening mammogram (Box 3). Among women aged 30-39 years, approximately 6% reported having been screened, and this proportion rose to approximately 70% in the 50-69 years target age group. Having had a screening mammogram was not associated with area of residence or with education. In the target age group (50-69 years), 49.5% of women reported being screened in the national program within the last two years, and this was not influenced by area of residence or educational level. Another 12.1% reported having been screened outside the national program within the last two years. Among women 30-39 years of age, only 3% had been screened in the last two years, mostly outside the national program. In the older age groups, most women reported being screened within the national program (Box 4). Discussion Our findings are the first validated, baseline estimates of Australian women's knowledge of, and participation in, mammographic screening since the establishment of the national program. Our adjusted response rate of 64% compares well with those of similar reported surveys.6-8 The estimate by the ABS for the identical question Have you ever had a mammogram? was 50% (95% CI, 46.9-53.2) compared with ours of 55% (95% CI, 53.2-56.8), suggesting that our estimates are likely to be only minimally affected by selection bias. However, we excluded some women, notably non-English speakers and those living in homes without telephones. Also, as it is likely that women who chose to participate were more aware of breast cancer and screening mammography than those who refused, our data may overestimate both women's knowledge of, and participation in, such screening. Awareness of the national program was high (nearly 90%). Although asking a prompted question may have inflated this estimate, the result does suggest that the promotion of the program has been effective. The vast majority of women knew that the national program is free, and that it recommends women start screening at around 50 years of age and have a screening mammogram every two years. Most women also felt very confident in knowing how to access the program. The absence of significant variation in knowledge about screening mammography according to area of residence or educational level suggests that the national program has been successful in widely promoting screening. However, consistent with a previous study,9 most women were not aware that screening is intended only for asymptomatic women. Most women thought symptoms didn't matter, suggesting they appreciate to some extent that the national program is not designed for the evaluation of symptoms. While this may be encouraging, it is still of some concern as people who do not appreciate the distinction between diagnostic and screening tests may be more likely to seek compensation for missed diagnoses.9 As most women reported that their GPs had never recommended they attend the national program for screening, there is a greater opportunity for GPs to recruit more women to screening. Our findings indicate that attendance for mammography is becoming increasingly common. Surveys conducted in 1988 found that only 18% of women spontaneously mentioned mammography as a means of detecting breast cancer in the early stages, and 50% claimed to have heard of it when prompted.10 Only about 10%-20% of women had ever had a mammogram, about half for diagnostic and half for screening purposes.7,11 Clearly, this situation has changed dramatically, with 60% of women now nominating mammography as a means of early detection in an unprompted question, 55% of all women reporting having ever had a mammogram, and 37% of women reporting having had at least one screening mammogram. High proportions of women in the age group targeted by the national program reported having been screened at least once (70%) and having been screened in the last two years (about 60%). Many more of these women are being screened as part of the national program than outside it. Our finding that 49.8% of women in the target age group had been screened within the national program in the last two years is consistent with BreastScreen Victoria's estimated participation rate of 47.7%.12 Recent meta-analyses showing a small reduction in mortality after about 10 years of screening for women aged 40-49 years13 have prompted heated debate over whether younger women should also be targeted for screening. It is interesting to note that we found quite high screening rates among women aged 40-49 years, indicating that many women in this age group are, in fact, already being screened. References Taylor R, Smith D, Hoyer A, et al. Breast Cancer in New South Wales 1972-1991. Sydney: NSW Cancer Council, 1994. Kerlikowske K, Grady D, Rubin SM, et al. Efficacy of screening mammography. A meta-analysis. JAMA 1995; 273: 149-154. Glasziou P, Woodward AJ, Mahon CM. Mammographic screening trials for women aged under 50. A quality assessment and meta-analysis. Med J Aust 1995; 162: 625-629. Department of Primary Industries and Energy, Department of Human Services and Health. Rural, remote and metropolitan areas classification. Canberra: AGPS, 1994. Australian Bureau of Statistics. Labour force status and educational attainment, Australia. Canberra: Australian Bureau of Statistics, 1994. (Catalogue No. 6235.0.) Etzi S, Lane DS, Grimson R. The use of mammography vans by low-income women: the accuracy of self-reports. Am J Public Health 1994; 84: 107-109. Hill D, White V, Borland R, Cockburn J. Cancer-related beliefs and behaviours in Australia. Aust J Public Health 1991; 15: 14-23. Smith W, Chey T, Jalaludin B, et al. Increasing response rates in telephone surveys: a randomized trial. J Public Health Med 1995; 17: 33-38. Cockburn J, Redman S, Hill D, Henry E. Public understanding of medical screening. J Med Screening 1995; 2: 224-227. Cockburn J, Murphy B, Schofield P, et al. Development of a strategy to encourage attendance at screening mammography. Health Ed Res Theory Practice 1991; 6: 279-290. Irwig L, Cockburn J, Turnbull D, et al. Women's perceptions of screening mammography. Aust J Public Health 1991; 15: 24-32. BreastScreen Victoria: 1995 annual statistical report. Melbourne: BreastScreen Co-ordination Unit, 1996. Breast-cancer screening with mammography in women aged 40-49 years. Report of the Organizing Committee and Collaborators, Falun Meeting, Falun, Sweden 1996. Int J Cancer 1997; 68: 693-699. (Received 11 Mar, accepted 12 Aug, 1997) Authors' details Department of Public Health and Community Medicine, University of Sydney, NSW. Alexandra L Barratt, PhD, FAFPHM, Lecturer. Discipline of Behavioural Science in Relation to Medicine, University of Newcastle, NSW. Jill Cockburn, PhD, Head. National Health and Medical Research Council National Breast Cancer Centre, Sydney, NSW. Sally Redman, PhD, Director; Christine Paul, PhD, Consultant Behavioural Scientist. New South Wales Cancer Council Cancer Education Research Program, Wallsend, NSW. Janice Perkins, PhD, Research Associate. Currently at the Discipline of Behavioural Science in Relation to Medicine, University of Newcastle, NSW. No reprints will be available. Correspondence: Dr A L Barratt, Department of Public Health and Community Medicine, Building A27, University of Sydney, NSW 2006. - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Evaluation of the ThinPrep Pap test as an adjunct to the conventional Pap smear Jennifer M Roberts, A Marion Gurley, Julia K Thurloe, Ronald Bowditch and Colin R A Laverty For editorial comment, see Wain 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 evaluate the ThinPrep Pap test as an adjunct to the conventional Pap smear. Design and setting: Prospectively collected cervical samples were split for independent screening at a large specialised private gynaecological pathology practice in Sydney. Main outcome measures: Detection of additional significant abnormalities (cervical intraepithelial neoplasia 1, or more severe); changed management recommendations from "repeat smear in 12 months" or "...six months" to "colposcopy"; a reduction in unsatisfactory reports. Results: 35 560 paired (split-sample) conventional and ThinPrep slides were prepared. Significant abnormalities were detected in 724 conventional smears (2%). Additional significant abnormalities were found in 85 ThinPrep slides whose corresponding conventional smear was negative or unsatisfactory even after review, representing a 12% increase in the detection of significant abnormalities. As a result of the addition of ThinPrep, management recommendations were changed from "repeat smear in 12 months" or "...six months" to "colposcopy" for 89 of 1669 women whose conventional Pap smears showed minor non-specific changes or papillomavirus. There were 1258 conventional smears (3.5%) that were unsatisfactory compared with 235 ThinPrep slides (0.7%); for only 74 samples (0.2%) were both slides unsatisfactory. Conclusions: The addition of the ThinPrep Pap test improves detection and clinical management of cervical abnormalities, and reduces the number of unsatisfactory samples which would otherwise require repeat tests. MJA 1997; 167: 466-469 Introduction The conventional Pap smear has been the mainstay of screening for cervical precancer for approximately 50 years, without major changes in techniques relating to preparation and interpretation. In recent years there has been increasing pressure to improve Pap smear standards to reduce the occurrence of false negative results, with their associated morbidity and mortality for the women involved, and legal consequences for health professionals.1,2 Many false negative cases are the result of problems of sample transfer and smear quality.3,4 The conventional Pap smear represents only a small subsample of the cellular material collected on the sampling implement,5,6 with the remainder traditionally being discarded. Importantly, this small subsample is a non-random fraction of the material collected and is not necessarily representative of the whole. The traditional smearing technique also produces slides which vary greatly in quality, making it sometimes difficult to find and interpret abnormal cells. Improvements in both subsample selection and slide quality should therefore reduce the number of false negative cases. The ThinPrep Pap test is an automated technique developed with the aim of producing better quality slides.7 Each cervical sample is rinsed into a vial of fixative fluid. In the laboratory the sample is homogenised, and a representative subsample is collected on a single-use filter, transferred to a glass slide, and stained in the routine fashion. This technique results in a better quality preparation, as the problems of poor fixation, uneven thickness of the cellular spread, and obscuring of cells by blood and inflammatory exudate are overcome. We aimed to evaluate the impact of this technology on detection rates of significant abnormalities, accuracy in reporting, and numbers of unsatis - fact ory preparations when it was used in addition to the conventional Pap smear. Methods In a pilot study in the first half of 1996, we evaluated 1051 samples to test the performance of the ThinPrep 2000 machine (Cytyc Corporation, Boxborough, Mass., USA), as previous experience with an earlier model had highlighted some technical problems.8 The pilot study showed slides of uniformly high quality and so, in July 1996, the test was offered to all referring practitioners at a charge to patients of $20.30. For this study, we analysed paired samples collected between 1 July 1996 and 30 May 1997 by practitioners who chose to offer ThinPrep (TP) to their patients as an adjunct test. We used a split-sample protocol in which routine samples of the transformation zone (squamo-columnar junction) -- the area of the cervix where abnormalities are most likely to occur -- were taken with a broom-like device, the Cervex brush (Rovers BV, Netherlands). We insisted on the use of this implement as our earlier study8 had shown that sampling with a spatula was more likely to result in a TP slide with insufficient cells. For postmenopausal women and those who had had previous cervical surgery or ablation, an endocervical brush sample was added. After a conventional Pap smear was made, the sampling implement was vigorously rinsed in a vial of PreservCyt fixative fluid (Cytyc Corporation, Boxborough, Mass., USA). TP slides were prepared from the vial by the ThinPrep 2000 machine and both slides were stained routinely. A duplicate of each request form was made, and the conventional smear and the TP slide were examined independently by different cytotechnologists. Nineteen of our 28 cytotechnologists were involved in reading the TP slides; all 28 read conventional smears. Any slide showing minor abnormalities was reviewed by a second experienced cytotechnologist. If cervical intraepithelial neoplasia (CIN) of any grade was detected, or if a high grade lesion was suspected, the case was referred to a cytopathologist for review. Slide pairs (conventional Pap smear and TP) displaying a significant discrepancy were also reviewed. The final report issued to the referring doctor was structured according to the National Health and Medical Research Council (NHMRC) reporting terminology9 (see Box 1) and contained any relevant information obtained from both slides, together with the relevant management recommendations. For the purposes of analysis, separate final results of the two slides were also recorded. A significant abnormality was defined as one for which the management recom mendation is "colposcopy" (see Box 1). This includes any grade of CIN, adenocarcinoma in situ (AIS), invasive carcinoma or the suspicion of a high grade abnormality ("inconclusive" in NHMRC terminology). Results Approximately 500 referring practitioners chose to offer TP to their patients as an adjunct test. Some of these doctors offered the TP test to all women, and others only to selected women. Thirty-five per cent of women having non-screening cytological tests had TP, whereas only 24% of women having routine cytological tests had TP. Currently, about 30% of all smears received in this laboratory are accompanied by a TP sample. We received 35 560 paired split-sample conventional Pap smear slides and TP samples for analysis in this study. Box 1 presents a comparison of final (i.e., reviewed) results for TP and conventional Pap smear slides. Of the 34 141 paired results that were satisfactory for both slides, 32 195 (94.3%) showed total agreement and 1946 (5.7%) did not. Of the latter group, the TP slide showed a more severe abnormality than the conventional slide in 1194 (61.4%), and the opposite was true in 752 (38.6%; chi-squared = 100.4; df = 1; P < 0.001). For the 1946 paired slides which did not show total agreement, 271 had substantial discrepancies in which colposcopy would have been recommended based on the result of one test, but not the other. Of these, colposcopy would have been recommended on the basis of the TP result alone for 167 (61.6%), and on the basis of the conventional Pap smear result alone for 104 (38.4%; chi-squared = 14.6; df = 1; P < 0.001). Significant abnormalities were detected in 724 conventional smears. An additional 85 significant abnormalities were detected on TP slides for which the corresponding conventional slides, even after review, were either negative (78) or unsatisfactory (7). This represents a 12% increase in the detection of significant abnormalities. There were 14 TP slides that predicted high-grade epithelial abnormality (HGEA), while the corresponding conventional smears were either negative or unsatisfactory. Histological follow-up of 11 of these confirmed HGEA in eight, and low-grade epithelial abnormality (LGEA) in three. There were also 27 TP slides reported as inconclusive, while the corresponding conventional smears were either negative or unsatisfactory. Histological follow-up of 17 of these showed HGEA in seven, LGEA in eight, and inflammation in only two. Further, 15 conventional smears originally reported as negative, and reviewed because their TP counterparts showed an abnormality, were subsequently reported as HGEA or inconclusive. These "screening" false negatives are not represented in Box 1, which shows only final results (i.e., after review). ThinPrep slides not only increased detection of abnormalities, but also influenced management recommendations. On the basis of conventional smear tests, the recommendations for 1669 women (4.7%) with minor non-specific changes or features of human papillomavirus (HPV) effect were "repeat smear in 12 months" or "...six months", respectively. For 89 of these women (5.3%), this recommendation was changed to "colposcopy" as a result of a higher grade abnormality being detected on the TP slide. Histological follow-up concentrated on the predicted HGEA and inconclusive categories. Findings are shown in Box 2 (below). Of conventional smears, 1258 (3.5%) were found to be unsatisfactory, but only 74 (0.2%) were unsatisfactory by both methods, representing a 94% reduction in unsatisfactory reports. TP predicted HGEA in four smears reported as unsatisfactory on the conventional smear; all four have been histologically confirmed to be HGEA. Minor abnormalities (minor non- specific changes/HPV) were detected in 1669 (4.7%) of the conventional smears and 2027 (5.7%) of the TP slides. An endocervical component was absent in 8.3% of the conventional smears and in 20.0% of the TP slides. In 6.4% of cases, neither slide displayed an endocervical component. With respect to glandular abnormalities, 13 cases of adenocarcinoma in situ (AIS) or adenocarcinoma were detected by both methods. There was one histologically confirmed case of adenocarcinoma in which the conventional smear was reported as inconclusive (suspicious of AIS) and the corresponding TP slide was negative. Further TP slides were made from the remaining sample in the vial but none of these contained abnormal cells. Discussion Overall, we found that diagnostic agreement between the conventional Pap smear and the TP Pap test was high. Where there was disagreement, a higher grade abnormality was predicted significantly more often by TP than by the conventional smear. The addition of the TP test resulted in detection of additional histologically confirmed HGEA, leading to a reduction in the number of false negatives and a corresponding increase in sensitivity. The fact that the same proportion of HGEA (83%) was histologically confirmed for both conventional Pap smear and TP shows that TP does not result in undue overreporting, and that, although sensitivity has been increased, the positive predictive value of the test has been maintained. The extra significant abnormalities detected on TP and the increased accur acy of reporting are mainly attributable to improved subsampling of the cervical specimens, resulting in fewer "subsampling" false negatives. Computer-assisted rescreening of conventional smears would have no impact on this area. "Screening" false negatives (although few in this study) will also be reduced by the addition of a slide of much higher quality, and by the independent screening of additional material. That there were cases in which an abnormality detected on conventional smear was not detected on TP is not surprising, as the split-sample protocol favours the conventional smear. In these cases it appears that all abnormal cells in the sample were transferred to the conventional smear, leaving none in the TP vial. A "direct-to-vial" protocol in which 100% of the material collected is rinsed into the fluid fixative should eliminate this problem. However, if only a very small number of abnormal cells are present in the vial, then they may not be represented on any single TP slide. The addition of the TP test resulted in a large reduction in reporting of unsatisfactory preparations. This is a direct result of removal of the many variables associated with the conventional Pap smear technique (poor fixation, uneven thickness of the cellular spread, and obscuring of cells by blood and inflammatory exudate), and represents significant time and cost savings, as the need for a repeat smear is avoided. Significantly, there were four women with histologically confirmed HGEA which was predicted by TP, but whose conventional smears were reported as unsatisfactory. These abnormalities may have been detected by the recommended repeat smear three months later, but there is always a risk that women will not return for follow-up. A very small percentage of TP slides were unsatisfactory and this was always the result of there being insufficient cells in the specimen. In these cases the machine reported a dilute specimen. We believe that a number of these cases were the result of the use of incorrect sampling implements, contrary to the recommended protocol. Of some surprise to us was the increase in reporting of minor non-specific changes. While some of this no doubt represents a genuine increase in detection of minor abnormalities, we feel that other factors must be contributing. In particular, we believe that the improved nuclear morphology obtained in the TP process requires cytotechnologists and cytopathologists to "relearn" subtle criteria used at this end of the diagnostic spectrum. We noted this trend early in the study period and have been addressing it with numerous educational sessions. We continue to monitor reporting in this category. The addition of TP tests resulted in a decreased proportion of combined reports lacking an endocervical compon ent. However, TP alone had a higher rate of absent endocervical compon ent. The reason for this is unclear, but may relate to TP slides being prepared from left-over cellular material. We can only speculate that the "endocervical component present" rate may improve in a direct-to-vial situation. Even though there were more TP slides lacking an endocervical component, there was only one case in which there was a significant glandular abnormality present in the conventional smear and not in the TP slide. As further slides prepared from the TP vial also failed to show abnormal cells, we assume that no abnormal cells were present in the vial. An important advantage of the TP process is the presence of further cellular material in the fluid fixative which can be used to prepare more slides, or for HPV typing which may have clinical relevance in the triage of patients with low grade abnormalities.10 In the United States, the Food and Drug Administration has approved the TP Pap test as a replacement for the conventional Pap smear.11 This decision was based on analysis of data on 7360 paired samples derived from six different centres (Data on file, Cytyc Corporation, Boxborough, Mass., USA). Our data, on a larger sample from a single practice, support the assertion that the TP Pap test performs substantially better than the conventional smear on analysis of significant parameters. While we continue to offer the TP Pap test as an additional proced ure, we anticipate that the machine-made slide may replace the conventional smear in the future. Acknowledgements We thank Tabatha Lovelace, Lisa Wong, Rozanne Van Gramberg and Samira Bounassif for technical assistance. Statement of potential conflict of interest: The Cytyc Corporation (Boxborough, Mass., USA) lent us one of the Thinprep 2000 machines used in this study. The company was not involved in the design of the study, collection of data, analysis of results or preparation of the manuscript. References DeMay RM. To err is human -- to sue American. Diagn Cytopathol 1996; 15: iii-vi. Skoumal SM, Florell SR, Bydalek MK, Hunter WJ. Malpractice protection: communication of diagnostic uncertainty. Diagn Cytopathol 1996; 14: 385-389. Gay JD, Donaldson LD, Goellner JR. False-negative results in cervical cytologic studies. Acta Cytol 1985; 29: 1043-1046. Joseph MG, Cragg F, Wright VC, et al. Cyto-histological correlates in a colposcopic clinic: a 1 year prospective study. Diagn Cytopathol 1991; 7: 477-481. Hutchinson ML, Isenstein LM, Goodman A, et al. Homogeneous sampling accounts for the increased diagnostic accuracy using the ThinPrep Processor. Am J Clin Pathol 1994; 101: 215-219. Goodman A, Hutchinson ML. Cell surplus on sampling devices after routine cervical cytologic smears. A study of residual cell populations. J Reprod Med 1996; 41: 239-241. Zahniser DJ, Hurley AA. Automated slide preparation system for the clinical laboratory. Cytometry 1996; 26: 60-64. Laverty CRA, Thurloe JK, Redman NL, Farnsworth A. An Australian trial of ThinPrep: a new cytopreparatory technique. Cytopathology 1995; 6: 140-148. National Pathology Accreditation Advisory Council, Commonwealth Department of Health and Family Services. Requirements for gynaecological (cervical) cytology. Canberra: AGPS, 1997. Sherman ME, Schiffman MH, Lorincz AT, et al. Cervical specimens collected in liquid buffer are suitable for both cytological screening and ancillary Human Papilloma virus testing. Cancer 1997; 81; 89-97. Communication, 20 May 1996. Rockville, Md.: Center for Devices and Radiological Health, Food and Drug Administration, 1996. (Received 3 Feb, accepted 14 July 1997) Authors' details Dr Colin Laverty & Associates, Pathologists, Eastwood, NSW. Jennifer M Roberts, MB BS, FRCPA, Pathologist; A Marion Gurley, MB ChB, FIAC, Pathologist; Julia K Thurloe, BSc, MEc, Statistician; Ronald Bowditch, BScAg CT(ASC), Senior Cytotechnologist; Colin R A Laverty, MB BS, FRCPA, Principal Pathologist. Reprints: Dr C R A Laverty, Dr Colin Laverty & Associates, Pathologists, 18 Glen Street, Eastwood, NSW 2122. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Reduction of inappropriate use of blood products by prospective monitoring of transfusion request forms Annabel Tuckfield, Michael N Haeusler, Andrew P Grigg and Jack Metz For editorial comment, see Allain & Williamson 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 the effect of prospective monitoring on appropriateness of transfusions of red cells, platelets and fresh frozen plasma (FFP). Design: Prospective interventional study. Setting: Royal Melbourne Hospital (a tertiary teaching hospital), Melbourne, Victoria, March-May 1996. Intervention: The blood product request form was modified to incorporate indications for transfusion and clinical and laboratory data. Requests were monitored by blood bank laboratory staff for conformation with hospital transfusion guidelines; non-conforming requests were discussed with the requesting medical practitioner by the Haematology Registrar before blood products were issued. In cases of disagreement, blood products were always issued. Subjects: 200 consecutive transfusion episodes for each product (red cells, platelets and FFP). Outcome measures: Appropriateness of transfusion, assessed by a Consultant Haematologist according to hospital guidelines. Rates of inappropriate transfusion episodes after intervention were compared with rates in a previous study. Results: After intervention, rates of inappropriate transfusion episodes fell significantly (red cells, 16% to 3% [P=0.004]; platelets, 13% to 2.5% [P=0.02]; and FFP, 31% to 15% [P=0.02]). Almost all inappropriate FFP transfusion episodes post-intervention were due to failure to demonstrate prolongation of prothrombin or activated partial thromboplastin times more than 1.5 times the control value. Conclusion: Prospective monitoring of request forms can reduce rates of inappropriate transfusions. High rates of inapproriate FFP transfusions possibly reflect uncertainty about appropriate laboratory criteria for FFP transfusion. While results of large prospective randomised controlled clinical trials of FFP transfusions are awaited, current laboratory criteria can be retained, but should be applied with flexibility. MJA 1997; 167: 473-476 Introduction In 1995, we reported results of an audit of blood product use at a tertiary teaching hospital (Royal Melbourne Hospital, Victoria).1 Indications for transfusion were analysed, mainly by retrospective review of medical records. We found that blood product use was inappropriate for 16% of red cell, 13% of platelet and 31% of fresh frozen plasma (FFP) transfusion episodes. In a significant number of episodes, the specific indication for transfusion was not documented in the medical record. Blood products must be used appropriately to minimise patient exposure to potential hazards, to conserve a limited resource and to contain costs. Measures to reduce inappropriate use of blood products have had varying results. While retrospective audit and education do not produce consistent and continuing improvements,2-8 prospective monitoring (monitoring of requests for blood products before issue) has usually been more successful.9-15 Consequently, in March 1996, the Royal Melbourne Hospital introduced prospective monitoring of transfusion requests with the aim of reducing inappropriate use of blood products. We present the results of the first three months of this intervention. Methods Intervention Blood products request form: The blood products request form was redesigned to incorporate the indication for transfusion and relevant clinical and laboratory data. These included: For red cells: haemoglobin level and clinical parameters (pulse rate and blood pressure); For platelets: platelet count and presence or absence of bleeding; For FFP: results of coagulation tests (prothrombin time [PT] or international normalised ratio [INR] and activated partial thromboplastin time [APTT]); and For all blood products: reasons for transfusion and operation (if applicable). In addition, the redesigned request form stipulates that the indication for transfusion must conform with the hospital's transfusion guidelines, which are printed on the reverse of the form (Box 1). Criteria for appropriate transfusions: The criteria were the same as those used in the audit.1 For FFP use, the requirement for coagulation times to be prolonged by more than 50% translated to PT >20 seconds or APTT >40 seconds. For massive blood transfusion (10 or more units of red cells in less than 24 hours), blood products were issued before laboratory results were available, and these transfusions were accepted as appropriate. In view of the potentially devastating effects of minor haemorrhage associated with neurosurgical procedures, these were exempted from the criteria for FFP use.1 Monitoring: On receiving a completed blood product request form, the senior medical laboratory scientist determined that the necessary information had been provided, and telephoned the requesting doctor to obtain any missing information. The scientist then checked that the indications conformed with transfusion guidelines, and if so, blood products were issued. If clinical or laboratory indications did not conform, the request was referred to the Haematology Registrar who consulted the requesting doctor. There were three possible outcomes: they agreed (i) either that the transfusion was not indicated and the blood products were not issued or (ii) that it was indicated and the products were issued or (iii) they disagreed and the products were issued. The consultation was never confrontational, and the blood product was always issued when there was disagreement. However, for the study these cases were subsequently referred to the Consultant Haematologist who reviewed the haematological data, transfusion request and medical record to decide if the transfusion was indeed inappropriate. Analysis of outcomes For each type of blood product (red cells, platelets and FFP), we analysed 200 consecutive transfusion episodes between March and May 1996. As in the initial audit, we excluded FFP transfusions for patients with thrombotic thrombocytopenic purpura, because of the different rationales for FFP use in this condition and in coagulation factor depletion. Rates of inappropriate blood product use after introduction of prospective monitoring were compared with those found during the previous audit (pre-intervention) with two-sided Fisher's exact tests. Results Indications for transfusion of red cells, platelets and FFP after introduction of prospective monitoring are shown in Box 2 (below). They were the same as in the pre-intervention audit.1 Numbers of transfusions referred to the Consultant Haematologist for review were: red cells, eight; platelets, 12; and FFP, 41. Final numbers of transfusion episodes deemed inappropriate were: red cells, six (3%); platelets, five (2.5%); and FFP, 30 (15%). Compared with the pre-intervention audit, rates of inappropriate transfusion episodes were significantly reduced, from 16% to 3% for red cells (P= 0.004), 13% to 2.5% for platelets (P=0.02) and 31% to 15% for FFP (P= 0.02). Of the six patients in whom red cell use was deemed inappropriate, five had a pretransfusion haemoglobin concentration greater than 100 g/L, the threshold for appropriate transfusion (range in these patients, 104-114 g/L). The sixth patient had a haemoglobin concentration of 98 g/L, but no clinical indications to warrant transfusion. In four of the five inappropriate platelet transfusion episodes, the platelet count was greater than 63x109/L (range, 63x109-159x109/L), a level at which platelets are not indicated except in the case of excessive bleeding with cardiac bypass surgery. Although three of these four transfusions were given in association with cardiac bypass surgery, there was no evidence of excessive bleeding. In 30 patients, FFP transfusion was deemed inappropriate as coagulation test results did not meet the criterion of a 50% prolongation of coagulation times. In one of these 30, this was because no coagulation tests had been performed. Discussion We found that the rate of inappropriate transfusion episodes fell significantly after introduction of prospective monitoring, from 16% to 3% for red cells, from 13% to 2.5% for platelets and from 31% to 15% for FFP. The success of prospective monitoring in reducing rates of inappropriate transfusions for red cells and platelets was not matched for FFP. This agrees with results of three previous studies, which have found persistently high rates of FFP transfusions despite monitoring (>40%,8 33%13 and 27%,15 respectively). As in these studies, we found the reason for deeming FFP use inappropriate was almost invariably failure to show sufficient abnormality in coagulation test results. The need to document abnormal coagulation with a PT or APTT greater than 1.5 x the control value, before FFP transfusion is deemed appropriate, rests on the assumptions that abnormal bleeding is unlikely if coagulation times are shorter than this but likely if they are longer, and that, when coagulation times are greater than 1.5 x the control value, FFP transfusion is likely to prevent or control bleeding. Detailed analysis of published data suggests that these assumptions are questionable.16-23 It is of interest that we found that lowering the cut-off for appropriate FFP transfusions from PT >20 seconds (1.5 times the control value) to PT >17 seconds would have lowered the rate of inappropriate transfusions from 15% to 3%, comparable to the rate found for red cell and platelet transfusions. A PT of 17 seconds is still 3.5 seconds longer than the median control value. Further investigation is needed to establish the clinical guidelines for FFP transfusion. Two publications24,25 have pointed to the need for a large multicentre prospective randomised controlled clinical trial to provide a definitive answer for the role of FFP in patients with acquired multiple coagulation defects. In the interim, it would seem reasonable to require docu mentation of abnormal coagulation as a criterion for appropriate FFP use, but the available evidence does not warrant rigid application of a cut-off level, such as 50% prolongation of PT or APTT. Other issues that must be addressed before a system of prospective monitoring can be introduced include exemption criteria. Some protocols exempt operating room patients,6 "desperate situations"14 and haematology and oncology patients.13 Emergency situations are also usually exempted from the requirement for laboratory data if the laboratory cannot provide urgent results at all times. If the criteria are to be applied to emergency situations, laboratory facilit ies must be available to provide the data quickly. In some programs of prospective monitoring, blood products are never withheld, but apparently inappropriate transfusions are later reviewed.11,14 Refusal to issue blood products leads to an adversarial relationship between clinicians and laboratory staff, which may compromise patient care. Refusal might also have medicolegal implications if subsequent patient morbidity or death could be attributed to withholding of the transfusion. For sustained improvement in practice, prospective monitoring must be continued indefinitely.11 This is both time consuming and demanding of staff. The demand might be lessened by computerised audit of transfusion requests; clinical and laboratory data could be entered into a program which flags non-compliant requests for review by blood bank staff.26 In conclusion, prospective monitoring was successful in reducing inappropriate use of red cells and platelets, but only partly successful for FFP. This probably reflects uncertainty about the appropriate clinical guidelines for FFP use, and although current laboratory criteria for FFP use should probably be retained, they should be applied with flexibility. References Metz J, McGrath KM, Copperchini ML, et al. Appropriateness of transfusions of red celIs, platelets and fresh frozen plasma. An audit in a tertiary care teaching hospital. Med J Aust 1995; 162: 572-577. Lam HTC, Schweitzer SO, Petz L, et al. Are retrospective peer-review transfusion monitoring systems effective in reducing red blood cell utilization? Arch Pathol Lab Med 1996; 120: 810-816. Toy PTCY. Audit and education in transfusion medicine. Vox Sang 1996; 70: 1-5. Bamerte RE, Fish DJ, Eisenstaedt RS. Modification of fresh frozen plasma transfusion practices through educational intervention. Transfusion 1990; 30: 253-257. Soumerai SB, Salem-Schatz S, Avorn J, et al. A controlled trial of educational outreach to improve blood transfusion practice. JAMA 1993; 270: 961-966. Solomon RR, Clifford JS, Gutman SI. The use of laboratory intervention to stem the flow of fresh frozen plasma. Am J Clin Pathol 1988; 89: 518-521. Brien WF, Buttier RJ, Inwood MJ. An audit of blood component therapy in a Canadian general teaching hospital. Can Med Assoc J 1989; 140: 812-815. Shanberge JN, Quattrochiocchi-Longe T. Analysis of fresh frozen plasma administration with suggestions for ways to reduce usage. Transfus Med 1992; 2: 189-194. Simpson MB. Prospective concurrent audits and medical consultation for platelet transfusions. Transfusion 1987; 27: 192-195. McCullough J, Steeper TA, Connelly DP, et al. Platelet utilization in a university hospital. JAMA 1988; 259: 2414-2418. Silver H, Tahhan HR, Anderson J, et al. A non- computer dependent prospective review of blood and blood component utilization. Transfusion 1992; 32: 260-265. Brandis K, Richards B, Ghent A, et al. A strategy to reduce inappropriate red blood cell transfusion. Med J Aust 1994; 160: 721-722. Hawkins TE, Carter JM, Hunter PM. Can mandatory pretransfusion approval programmes be improved? Transfus Med 1994; 4: 45-50 Cheng G, Wong HF, Chan A, et al. The effects of a self-educating blood component request form and enforcements of transfusion guidelines on FFP and platelet usage. Clin Lab Haem 1996; 18: 83-87. Marconi M, Almini D, Pizzi MN, et al. Quality assurance of clinical transfusion practice by implementation of the privilege of blood prescription and computerized prospective audit of blood requests. Transfus Med 1996; 6: 11-19. Counts RB, Haisch C, Simon TL, et al. Hemostasis in massively transfused trauma patients. Ann Surgery 1979; 190: 91-99. Braunstein AH, Oberman HA. Transfusion of plasma components. Transfusion 1984; 24: 281-286. Ciavarella D, Reed RL, Counts RB, et al. Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient. Br J Haematol 1987; 67: 365-368. Harvey MP, Greenfield TP, Sugrue ME, et al. Massive blood transfusion in a tertiary referral hospital. Clinical outcomes and haemostatic complications. Med J Aust 1995; 163: 356-359. Houry S, Georgeac C, Hay J, et al. A prospective multicentre evaluation of preoperative hemostatic screening tests. Am J Surg 1995; 170: 19-23. Gelb AB, Roth RI, Levid J, et al. Changes in blood coagulation during and following cardiopulmonary bypass. Lack of correlation with clinical bleeding. Am J Clin Pathol 1996; 106: 87-99. Murray DJ, Olson JD, Strauss AR, et al. Coagulation changes during packed red cell replacement of major blood loss. Anesthesiology 1988; 69: 839-845. Murray DJ, Pennell BJ, Weinstein SL, et al. Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding. Anesth Analg 1995; 80: 336-342. McVay PA, Toy PTCY. Lack of increased bleeding after liver biopsy in patients with mild hemostatic abnormalities. Am J Clin Pathol 1990; 94: 747-753. Cohen H. Avoiding the misuse of fresh frozen plasma. BMJ 1992; 307: 395-396. Gardner RM, Golubjatnikov OK, Laub RM, et al. Computer critiqued blood ordering using the HELP system. Comput Biomed Res 1990; 23: 514-528. (Received 20 Mar, accepted 1 Jul 1997) Authors' details Department of Diagnostic Haematology, Royal Melbourne Hospital, Melbourne, VIC. Annabel Tuckfield, FRACP, FRCPA, Registrar; Michael N Haeusler, FAIMS, Senior Scientist, Blood Bank; Andrew P Grigg, FRACP, FRCPA, Haematologist; Jack Metz, MD, FRCPA, Head. Reprints will not be available from the authors. Correspondence: Dr A Tuckfield, Diagnostic Haematology, Post Office, Royal Melbourne Hospital, Parkville, VIC 3050. E-mail: depATmis.medrmh.unimelb.edu.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

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

Early discharge and risk for postnatal depression Anthea R Hickey, Philip M Boyce, David Ellwood and Allen D Morris-Yates For editorial comment, see Buist 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 whether early discharge ( < 72 hours) after childbirth increased the risk for women developing postnatal depression. Design: Prospective cohort design consisting of an initial interview, and six-weekly assessments for 24 weeks using a self-report questionnaire and the Edinburgh Postnatal Depression Scale (EPDS). Women discharged within 72 hours were compared with the remaining women. Setting: Tertiary referral hospital in western Sydney, New South Wales, 1993. Participants: All 749 women delivering over a three-month period were recruited. Of the 522 participants, 425 women completed the study. Main outcome measures: Women scoring > 13 on the EPDS on two or more occasions were considered potential "cases" of postnatal depression. The diagnosis was confirmed using the Structured Clinical Interview for DSM-III-R disorders (SCID). Results: Of the 153 women (36%) discharged early, 22 women (14.4%) developed postnatal depression over the study period compared with 20 of the 272 women (7.4%) who had standard length of stay. Women who were discharged within 72 hours had a significantly increased risk for developing postnatal depression (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.07-4.21). This risk persisted when other sociodemographic, obstetric and psychosocial risk factors were controlled for in a logistic regression analysis (OR, 3.06; 95% CI, 1.22-7.69). Conclusion: Women planning early discharge after childbirth should be carefully assessed before discharge and follow-up should be rigorous. The potential to develop postnatal depression should be considered in all women choosing early discharge from hospital. MJA 1997; 167: 244-247 Introduction Over the past 20 years, technological advances have contributed to improved maternal and infant outcomes. In parallel, women have become more involved in their obstetric care: wanting to be more informed, be able to make choices and have childbirth demedicalised and "normalised". One initiative aimed at normalising the process has been early discharge programs, enabling women to return home earlier after childbirth than had been traditional. Women's desire for early discharge has fitted in well with the financial constraints put upon health care systems; reduced length of stay is seen as desirable because it reduces the cost of obstetric care. Postpartum studies have reported early-discharge programs to be a safe, cost-effective and satisfying alternative to the standard length of hospital stay among low-risk mothers and their infants.1-5 While these studies have shown that early discharge has no adverse physical effects, the only psychological effects examined have been women's satisfaction about making a choice or taking control of discharge rather than psychological morbidity.5,6 As postnatal depression is a common disorder which may have a long-term impact on the mother and her infant,7 the psychological outcome after childbirth is increasingly being recognised as important.8 Postnatal depression is associated with psychosocial factors, such as an excess of adverse life events, lack of social support, dysfunctional personality style and a past history of depression.8,9 Obstetric factors, such as emergency caesarean section, have also been implicated,10,11 but the impact of early discharge has not been extensively examined. The aim of our study was to investigate whether early discharge following childbirth had an effect on the development of postnatal depression in a heterogeneous sample of women. Methods Subjects All women who delivered at the Nepean Hospital, NSW, over a three-and-a-half-month period in 1993 were invited to participate in the study. Women were excluded from the study if their baby was stillborn, born with congenital abnormalities, adopted out, transferred to another hospital, or if the mother was diagnosed as suffering from puerperal psychosis. Early discharge was defined as discharge within 72 hours (the definition used at Nepean Hospital). Survey instruments Questionnaire: A self-report questionnaire was used to assess social and demographic circumstances. Socioeconomic status was determined according to a status-ranking list of occupations in Australia,12 using the women's partner's occupation (or her parents' occupation when this was not appropriate). A nine-item personality scale was included that identified different personality traits, scored on a 5-point Likert scale. Factor analysis of this personality scale identified "vulnerable" and "resilient" personality dimensions. The vulnerable personality dimension included being a worrier, nervy, timid and unassertive, sensitive, liable to emotional outbursts and needing to do things right. This scale is reliable (Cronbach α= 0.75), and is associated with increased risk for postnatal depression (Boyce P M, Hickey A R, Greenstock J A and Talley N J, Nepean Hospital, unpublished data). Interview: A semi-structured interview (conducted by A R H) was used to assess obstetric history, satisfaction with the labour, whether the delivery was congruent with expectations, the quality of the woman's social support, her personal and family psychiatric history, and the quality of her intimate relationships. We also obtained obstetric details from the labour ward computerised database. Edinburgh Postnatal Depression Scale (EPDS):13 The EPDS is a specifically designed measure of postnatal depression that has shown reliability and validity for the postpartum period.14-16 It consists of a 10-item self-report scale, with each item scored 0-3. A score of 13 or above is indicative of postnatal depression. It is not contaminated by symptoms (e.g., fatigue, weight loss, broken sleep) which may be reported by healthy nursing mothers. Tennant and Andrews life events scale:17,18 A self-report scale comprising 10 relevant life events (e.g., death of a family member or close friend, moving house, marriage); subjects were asked whether each event had happened to her over the past 12 months. A modified version of this scale was used in our study. Structured Clinical Interview for DSM-III-R (SCID):19 The SCID was administered to confirm postnatal depression "caseness". Postnatal depression was defined as meeting the criteria for major depression according to the Diagnostic and statistical manual of mental disorders, third edition, revised (DSM-III-R).20 Procedure The women were recruited immediately after delivery and asked if they would participate in a longitudinal study of postnatal depression. Women who agreed were given an initial semi-structured interview on the second or third day post partum, a self-report questionnaire and a baseline EPDS. The women were assessed a further four times -- at six, 12, 18 and 24 weeks post partum. At each interval, the women were posted the EPDS, a self-report questionnaire (consisting of questions on the baby's condition and feeding patterns as well as the quality of the women's relationship) and a stamped self-addressed envelope for returning the forms. Women who scored > 13 on the EPDS on two occasions (excluding their baseline EPDS score) were further interviewed using the SCID to determine postnatal depression "caseness". An equal number of women who scored < 13 on the EPDS were randomly selected and interviewed using the SCID. Statistical analysis Statistical analysis was performed using the SPSS computer program.21 Women were categorised as "cases" or "non-cases" of postnatal depression and into early and standard length of stay. Categorical data were analysed using odds ratios (OR), and chi-squared and t tests were used for comparing groups on dimensional data. A logistic regression analysis was used to determine whether length of stay remained a risk factor when controlling for other risk factors. Results Sample Of the 749 women who delivered during the three-and-a-half month period, 522 women (69.7%) agreed to participate in the study. Full data were available for 425 women (81.4%). The mean age of the sample was 26.9 years (standard deviation [SD], 5.0; range, 15-43), 367 women (86.4%) were married or in a de facto relationship, 58 women (13.6%) were single or separated, and 184 women (43.3%) were primiparous. The average period of formal education was 11.4 years (SD, 1.9; range, 9-15). Twenty-six women did not meet the inclusion criteria, 122 refused to participate in the study and 79 were unable to be contacted. There were no statistically significant differences in demographic and obstetric details between women who consented to participate and women who did not consent. The 97 women who withdrew from the study or had insufficient data were more likely to be younger (t = 5.91; P < 0.01), unemployed (chi-squared = 33.37; P < 0.01), single or separated (chi-squared = 59.46; P < 0.01) and have fewer years of formal education (t = 3.47; P < 0.01) compared with women who had full data. Forty-two women (9.9%) were categorised as having major depression, based upon scoring > 13 on the EPDS on two occasions and meeting DSM-III-R criteria for major depression. All of these women met "caseness" criteria for major depression on the SCID. None of the sample of women who screened negative (< 13) on the EPDS and were interviewed using the SCID met "caseness" criteria for major depression. Length of stay The average length of stay in hospital following delivery was 90.9 hours (SD, 43.1 hours; range, 16-307). Of the 425 participants in the study, 153 women (36%) were discharged within 72 hours (early-discharge group) and 272 women (64%) were discharged after 72 hours (standard-length-of-stay group). We compared sociodemographic and risk factors for the early-discharge and standard-length-of-stay groups of women. The early-discharge group were more likely to be multiparous (71.2% v. 48.5%; OR, 2.63; 95% confidence interval [CI], 1.69-4.10), have fewer years of formal education (11.01 years v. 11.5 years; t = 3.09; P < 0.01), to bottle feed in the first week post partum (20.9% v. 12.1%; OR, 1.91; 95% CI, 1.06-3.46), and report a poor relationship with parents (52.9% v. 40.1%; OR, 1.68; 95% CI, 1.11-2.56). They were also more likely to have a history of depression or postnatal depression, but this was not statistically significant (9.1% v. 4.4%; OR, 2.18; 95% CI, 0.92-5.19). The two groups did not differ with respect to age, marital or socioeconomic status, number of life events in the past year, or global satisfaction with their partner. Women in the early discharge group did not have a more vulnerable personality style and did not differ in baseline EPDS scores (5.1 v. 5.9; t = 0.24). Postnatal assessment The proportion of women who developed postnatal depression (as defined above) was higher among those discharged early than those discharged after three days. Three of the 13 women (23.1%) discharged within 24 hours, nine of the 58 women (15.5%) discharged between 24 and 48 hours, and 10 of the 82 women (12.2%) discharged between 48 to 72 hours developed postnatal depression. Of the 153 women discharged early (within 72 hours), 22 (14.4%) developed postnatal depression compared with 20 of the 272 women (7.4%) who had standard length of stay (OR, 2.12; 95% CI, 1.07-4.21). Of the 42 women who developed postnatal depression, 22 (52.4%) were discharged early. The possibility that the increased risk associated with early discharge could have arisen as a result of other, antecedent, risk factors for postnatal depression was examined using a hierarchical logistic regression,22 with postnatal depression as the dependent variable. Sociodemographic, historical, obstetric, and psychosocial factors (see below) were entered in the first step, baseline EPDS score in the second step and early discharge in the final step to see whether it would remain a risk factor after controlling for other risk factors. Sociodemographic factors: Age (5-yearly intervals), level of education (less or more than 10 years), social class (low or high socioeconomic status) and marital status (single, married or de facto relationship). Obstetric factors: Parity (multiparous or primiparous) and delivery type (spontaneous vaginal delivery, instrumental delivery or caesarean section). Psychosocial risk factors: Personality style (high or low vulnerability [extracted from the personality scale, with women scoring one standard deviation above the mean on the vulnerability component of the scale considered to be vulnerable]); quality of relationship with parents and in-laws (poor or good); satisfaction with relationship with partner (dissatisfied or satisfied); history of depression or postnatal depression; experience of none, one or two, or three or more life events over the previous 12 months; and whether they had had the desired-sex baby. When all sociodemographic, obstetric and psychosocial factors were entered, the model was highly significant (Box), with significantly increased risk for postnatal depression associated with dissatisfaction with partner relationship(s), reporting three or more life events in the past 12 months, and having a vulnerable personality. The model significantly improved (had better predictive power; chi-squared = 41.5; P < 0.0001) when baseline EPDS score was entered, and again when early discharge was entered. Early discharge increased the risk threefold (OR, 3.06; 95% CI, 1.22-7.69), after controlling for other risk factors. These results also support the more specific finding of early discharge, in which there was a 2.1-fold increased risk (95% CI, 1.07-4.21) of developing postnatal depression. Discussion Early discharge following childbirth is becoming more routine. It has been shown that neither maternal nor infant health is compromised by this practice; however, there is a paucity of research evaluating the psychological functioning of the mother following early discharge. We are aware of only one prospective study of the psychological morbidity associated with early discharge compared with customary length of stay in hospital. Beck et al.23 assessed depressive symptoms among 49 women at six and 12 weeks post partum using the Beck Depression Inventory (BDI).24 They found no significant difference between the early- versus standard-discharge groups on BDI scores. However, this study was confined to privately insured, primiparous women who had had uncomplicated pregnancy and labour. Therefore, their results have limited generalisability because most studies have identified that women opting for early discharge are more likely to be multiparous, older, have fewer years of formal education and lower socioeconomic status.25,26 While there have been no prospective studies on the psychological impact of early discharge in heterogeneous samples, one retrospective study found that women who reported that their postnatal hospital stay was too short were significantly more likely to have postnatal depression than those who reported the right length of stay.27 Our study shows that women discharged within three days of childbirth had an increased risk of developing postnatal depression. This increased risk is not the result of other well recognised risk factors for postnatal depression, such as experiencing life stresses, having a dysfunctional personality style, unsatisfactory interpersonal relationships28 or a history of depression. When these risk factors were controlled in a logistic regression analysis, early discharge was still a significant risk for postnatal depression, with an odds ratio of 3.06. Therefore, early discharge exerted an independent effect on the development of postnatal depression and was not simply a proxy for other, pre-existing, risk factors. We also found that one-third of the women who stayed in hospital for more than five days also experienced postnatal depression. However, they had all experienced complicated labours and some infants had been in neonatal intensive care for a prolonged period, which may have contributed to the higher rates of postnatal depression. Women discharged within three days of giving birth may be at an increased risk of postnatal depression because they have had insufficient time to recover from and work through the experience of childbirth. They may still be tired from the physical demands of childbirth and have to return to the stresses of everyday life, which includes looking after a household, their new baby and, in many cases, other children. This additional stress so soon after childbirth may increase the risk of depression. The "blues" are minor, transient depressive symptoms which generally arise on the third to fifth day post partum. Therefore, women on an early-discharge program leave hospital before the onset of the "blues". If they return to an environment where there is insufficient support, experiencing the "blues" may lead to depressive symptoms being perpetuated and contribute to the development of postnatal depression. Finally, women discharged early go home without having properly established breastfeeding, and therefore without the supervision and round-the-clock support of midwives to help them with the inevitable difficulties (e.g., breast engorgement, change in milk flow, unable to latch the baby correctly, leading to cracked, sore nipples) that arise after the milk "comes in" (generally on the third day). These difficulties can lead to an irritable baby and a tired, depressed mother. The association we found between early discharge and postnatal depression merely suggests causality. A prospective controlled study with women randomly assigned to early- or standard-discharge programs (controlling for parity, social support and past history) is needed to identify any causal link between early discharge and postnatal depression. The association between early discharge and postnatal depression has major public health implications. While health services are having to cut costs, early discharge may result in short-term cost savings. However, the consequences of postnatal depression could lead to escalating health care costs in the long term. Women entering an early-discharge program need a careful assessment, particularly those at risk for postnatal depression (e.g., poor family support or a history of depression). The possibility of postnatal depression should be kept in mind for all women who have been discharged early when they return for their postnatal check-ups. The EPDS could be used as a routine screen for such women. Finally, women with a history of postnatal depression should have counselling if they are considering early discharge and be advised that a longer hospital stay may reduce their risk of recurrent depression. References Yanover MJ, Jones D, Miller MD. Perinatal care of low-risk mothers and infants: Early discharge with home care. N Engl J Med 1976; 294: 702-705. Avery MD, Fournier LC, Jones PL, Sipovic CP. An early postpartum hospital discharge program: implementation and evaluation. J Obstet Gynecol Neonatal Nurs 1982; 11: 233-235. Burnell I, McCarthy M, Chamberlain GVP, et al. Patient preference and postnatal hospital stay. J Obstet Gynaecol 1982; 3: 43-47. Lemmer CM. Early discharge: outcomes of primiparas and their infants. J Obstet Gynecol Neonatal Nurs 1987; 16: 230-236. Hall WA, Carty EM. Managing the early discharge experience: taking control. J Adv Nurs 1993; 18: 574-582. Kenny P, King MT, Cameron S, Shiell A. Satisfaction with postnatal care -- the choice of home or hospital. Midwifery 1993; 9: 146-153. Murray L, Cooper PJ, Stein A. Postnatal depression and infant development. BMJ 1991; 302: 978-979. Boyce PM, Stubbs JM. The importance of postnatal depression [editorial]. Med J Aust 1994; 161: 471-472. O'Hara MW, Swain AM. Rates and risks of postpartum depression -- a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54. Boyce PM, Todd AL. Increased risk of postnatal depression after emergency caesarean section. Med J Aust 1992; 157: 172-174. Murray L, Cartwright W. The role of obstetric factors in postpartum depression. J Reprod Infant Psychol 1993; 11: 215-219. Congalton AA, Cheshire FW. Status and prestige in Australia. Melbourne: Chesire Publishing Pty Ltd, 1969. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782-786. Harris B, Huckle P, Thomas R, et al. The use of rating scales to identify post-natal depression. Br J Psychiatry 1989; 154: 813-817. Murray L, Carothers AD. The validation of the Edinburgh Postnatal Depression Scale on a community sample. Br J Psychiatry 1990; 157: 288-290. Boyce PM, Stubbs JM, Todd AL. The Edinburgh Postnatal Depression Scale: validation for an Australian sample. Aust N Z J Psychiatry 1993; 27: 472-476. Tennant C, Andrews G. A scale to measure the cause of life events. Aust N Z J Psychiatry 1977; 11: 163-167. Brugha T, Bebbington P, Tennant C, Hurry J. The list of threatening experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol Med 1985; 15: 189-194. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R: SCID user's guide for the structured clinical interview for DSM-III-R. Washington: American Psychiatric Press Inc, 1990. American Psychiatric Association. Diagnostic and statisitical manual of mental disorders, third edition revised (DSM-III-R). Washington DC: American Psychiatric Association, 1987. SPSS: Statistical package for the social sciences [computer program], release 6.1. Chicago, Ill: SPSS Inc, 1994. Fleiss JL, Williams JBW, Dubro AF. The logistic regression analysis of psychiatric data. J Psychiatr Res 1986; 20: 195-209. Beck CT, Reynolds MA, Rutowski P. Maternity blues and postpartum depression. J Obstet Gynecol Neonatal Nurs 1992; 21: 287-293. Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-571. Scott A. A cost analysis of early discharge and domiciliary visits versus standard hospital care for low-risk obstetric clients. Aust J Public Health 1994; 18: 96-100. Mitchell SD, Counsell AM, Geddis DC. Planned early discharge from New Zealand maternity hospitals. N Z Med J 1993; 106: 152-154. Astbury J, Brown S, Lumley J, Small R. Birth events, birth experiences and social differences in postnatal depression. Aust J Public Health 1994; 18: 176-184. O'Hara MW, Zekoski EM. Postpartum depression: a comprehensive review. In: Kumar R, Brockington IF, editors. Motherhood and mental illness 2: causes and consequences. London: Wright, 1988: 17-63. (Received 17 Feb, accepted 5 June 1997) Authors' details Department of Psychological Medicine, Nepean Hospital, Penrith, NSW. Anthea R Hickey, Psychologist, BPsych, MMedSc; Philip M Boyce, MD, FRANZCP, Professor of Psychiatry; Allen D Morris-Yates, BA(Hons), Senior Research Officer. Department of Obstetrics and Gynaecology, Canberra Hospital, ACT. David Ellwood, FRACOG, DPhil(Oxon), Professor of Obstetrics and Gynaecology. Reprints: Prof P M Boyce, Department of Psychological Medicine, Nepean Hospital, PO Box 63, Penrith, NSW 2751. E-mail: pboyceATmail.usyd.edu.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Anthea R Hickey · Philip M Boyce · David Ellwood · Allen D Morris-Yates

Men's estimates of prostate cancer risk and self-reported rates of screening Jeanette E Ward, Ann-Maree Hughes, Geoffrey H L Hirst and Lorraine Winchester For editorial comment, see Stricker & Eisinger 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 determine rates of prostate cancer screening and predictors of men's participation in this screening in the light of national recommendations against prostate cancer screening. Design: Community-based study (computer-assisted telephone survey). Setting: Central Sydney Area Health Service. Participants: Randomly selected men aged 40-80 years. Results: 340 men participated (65% response rate). While the true lifetime (0-74 years) risk of developing or dying from prostate cancer is reported to be one in 18 (6%) and one in 65 (1.5%), respectively, 37% of respondents thought that at least one in five men (20%) would develop prostate cancer before the age of 75 years and 11% that one in five (20%) would die from it. Twenty-two per cent of men aged 50 years or over had been screened for prostate cancer within the previous 12 months. Ever worrying about prostate cancer and bothersome urinary symptoms independently predicted the probability of screening within the previous year. Sociodemographic characteristics such as age, occupation and country of birth were not associated with screening. Conclusions: Public health initiatives to discourage prostate cancer screening should focus particularly on men with bothersome urinary symptoms and those who worry about prostate cancer. Accurate information about the low risks of dying from prostate cancer needs to be communicated, and the speculative nature of current evidence in support of screening as a means of reducing this risk should be emphasised. MJA 1997; 167: 250-253 Introduction Despite repeated advice to the contrary, screening for prostate cancer is being requested by patients and conducted by doctors. Advice against screening has come from a policy statement for health professionals released in 1995 by the Australian Cancer Society,1 and a 1996 report of a multidisciplinary committee convened by the Australian Health Technology Advisory Committee on the basis that the evidence did not meet accepted criteria for benefits, risks and costs.2 In addition, the National Health and Medical Research Council (NHMRC) evidence-based guidelines for the management of men with uncomplicated lower urinary tract symptoms (LUTS)3 state that there is no evidence that prostate specific antigen (PSA) tests are required for men with uncomplicated LUTS as men with these symptoms are at no greater risk of prostate cancer than asymptomatic men.4 Data indicating that screening is occurring come from the Department of Veterans' Affairs,5 as well as surveys of urologists6 and general practitioners (unpublished data). In describing this "conundrum", Horner identified a pressing need for research to support educational programs for men, focusing on "strategies to combat uninformed patient demand".7 While the Australian Health Technology Advisory Committee guidelines advocate national action involving the NHMRC,2 the need for health services to intervene actively at a local level to discourage prostate cancer screening has also been recognised in New South Wales.8 In the absence of more recent data, we used the opportunity of a large population-based study about men's health to determine the prevalence and predictors of participation in screening for prostate cancer in the area defined by the Central Sydney Area Health Service. Methods The study was approved by the Royal Prince Alfred Hospital Ethics Review Committee. Community sampling Two thousand names, addresses and telephone numbers within the 35 postcodes constituting the Central Sydney area were randomly selected from the Electronic White Pages.9 To maximise participation rates, each household received a one-page letter outlining the Men's Health Study and anticipating telephone contact, supported by a media release to further publicise the study. The initial sample size of 2000 was estimated to be sufficient to provide between 250-350 completed surveys given an estimated prevalence of 38%10 of eligible male respondents in contacted households and a conservative consent rate. Computer-assisted telephone interview survey A market research company with computer-assisted telephone interview facilities contacted all 2000 households between 26 November and 12 December 1996 on weekdays between 1500 and 2100. Where the first contact was unsuccessful, a further five attempts were made at different times and on different days. Men aged between 40 and 80 years residing in the household and fluent in English were eligible to participate. If there was more than one man in the household meeting these criteria, the one with the most recent birthday was asked to participate. Due to the sensitive nature of the survey, all telephone interviewers were mature females with previous experience in conducting health-related surveys. A briefing session for interviewers was conducted to address potential difficulties with medical jargon, to ensure sensitivity towards the issues and to standardise the interviews. Survey instrument At the beginning of the interview, respondents were asked standard sociodemographic questions, as well as whether they had ever been diagnosed with a urological condition and questions modified from the International Prostate Symptom Score11 to assess the presence of and degree of "bother" attributable to urinary symptoms. We then asked respondents five questions about prostate cancer. 1. "Have you ever worried that you might have prostate cancer?" Those answering "yes" were asked "For what reasons?". 2. "Have you had any test to detect prostate cancer in the last 12 months?" Those answering "yes" were asked to name the test(s). 3. "Have you heard of any tests for prostate cancer?" 4. "Out of 100 Australian men, how many or what percentage do you think will get prostate cancer before the age of 75?" If the respondent was unable to quantify his response, the interviewer was instructed to establish a range by saying "Would it be more or less than 1%? Less than 5%? Between 5% and 9%? More than 10% or more than 20%?" until an answer was given. 5. "Out of 100 Australian men, how many or what percentage do you think will die from prostate cancer before the age of 75?" If necessary, an answer to this question was prompted in the same way as Question 4. For Questions 4 and 5, interviewers were unaware of the correct answers. Questions 4 and 5 were modelled on previous research. 12 Data analysis Data were analysed using SAS13 and Epi Info.14 We used chi-squared tests to examine associations between knowledge of prostate cancer screening tests and eight respondent characteristics: age (40-49, 50-59, 60-69, 70-80 years); country of birth (Australia v. other); socioeconomic status based on occupation (manager/ administrator and professional/para-professional combined v. all other categories [tradesperson/clerk/salesperson and personal service worker/plant and machine operator/driver and labourer]);15 education (up to and including Intermediate or School Certificate [Year 10] v. Leaving or Higher School Certificate [Year 11 or 12] and beyond); moderate or severe "bother" from urinary symptoms (a score equal to or greater than six from a possible range of 0-18); ever worrying about prostate cancer (yes v. no); estimate of risk of developing prostate cancer (correct or lower estimate v. overestimate); and estimate of risk of death from prostate cancer (correct or lower estimate v. overestimate). Jelfs et al. report a lifetime risk of developing prostate cancer of one in 18 (6%).16 We considered an estimate of 10% or greater to be an overestimate of incidence risk. Using the Jelfs data,16 we calculated the lifetime risk of dying of prostate cancer as one in 65 (1.5%). We considered an estimate of 5% or greater as an overestimate of mortality risk. For the sample of men 50 years and over, we used chi-squared tests to determine associations between the outcome variable -- having had either a prostate specific antigen test, a digital rectal examination, or both, within the previous 12 months -- and these eight variables as well as knowledge of prostate cancer tests. Logistic regression analysis was performed, using significant univariate variables and any plausible non-significant variable. Results Response rate and characteristics of the sample Of 2000 randomly selected households, 1481 (74%) were ineligible. Of the remaining 519 households with an eligible male resident, 340 agreed (65% response rate). Men who refused were significantly older than those who participated (t27.49 = 4.19; P < 0.01). Compared with 1991 Census data12 (Box 1), the sample under-represented older men. No respondent indicated a past history of prostate cancer. Respondents' worry about prostate cancer, estimates of risk and knowledge of tests Ninety-nine men (29%) indicated they had ever worried about prostate cancer. The three most frequently cited reasons were: presence of urinary symptoms (36 men [11%]), age (26 men [8%]), and media publicity (24 men [7%]). Of the sample, 216 men (63%) overestimated lifetime risk of developing prostate cancer (Box 2). Respondents were significantly more likely to overestimate the risk of death from prostate cancer than the risk of developing it (McNemar's test, 10.800; df = 1; P = 0.001). Ever having worried about prostate cancer was not associated with correctly estimating the risk of developing it or the risk of dying from it. Of the total sample, 237 (70%) and 228 (67%) required no prompting to estimate lifetime risk of developing or dying from prostate cancer, respectively. One hundred and seventy-two men (51%) reported they had heard of one or more tests for prostate cancer. Respondents who had heard of any test were more likely to be managers or professionals than to have other occupations (chi-squared = 4.04; df = 1; P = 0.044) or were educated to Year 12 or beyond (chi-squared = 5.49; df = 1; P = 0.019). Knowledge of tests was unrelated to age, country of birth, perception of risk, "bother" from urinary symptoms or anxiety. Rates and predictors of prostate cancer screening within the previous 12 months Of the total sample, 52 men (15%) had had at least one prostate cancer screening test within the previous 12 months (Box 3). Almost all tests (97%) were reported by men 50 years or older, yielding an annual screening rate of 22% for this older group. For the subsample of 186 men aged 50 years or over, univariate analyses revealed only two variables to be significantly associated with having had a prostate cancer screening test within the past year: moderate or severe "bother" from urinary symptoms (chi-squared = 13.41; df = 1; P < 0.001), and "ever worrying" about prostate cancer (chi-squared = 18.38; df = 1; P < 0.001). Knowledge of available tests and other sociodemographic variables were not associated with having had a test within the past year. However, as age was a potential confounder, it was included with the two significant univariate associations in the logistic regression analysis. After adjustment, "bother" and "anxiety" remained independent predictors (Box 4). Discussion Just over one in five of the men in our study 50 years or over had had a prostate cancer screening test within the previous 12 months, a rate almost double that given in an earlier report of national claims data.5 Screening was significantly more likely among those who had ever worried about prostate cancer or were bothered by urinary symptoms. In contrast to research in other countries demonstrating that economic and ethnic factors influence participation in prostate cancer screening,17,18 our study showed no association between screening and men's occupation, education or country of birth. As a priority for public campaigns, men who experience uncomplicated LUTS -- nocturia, frequency, dribbling, urgency, hesitancy or reduced stream -- in the absence of haematuria need to be reassured that there is no empirical evidence of a relationship between such symptoms and early prostate cancer.3 Men's anxiety about prostate cancer may also be explained, in part, by their overestimation of the actual risks of prostate cancer. More than a third of respondents thought that at least one in five men would develop prostate cancer before the age of 74 years, and 11% thought that one in five would actually die from this disease before that age. Reasons for consistent overestimation of risk remain speculative but might reflect extensive media coverage of prostate cancer, possibly fuelled by commercial interests, which increases men's anxiety, and, in turn, raises their perception of risk.19 In contrast, McCormick20 has argued that informed public participation in screening should be founded on clear messages about absolute risk, the evidence from rigorous randomised trials for reduction in risk, the costs and adverse outcomes. Our study is the first to quantify a considerable gap between men's perceptions of risk and the actual risk. When provided with impartial information on an individual basis about the risks and unknown benefits of prostate cancer screening, men are less inclined to have a screening test.21 Given our collective failure to convey accurate health risk information to the public about risks for other cancers,9 risk reduction22 or screening,23 a systematic approach to the development, implementation and evaluation of a public health initiative to discourage prostate cancer screening is required. The recent release of the guidelines for the management of uncomplicated LUTS in men3 provides a focus for such an initiative. Our study suggests that men who are anxious about prostate cancer or have bothersome urinary symptoms represent priority target groups for educational messages via general practice, men's service and recreation clubs, mass media and peak groups such as the Council of the Ageing and the Consumers' Health Forum. Because of the limitations of our study, we also recommend that a dedicated survey about prostate cancer be conducted which examines in depth men's knowledge of indolent and aggressive cancer types, their health beliefs and attitudes towards early detection, their awareness of the speculative and controversial nature of screening, and their knowledge of treatment options and their effectiveness. Men's recall of the recommendations of their GP in either promoting or discouraging prostate cancer screening could also be ascertained. As female partners represent a key source of health information for men,24 a concurrent survey of partners of men in these age groups is also recommended. Acknowledgements The Men's Health Study was conducted for the NHMRC Working Party developing guidelines for the management of lower urinary tract symptoms in men with funds from the Commonwealth Department of Health and Family Services. We thank members of the Working Party for comments on survey protocols; the men who participated in the computer-assisted telephone interview and the Hunter Valley Research Foundation for diligent administration of the survey; Jo Williams and the Central Sydney Area Health Service Public Relations Unit for assisting with the media release; and Neil Donnelly for statistical advice. References Australian Cancer Society. Prostate cancer screening: guidelines for health professionals. Cancer Forum 1995; 19: 47-50. Australian Health Technology Advisory Committee. Prostate cancer screening. Canberra: AGPS, 1996. NHMRC clinical practice guidelines. The management of uncomplicated lower urinary tract symptoms in men. Canberra: AGPS, 1996. Catalona W, Ritchie J, Ahmann F, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 1994; 151: 1283-1290. 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Health Promot Int 1991; 6: 93-101. SAS [computer program], version 6. 3rd ed. Cary, NC: SAS Institute, 1990. Dean AG, Dean JA, Burton AH, Dicker RC. Epi Info, version 5: a word processing database, and statistics program for epidemiology on microcomputers. Stone Mountain, Ga: USD Inc, 1990. Australian Bureau of Statistics. Australian standard classification of occupations. 1st ed. Canberra: AGPS, 1992. Jelfs P, Coates M, Giles G, et al. Cancer in Australia 1989-1990 (with projections to 1995). Canberra: Australian Institute of Health and Welfare, 1996 (Cancer Series No. 5). Schwartz K, Kau T, Severson R, Demers R. Prostate-specific antigen in a community screening program. J Fam Pract 1995; 41: 163-168. Williams R, Boles M, Johnson R. Use of prostate-specific antigen for prostate cancer screening in primary care practices. Arch Fam Med 1995; 4: 311-315. Wasson J. Prostate cancer fears and facts. In: Proceedings of the National Men's Health Conference; 10-11 August 1995. Canberra: AGPS, 1996: 69-72. McCormick J. Medical hubris and the public health: the ethical dimension. J Clin Epidemiol 1996; 49: 619-621. Wolf A, Nasser J, Wolf A, Schorling J. The impact of informed consent on patient interest in prostate-specific antigen screening. Arch Intern Med 1996; 156: 1333-1336. Hancock L, Sanson-Fisher RW, Redman S, et al. Knowledge of cancer risk reduction practices in rural towns of NSW. Aust N Z J Public Health 1996; 20: 529-537. Cockburn J, Redman S, Hill D, Henry E. Public understanding of medical screening. J Med Screen 1995; 2: 224-227. Norcross W, Ramirez C, Palinkas L. The influence of women on the health care-seeking behaviour of men. J Fam Pract 1996; 43: 475-480. (Received 24 Feb, accepted 22 May 1997) Subsequently cited in Prostate-specific antigen testing in Australia and association with prostate cancer incidence in New South Wales by David P Smith and Bruce K Armstrong, Med J Aust 1998; 169: 17-20 Authors' details Central Sydney Area Health Service, Needs Assessment & Health Outcomes Unit, Sydney, NSW. Jeanette E Ward, PhD, FAFPHM, Director; Ann-Maree Hughes, BEd, GradDipAppSci(Nursing), Research Assistant; Lorraine Winchester, BSocSc(Hons), Data Manager. Taylor Medical Centre, Brisbane, QLD. Geoffrey H L Hirst, MB BS, FRACS, Urologist. Reprints: Associate Professor J E Ward, Central Sydney Area Health Service, Needs Assessment & Health Outcomes Unit, PO Box 374, Camperdown, NSW 2050. E-mail: jward AT nah.rpa.cs.nsw.gov.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Jeanette E Ward · Anne-Maree Hughes · Lorraine Winchester

A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance John W Kelly, Josephine M Yeatman, Cheryl Regalia, Grahame Mason and Amanda P Henham 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 Objectives: (1) To assess the incidence of melanoma in a cohort of patients with dysplastic melanocytic naevi (DMN) and the relationships between incident melanomas and preexisting naevi and between melanoma risk and numbers of DMN. (2) To examine the role of the patient versus the physician in detecting melanoma and the relative value of surveillance versus prophylactic excision. Design: Prospective cohort study. Patients and setting: Two hundred and seventy-eight adults, each with five or more DMN, were followed up for a mean period of 42 months in a private dermatology practice. DMN were clinically diagnosed. Results: Twenty new melanomas were detected in 16 patients, corresponding to an age-adjusted incidence of 1835/100 000 person-years, 46 times the incidence in the general population. Eleven were detected because of changes evident in comparison with baseline photographs and nine were detected by patients or their partners. Thirteen of the 20 melanomas arose as new lesions and only three from DMN. Melanoma risk rose with increasing numbers of DMN. Conclusions: Increasing numbers of DMN are associated with increasing melanoma risk. Surveillance (baseline photography and follow-up) enabled early diagnosis of melanoma and was very much more cost-effective in preventing life-threatening melanoma than prophylactic excision of DMN. MJA 1997; 167: 191-194 Introduction Eight case-control studies have indicated that dysplastic melanocytic naevi (DMN) are a strong and independent risk factor for the development of melanoma.1-8 Cohort studies show that individuals with DMN develop more melanomas than the general population.9-14 Only one cohort study has assessed the association of incident melanomas with preexisting naevi and the role of the patient versus the clinician in detection.10 None has examined an Australian cohort or addressed the relationship between DMN numbers and melanoma risk, the cost-effectiveness of surveillance compared with prophylactic excision or the occurrence of non-melanoma skin cancer in subjects with DMN. We followed a cohort of 278 Australian patients with DMN, using baseline skin surface photography to address these issues. Methods All patients who presented to the private dermatological practice of one of us (J W K) between March 1985 and November 1992 who required total body cutaneous examination were assessed for entry to the study. Any who had five or more clinically determined DMN and who were aged 18 years or more were offered baseline skin surface photography and follow-up on an annual basis. Over 80% had been referred for assessment of their atypical naevi or because of other melanoma risk factors, particularly a personal or family history of melanoma. In November 1993 all patients who had baseline photographs and had returned for at least one 12-month follow-up visit were entered in the study. The entry criterion of five DMN was based on the results of an earlier study that suggested to us that this number of DMN is associated with sufficient melanoma risk to justify entry to a screening program.2 A systematic set of 14 baseline photographs of the skin surface was used. A clinical photographer (A P H) worked with us in designing the views and did the photography, using anatomical site definitions to define standard views of recognisable body regions rather than using standard magnifications (Box 1). This reduced the number of views needed to cover the skin surface while providing adequate magnification. At entry to the study subjects were advised about their high risk of mela noma; three-monthly self-examination was recommended, the clinical features of early melanoma were discussed and appropriate sun protection measures were described. DMN were diagnosed clinically accor ding to published criteria.15 A naevus was considered clinically dysplastic if it had a macular component and showed at least three of the following five clinical features: ill-defined border, irregularly distributed pigmentation, background erythema, size greater than 5 mm, and irregular border. An exact count was made of the number of DMN and recorded in ranges 1-4, 5-10, 11-20, 21-50 and >50. The total number of MN was estimated and recorded in ranges <20, 21-50, 51-100 and 101-500. Patients were reviewed at 6- to 12- month intervals. Total body cutaneous examination was performed at each visit and the patient's pigmented lesions were compared with baseline photographs. Excisional biopsies were performed for any lesions that were clinically suggestive of melanoma and were not done routinely for histological confirmation of the presence of dysplastic naevi. All histo pathological specimens were examined at a single private pathology laboratory. All melanomas arising during the study were reviewed by one pathologist (G M). Melanomas detected at the initial visit were excluded from the analysis. Results The study enrolled 278 patients (162 women and 116 men). Mean age was 37 years (range, 18-67 years). Sixty-five patients (23%) had a family history of melanoma, 54 (19%) had a past history of melanoma, and 9 (3%) had both. None were from melanoma-prone families (as defined by a history of two or more affected first degree relatives). The mean period of follow-up was 42 months (range, 12-99 months). Twenty melanomas were detected in 16 patients over 955 person-years of follow-up. The age-adjusted incidence of melanoma in this group was 1835/100 000 person-years, 46 times the age-adjusted incidence of in-situ and invasive melanoma of 40/100 000 person-years for the population of Victoria in 1990 (G Giles, Anti-Cancer Council of Victoria, 1996, personal communication). The mean time from baseline to diagnosis of melanoma was 36 months (SD, 12 months; range, 11-75 months). Eleven of the 20 melanomas were detected at follow-up visits by comparison with the baseline photographs. These 11 patients were unaware of the changing lesion, and in most of these lesions the change would not have been apparent to the clinician without the use of photo graphs. Seven melanomas were detected by the patient as a change seen on self-examination and two were detected by patients' partners. Four were amelanotic melanomas that did not fulfil the normal diagnostic criteria for melanoma; nonetheless, one of these was detected by the patient. Detecting the 20 melanomas in these 278 patients required 1554 patient consultations (78 for each melanoma). Two hundred and ten biopsies were performed to assess changes observed during follow-up of 104 patients (10 biopsies for each melanoma detected). Not all changes in pigmented lesions led to a biopsy: if melanoma could be confidently ruled out on clinical examination and skin surface microscopy, the lesion was simply rephoto graphed. Histopathological results of these biopsies are shown in Box 3. Changing dysplastic naevi were the predominant source of clinically suspicious change; we do not know how many of these may have progressed to melanoma if they had not been removed. Nineteen non-melanoma skin cancers were detected during follow-up in this group of patients and removed: 16 basal cell carcinomas, one squamous cell carcinoma, one keratoacanthoma, and one Bowen's disease. Of the 16 patients who developed mela noma, five had a family history and seven had a past history of melanoma. Patients with melanoma were more likely to have had a previous melanoma (P = 0.001) and to have a family history of melanoma (P = 0.05) than those who had not. The percentage of patients in each risk group who developed melanoma is shown in Box 2. Boxes 4 and 5 show the incidence of melanoma in the study cohort in relation to the number of dysplastic naevi and total naevi. For an Australian population, the total numbers of naevi were not remarkable (61% had 100 naevi or less), but there were large numbers of DMN (59% had more than 10). Melanoma incidence correlated more closely with increasing numbers of DMN than with increasing total numbers of naevi. Subjects with 21 to 50 DMN developed melanomas at a rate of 3.3% per year. The 20 incident melanomas were all superficial spreading in type. Twelve were invasive and eight were in situ. All the invasive lesions were less than 0.6 mm thick and level II,16 except one amelanotic melanoma that showed a desmoplastic component and invaded to 1 mm in thickness and reached level IV.16 According to the criteria of Clark et al.,17 15 were classified as radial growth phase lesions and four as vertical growth phase; one was classified separately as desmoplastic. The melanomas were widely scattered over the skin surface, with six on the upper limbs, four on the upper back, four on the lower limbs, three on the chest, two on the abdomen, and one on the head. Seven melanomas showed histological evidence of an associated benign naevus (intradermal naevoid remnants in four and features of dysplastic naevi in three). Nine melanomas evolved as a change in a preexisting pigmented lesion that had been evident on baseline photos. In two of these nine the preexisting pigmented lesion was likely to have been a de novo melanoma. One of these patients had a stable pigmented lesion on the right side of her chest over six years. It was excised when it began to enlarge and darken and was found to be a level II, 0.6 mm thick melanoma without histological evidence of any associated naevus. A second patient had a tiny, 2 mm diameter lesion on his chest at his first visit. At his initial review visit, six months later, this had enlarged slightly and become more angular in shape. Histologically, this was a level I melanoma with no associated naevus. Discussion In this study the presence of five or more clinically determined DMN identified a group of patients with 46 times the general population incidence of melanoma. None of these patients came from melanoma-prone families, in whom Clark et al. originally described dysplastic naevi.18 Five cohort studies of patients with DMN who are not from melanoma-prone families have been published and all showed a very high rate of mela noma.9-13 These findings confirm those from case-control studies showing that DMN constitute a strong and independent risk factor for melanoma.1-8 Our age-adjusted incidence of mela noma of 1835/100 000 person-years is higher than that reported in other studies (692-709/100 000 person-years).9,11 This may be explained by the relatively large numbers of DMN in our patients (Box 4) and by the higher background rate of melanoma in Austra lia than in the United States and United Kingdom. We did not examine a cohort of control patients, but Marghoob et al. did.12 They found a 10-year cumulative risk of melanoma of 10.7% among 287 patients with at least one large naevus, one atypical naevus and 100 total naevi. This risk compared with a 0.62% 10-year risk among 831 controls selected from patients requiring annual dermatological follow-up for other reasons. We have intentionally continued to use the word "dysplastic" rather than "atypical". These naevi have been studied because they are believed to be associated with melanoma risk. There are other naevi that are clinically atypical and that are not linked with melanoma risk. Examples are naevus spilus, blue naevus and halo naevus. We prefer the term "dysplastic" because it clearly does not embrace these other atypical naevi. There are several definitions in the literature for syndromes associated with atypical or dysplastic naevi. One includes patients with a single atypical naevus, a large (>8 mm diameter) naevus and >100 total naevi.12 Another depends on distribution of atypical naevi on the anterior scalp, dorsa of the feet, iris or buttocks.19 DMN have been demonstrated to be independently associated with mela noma risk and are not always associated with large numbers of naevi or naevi in certain locations. We prefer not to include DMN in a syndrome definition but rather to consider them as a continuous numerical variable. There is evidence from this study (Box 2) and from two case-control studies of increasing risk with increasing numbers of DMN.2,11 The risk associated with a single DMN is likely to be small and insufficient to justify our follow-up regimen. It is also difficult to accurately diagnose a single naevus as being dysplastic or otherwise on clinical grounds, but much more easy to identify the patient with numerous DMN. It is also difficult to apply definitions of large numbers of naevi in different geographical locations. A recent Australian study reported a mean total count of naevi (>2 mm diameter) that approached 100 in 15-year-old adolescents, which is considered a large number in the United States and United Kingdom.20 The proportion of the Australian adult population with five or more dysplastic naevi has not been defined. One study of 1123 Australian schoolchildren aged 6-15 years showed that 2.7% had three or more dysplastic naevi according to the clinical definition applied here.21 Two-thirds of the incident melanomas in this study were de novo lesions. This finding is similar to those of studies that examine the histological frequency of associated naevi with melanoma, which suggest that 43%-77% of melanomas are new lesions.22-24 The predominance of de novo melanoma in these patients supports management by photographic surveillance rather than by attempts at prophylactic excision. If every one of the 5838 DMN present in our cohort of patients had been excised at the outset, only three of the incident melanomas would have been prevented. Ninety-three DMN were excised in the course of the study because of changes evident in comparison with photographs and because the possibility of melanoma could not be confidently excluded. These changing DMN would seem to be the most likely pigmented lesions to develop into melanoma, and it is possible that some would have progressed to melanoma had they been left in place. When consultations and biopsies are costed at the Australian Government's Medi care Schedule rates for 1997 and $100.00 is allowed per set of photo graphs, the cost of diagnosing each mela noma in this study is $5583. Prophy lactic excision of all dysplastic naevi would have cost $1118038 and would have prevented only three of 20 mela nomas, at a cost of $395038 each. The use of baseline photographs in patients with many floridly atypical pigmented lesions provided knowledge of the stability of many lesions that would otherwise have demanded excisional biopsy, and greatly reduced the number of excisions needed in managing such patients. Patients commonly presented with concern about a change in a particular pigmented lesion. Reference to the photographs usually revealed no change and the lesion remained under observation. Only 10 biopsies were necessary to detect each melanoma and less than one biopsy was necessary per subject in the course of this study. The melanomas incident in this study were detected at an earlier stage than other melanomas that were incident in the State of Victoria in 1990. In-situ melanomas comprised 45% of those seen in the DMN cohort and 33% of those seen in Victoria for 1990 (G Giles, Anti-Cancer Council of Victoria, 1996, personal communication). Median tumour thickness was 0.40 mm in our cohort and 0.77 mm for the State in 1990. Mean tumour thickness for invasive melanoma in the cohort was 0.44 mm compared with 1.40 mm (95% confidence interval, 1.29-1.51) for the State. It is possible that such close surveillance leads to the detection of some melanomas that would otherwise have remained undetected and may have regressed spontaneously or failed to progress and become life threatening. Such "harvesting" of early melanomas may contribute to the very high incidence observed. We conclude that numerous dysplastic naevi identify patients at high risk of melanoma. Baseline photography of the entire skin surface and 6-12-monthly surveillance provides an effective method for early detection of incident melanomas. As most new melanomas were de novo lesions, prophylactic excision of dysplastic naevi would not have provided a satisfactory alternative to follow-up and does not provide sufficient risk reduction to justify the cost and morbidity of the procedure. References Grulich AE, Bataille V, Swerdlow AJH, et al. Naevi and pigmentary characteristics as risk factors for melanoma in a high-risk population: a case-control study in New South Wales, Australia. Int J Cancer 1996; 67: 485-491. Holly EA, Kelly JW, Shpall SN, et al. Number of melanocytic nevi as a major risk factor for malignant melanoma. J Am Acad Dermatol 1987; 17: 459-468. Swerdlow AJ, English J, MacKie RM, et al. Benign melanocytic naevi as a risk factor for malignant melanoma. BMJ 1986; 292: 1555-1559. Augustsson A, Stierner U, Rosdahl I, et al. Common and dysplastic naevi as risk factors for cutaneous malignant melanoma in a Swedish population. Acta Derm Venereol (Stockh) 1990; 71: 518-524. Halpern AC, Guerry D, Elder DE, et al. Dysplastic nevi as risk markers of sporadic (nonfamilial) melanoma. Arch Dermatol 1991; 127: 995-999. Grob JJ, Gouvernet J, Aymar D, et al. Count of benign melanocytic naevi as a major indicator of risk for nonfamilial nodular and superficial spreading melanoma. Cancer 1990; 66: 387-395. Garbe C, Kruger S, Stadler R, et al. Markers and relative risk in a German population for developing malignant melanoma. Int J Dermatol 1989; 28: 517-523. Roush GC, Nordlund JJ, Forget B, et al. Independence of dysplastic nevi from total nevi in determining risk for nonfamilial melanoma. Preventive Medicine 1988; 17: 273-279. Mackie RM, McHenry P, Hole D. Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high risk groups. Lancet 1993; 3421: 1618-1620. Rivers JK, Kopf A, Vinokur AF, et al. Clinical characteristics of malignant melanomas developing in persons with dysplastic naevi. Cancer 1990; 65: 1232-1236. Halpern AC, Guerry D, Elder DE, et al. A cohort study of melanoma in patients with dysplastic nevi. J Invest Dermatol 1993; 100: 346-349. Marghoob AA, Kopf AW, Bart RS, et al. Risk of cutaneous malignant melanoma in patients with "classic" atypical mole syndrome. Arch Dermatol 1994; 130: 993-998. Kang S, Barnhill RL, Mihm MC, et al. Melanoma risk in individuals with clinically atypical naevi. Arch Dermatol 1994; 130: 999-1001. Schneider JS, Moore DH, Sagebiel RW. Risk factors for melanoma incidence in prospective follow-up. The importance of atypical (dysplastic) nevi. Arch Dermatol 1994; 130: 1002-1007. Kelly JW, Crutcher WA, Sagebiel RW. Clinical diagnosis of dysplastic melanocytic nevi. J Am Acad Dermatol 1986; 14: 1044-1052. Clark WH Jr, From L, Bernadino EH, et al. Histogenesis and biological behaviour of primary human malignant melanoma of the skin. Cancer Res 1969; 29: 705-727. Clark WH, Elder DE, Guerry D, et al. Model predicting survival in stage I melanoma based on tumour progression. J Natl Cancer Inst 1989; 81: 1893-1904. Clark WH, Reimer RR, Greene M. Origin of familial malignant melanomas from heritable melanocytic lesions. Arch Dermatol 1978; 114: 732-738. Newton JA, Bataille V, Griffiths K, et al. How common is the atypical mole syndrome phenotype in apparently sporadic melanoma? J Am Acad Dermatol 1993; 29: 989-996. Kelly JW, Rivers JK, MacLennan R. Sunlight: a major factor associated with the development of melanocytic nevi in Australian school children. J Am Acad Dermatol 1994; 30: 40-48. Rivers JK, Maclennan R, Kelly JW, et al. The Eastern Australian childhood nevus study: prevalence of atypical nevi, congenital nevus-like nevi, and other pigmented lesions. J Am Acad Dermatol 1995; 32: 957-963. Marks R, Dorevitch AP, Mason G. Do all melanomas come from "moles"? A study of the histological association between melanocytic naevi and melanoma. Australas J Dermatol 1990; 31: 77-80. Sagebiel RW. Melanocytic nevi in histologic association with primary cutaneous melanoma of superficial spreading and nodular types: Effect of tumour thickness. J Invest Dermatol 1993; 100 Suppl: 322S-325S. Skender-Kalnenas TM, English DR, Heenan PJ. Benign melanocytic lesions: risk markers or precursors of cutaneous melanoma? J Am Acad Dermatol 1995; 33: 1000-1007. (Received 10 Dec 1996, accepted 10 Jun 1997) Authors' details Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC. John W Kelly, MD BS, FACD, Head; Head of Dermatology Unit, Alfred Hospital; Clinical Associate Professor, Monash University Department of Medicine. Dermatology Unit, Alfred Hospital, Melbourne, VIC. Josephine M Yeatman, MB BS, GradDipEpi, Registrar. Cheryl Regalia, Medical student, University of California at San Diego; now MD. Dorevitch Laboratories, Melbourne Grahame Mason, MB BS, FRCPA, Pathologist. Department of Photography, Northern Territory University, Darwin, NT. Amanda P Henham, BAppSci(Photog), SRN, Lecturer. Reprints: Dr J W Kelly, Victorian Melanoma Service, Alfred Hospital, Commercial Road, Prahran, VIC 3181. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

John W Kelly · Josephine M Yeatman · Cheryl Regalia · Grahame Mason · Amanda P Henham

Antibiotic use in the Australian community, 1990-1995 Peter McManus, M Leigh Hammond, Susan D Whicker, John G Primrose, Andrea Mant and Steven R Fairall For editorial comment see Turnidge 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 - International comparisons of antibiotic usage - Types of antibiotics used in Australia and indications - Discussion - Acknowledgement - References - Authors' details Make a comment - - ©MJA1997 Abstract Objective: To determine the pattern of antibiotic use in the Australian community, 1990-1995, and compare it with the pattern in other developed countries. Design: Survey of data from the national database on drugs dispensed in Australia (1990-1995), an international database on retail drug sales (1985-1994), and Australian prescriber surveys (1994, 1995). Main outcome measures: National and international retail sales of oral antibiotics (defined daily doses [DDDs]/1000 population/day) and antibiotic prescriptions dispensed through community pharmacies by drug type; antibiotic prescribing profiles for common conditions. Results: Antibiotic use in Australia remained steady between 1990 and 1995, with an estimated 24.7 DDDs/1000 population/day dispensed through community pharmacies in 1990 and 24.8 DDDs/1000 population/day in 1995. Amoxycillin, although declining in use, remained the most dispensed antibiotic. Compared with the other countries surveyed, Australia had the highest percentage use of tetracyclines, such as doxycycline, and the lowest percentage use of fluoroquinolones. Use of trimethoprim-sulfamethoxazole and flucloxacillin declined in Australia. In new cases of upper respiratory tract infection or pharyngitis, an antibiotic prescription was recorded for 57% of urban patient encounters and 73% of rural patient encounters. Conclusions: Antibiotic use in Australia is high, as in many other developed countries, but did not increase between 1990 and 1995. The overall profile of antibiotic use in Australia by drug class was similar to that in the United Kingdom. Antibiotics were still commonly prescribed for upper respiratory tract infection (which is usually viral), more commonly by rural than by urban general practitioners. MJA 1997; 167: 124-127 Introduction Patterns of antibiotic prescribing in Australia between 1987 and 1989 were reported previously by the Drug Utilization Sub-Committee (DUSC) of the Pharmaceutical Benefits Advisory Committee, Department of Health and Family Services.1 At the time, the Sub-Committee expressed concern over evidence of "inappropriate and unnecessarily expensive" practice, which was "directed too heavily towards the use of broad spectrum agents and newer more expensive drugs".1 To update these data, DUSC convened a working group in 1995, comprising representatives of DUSC, the Australian Pharmaceutical Manufacturers Association and the Therapeutics Resource and Educational Network for Doctors (TREND) project of the Royal Australian College of General Practitioners. This group reviewed Australian and international data on antibiotic sales and dispensing to determine patterns of antibiotic use in Australia between 1990 and 1995, and to compare these with patterns in similar developed countries. To understand trends in drug use, the group also analysed prescriber surveys of the indications for antibiotic use. Methods Data were derived from four sources: Prescription dispensing data: These were obtained from the database maintained by the DUSC secretariat which monitors dispensing of prescription medicines through community pharmacies in Australia. These data include dispensing to some private hospitals, but not public hospitals. The database contains information on all subsidised prescriptions processed by the Health Insurance Commission, together with an estimate of non-subsidised prescriptions from an ongoing survey of a sample of about 250 community pharmacies.2 Measurement units are either prescription volumes or number of defined daily doses (DDDs)/1000 population/day. The DDD is based on the assumed average daily dose of the drug when used for its main indication by adults. It is the unit approved by the World Health Organization for drug use studies and allows for comparisons independent of differences in price, preparation and quantity per prescription.3 Sales data: Data on sales of oral antibiotics to retail and hospital markets in a number of countries were obtained from Intercontinental Medical Statistics (IMS), Melbourne. This is a commercial market research organisation which collects sales data and surveys general practitioner (GP) prescribing in 33 countries.4 Data were retrieved as unit sales by form and strength and drug class and then converted to DDDs/1000 population/day. Prescriber survey: Diagnoses for which patients were prescribed anti biotics and patient ages were obtained from the Australian Medical Index (AMI), the survey of GP prescribing conducted by IMS. This uses a sample of 420 GPs stratified in line with the total Australian GP population by metropolitan/country location, age, year of graduation, and practice size (patient numbers). These GPs record all patient encounters over seven consecutive days in each quarterly survey period. The data are then projected to obtain quarterly estimates of prescribing patterns by diagnosis and by patient age and sex for the Australian GP population. At the end of a four-quarter cycle, GPs are invited to continue participating. About half agree, and the remainder are replaced by new recruits. As GPs start in various quarters of the year, there is continual turnover; GPs are not usually kept in the survey for more than two years. TREND project: Use of antibiotics for management of upper respiratory tract infection (URTI)/pharyngitis and influenza was examined using the database of 33 203 doctor-patient encounters recorded in August and September 1994 by the TREND project. This project was part of the development of a new practice assessment in therapeutics option within the RACGP Quality Assurance and Continuing Education Program. Participating GPs recorded prospectively their drug and non-drug management, including lifestyle advice, investigations and referrals, for 110 consecutive patient encounters of all types (including surgery and telephone consultations, home, hospital and nursing home visits). The GP sample was drawn from two urban and two rural areas in NSW which were selected randomly from all NSW Divisions of General Practice, after matching within urban (16 Divisions) and rural (11 Divisions) strata. Matching variables were the index of relative socioeconomic disadvantage (from the 1991 Census5 ) and GP-to-population ratios (from the Medicare claims database as at the end of June 1993) (Gordon Calcino, Acting Director, Technical Support Section of the General Practice Branch, Department of Health and Family Services, personal communication). The rural areas included both major and outlying towns, but not remote rural areas. All GPs from the four areas were eligible for the survey, based on a list provided by the General Practice Branch from the Medicare claims database. Of the 783 GPs approached, 303 (38.7%) completed the practice assessment in 1994. Participants had a similar sex distribution to the 1994 NSW GP population, but a somewhat younger average age.6 Results Between 1990 and 1995, there was little change in the level of antibiotics dispensed through Australian community pharmacies, with an estimated 24.7 DDDs/1000 population/day dispensed in 1990 and 24.8 DDDs/1000 population/day in 1995. Pharmaceutical industry sales data of 25.2 DDDs/1000 population/day in 1989 and 24.8 DDDs/ 1000 population/day in 1994 (0.3% fall on compound annual growth rate) confirm this stability in overall use. International comparisons of antibiotic usage Retail sales of oral antibiotics in Australia and seven major developed countries in 1985, 1989 and 1994 are compared in Figure 1. Like most developed countries, Australia had a high use of oral antibiotics. In 1994 retail sales in Australia were second to those in France and followed closely by those in the United States. However, between 1989 and 1994 sales in Australia did not show the compound annual growth seen in all the other countries except Canada -- France (up 2.8%), United States (up 2.3%), Italy (up 2.9%), West Germany (up 4.4%) and the United Kingdom (up 3%). Sales of oral antibiotics to hospitals in 1994 and the percentage this represented of the total market are shown in Box 1 (above). The percentage was similar in Australia, Canada and the UK (7%, 9% and 11%, respectively), lowest in the US (5%) and highest in West Germany (38%). Figure 2 shows the percentage split of the oral antibiotic market by drug class in 1994. Australia had the highest percentage use of tetracyclines (25.5% of total oral antibiotics), but the lowest use of fluoroquinolones (2.2%) and mid range use of penicillins -- both narrow spectrum (7.1%) and broad spectrum (35%). The overall profile of antibiotic use in Australia was similar to that in the UK. Types of antibiotics used in Australia and indications The top 10 antibiotics, on prescription volume, dispensed through Australian community pharmacies in 1990 and 1995 are shown in Box 2. Amoxycillin was the most-dispensed antibiotic in 1990 and, although declining in use, remained in this position in 1995. Dispensing of doxycycline and erythro mycin also declined, while that of amoxycillin-clavulanate increased. Cefaclor and roxithromycin were new additions to the top 10 dispensed antibiotics in 1995. Converting prescription volume to DDDs/1000 population/day altered the relative ranking of some drugs. For example, drugs in the tetracycline group, which have increased maximum quantities available for treatment of severe acne, rose in rank (1990). In contrast, cefaclor, which has a high DDD (1.5g) by Australian standards, fell from third to seventh position (1995). Box 2 also shows antibiotic prescribing profiles for various indications in 1995. For sinusitis, the most prescribed antibiotics were doxycycline (20.7%), amoxycillin-clavulanate (18.1%) and cefaclor (15.1%). For bronchitis, the most prescribed antibiotic was amoxycillin (18.1%), followed closely by roxithromycin (16.5%) and cefaclor (15.2%). In urinary tract infections, trimethoprim-sulfamethoxazole (28.5%) was most commonly prescribed, followed by cephalexin (18.9%) and amoxycillin-clavulanate (17.2%). Antibiotic prescribing for upper respiratory tract infection (URTI)/pharyngitis and influenza was examined in the TREND sample of GPs from the August-September 1994 audit; 11.6% of encounters were for URTI/pharyn gitis and 1.2% for influenza. For new cases of URTI/pharyngitis, an antibiotic prescription was recorded for 57% of urban patient encounters and for 73% of rural patient encounters. Corresponding figures for antibiotic prescribing in new cases of influenza without pneumonia were 30% of urban and 62% of rural patient encounters. The TREND project did not evaluate whether the prescription was to be filled only under certain conditions (e.g., if symptoms had not improved after a certain interval), but some GPs commented that this was their advice to patients. For symptomatic management, the most common choices were decongestants and analgesics. AMI survey data showed that overall antibiotic usage by age broadly followed the proportional representation of particular age groups in the community, with the exception of the 0-19 years age group. This group received 36.9% of antibiotic prescriptions, but made up only 28.7% of the population. However, for specific conditions the age patterns varied. For example, the TREND project showed that an antibiotic was less often prescribed for children aged 0-5 years with URTI (34.1%) than for adults aged 50 years and over (62.5%). Figure 3 shows quarterly fluctuations in dispensing of oral antibiotics compared with oral β-blockers -- a drug type used on an ongoing basis. Antibiotic dispensing was markedly seasonal, with higher levels in the winter quarters (April to June and July to September), while dispensing of oral β-blockers was low at the beginning of the year and high at the end. The second pattern was typical of "safety net" fluctuations.7 These result from Pharmaceutical Benefits Scheme (PBS) provisions that provide drugs free, or at lower cost, to the patient if they are dispensed after the patient has incurred a set expenditure on PBS items in a calendar year (the "safety net" threshold). Consequently, patients tend to fill repeat prescriptions towards the end of the safety net year, after they reach this threshold. Changes to reduce these fluctuations were introduced in November 1994. Discussion This report is a unique attempt by diverse groups to combine their data sources to give a more complete picture of antibiotic use in Australia than has previously been available. The comparison between seven major developed countries showed that community use of antibiotics in Australia between 1985 and 1994 was high -- second only to France, with the US a close third -- but did not increase during the 1990s, as it did in most of the other countries. In 1994, hospitals accounted for only 7% of retail sales of oral antibiotics in Australia, similar to the percentages seen in Canada and the UK. Similarly, a survey of cardiovascular drug use in Australian public hospitals found that hospital use accounted for less than 10% of the total use of all cardiovascular drug groups.8 The highest percentage of antibiotic use in the hospital sector was found in West Germany, where capping of GP prescribing budgets was introduced in 1993. It has been argued that these prescribing budgets for reimbursable drugs have increased hospital budgets.9 Australia had the highest percentage use of tetracyclines among the seven major developed countries, possibly because of its use in managing acne. In contrast, Australia had the lowest percentage use of fluoroquinolones, most likely because of PBS prescribing restrictions ("authority required"). Amoxycillin remains the antibiotic most dispensed through community pharmacies in Australia, but its use declined between 1990 and 1995, undoubtedly because of transfer prescribing to amoxycillin-clavulanate or other antibiotics. Concerns over an increased risk of severe adverse reactions with trimethoprim-sulfamethoxazole in the elderly10 and of hepatotoxicity with flucloxacillin11 were probably respon sible for the marked fall in use of these drugs and the rise in use of cephalexin, a substitute for flucloxacillin in skin and soft-tissue infections pending the availability of dicloxacillin (PBS listed in 1997).12 The winter increase in dispensing of oral antibiotics in Australia contrasted with the "safety net" fluctuations of the oral β-blockers, which are used on an ongoing basis, and probably reflected treatment of respiratory tract infections. In fact, antibiotics were prescribed for 57%-73% of new cases of URTI. This contrasts with peer consensus recommendations on the use of antimicrobial drugs in medical practice. The Antibiotic guidelines13 state that for URTI "the cause is almost invariably viral" and "antibiotics are not indicated". Furthermore, TREND data show that rural GPs are more likely to prescribe antibiotics for URTI than urban GPs. The difference may reflect rural GPs' concern for the greater patient travel and inconvenience in visiting the doctor in the country, with prescriptions being supplied for use if symptoms fail to resolve after a period of time. However, it may also reflect differences in access to continuing education and in industry promotion between rural and urban GPs. The data also provide insight into GPs' perceptions of antibiotic resistance among bacteria. For sinusitis, the most prescribed antibiotics were doxycycline, amoxycillin-clavulanate and cefaclor, which are recommended if resistance to amoxycillin issuspected or proven.13 For bronchitis, amoxycillin was most prescribed, followed closely by roxithro mycin and cefaclor, which are recommended if a b -lactamase producing organism is isolated or if the clinical response is slow. Our results indicate a strong perception among doctors that resistant organisms are a significant clinical problem, at least for sinusitis and bronchitis. Reasons for this are unclear and deserve investigation; they may include previous clinical experience of slow resolution of these infections with standard therapy, or awareness of the prevalence of resistant bacteria in the local community. A corollary to the study of antibiotic use is an examination of the patterns of antibiotic resistance in bacteria, which may be associated with levels of use of particular antibiotics and with total use. This issue is currently being explored in Australia by the Australian Group on Antimicrobial Resistance and by the National Antimicrobial Resistance Surveillance Program and internationally by the Alexander Project. Acknowledgement Members of the Antibiotic Working Group, which helped prepare these data were: Drug Utilization Sub-Committee: Julie Lindner, Peter McManus, John Marley, Andrew Parkes and John Primrose. Australian Pharmaceutical Manufacturers Association and pharmaceutical industry: Lee Ausburn, Roger Fraser, Steven Fairall, Mendel Grobler, Leigh Hammond, Peter Kofler and Jenny Winter. Royal Australian College of General Practitioners Therapeutics Resource and Educational Network for Doctors (TREND): Andrea Mant and Sue Whicker. The TREND project was funded by a grant from the Pharmaceutical Education Program of the Department of Health and Family Services. References Birkett DJ, Mitchell AS, Godeck A, et al. Profiles of antibacterial drug use in Australia and trends from 1987 to 1989. A report from the Drug Utilization Subcommittee of the Pharmaceutical Benefits Advisory Committee. Med J Aust 1991; 155: 410-415. Edmonds DJ, Dumbrell DM, Primrose JG, et al. Development of an Australian drug utilisation database. A report from the Drug Utilization Subcommittee of the Pharmaceutical Benefits Advisory Committee. PharmacoEconomics 1993; 3: 427-432. Nordic Council on Medicines. Nordic Statistics on Medicines 1990-1992. NLN publication number 34. Uppsala, Sweden: NLN, 1993. Hurley SF, McNeil JJ, Berbatis CG. Sources of Australian pharmacoepidemiology data. Community Health Studies 1988; 12: 82-96. Australian Bureau of Statistics. Index of relative socioeconomic disadvantage. Canberra: ABS, 1993. (Catalogue no 1356.0.) Australian Institute of Health and Welfare. Medical labour force 1992-93. National Health Labour Force Bulletin No. 3. Canberra: Australian Institute of Health and Welfare, Jul 1995. McManus P. Drug utilisation [letter]. Med J Aust 1993; 158: 724. Doecke C, Harvey R, Havas L. Cardiovascular drug use in Australian hospitals 1990. Summary report of a survey conducted by the Society of Hospital Pharmacists of Australia and the Australian Institute of Health for the Commonwealth Department of Community Services and Health. Canberra: the Department, Oct 1991. German drug caps boost hospital costs SCRIP 1993; 1877: 4. Adverse Drug Reactions Advisory Committee. Trimethoprim-sulphamethoxazole warning on elderly. Aust Adverse Drug React Bull 1990 Fed. Fairley CK, McNeil JJ, Desmond P, et al. Risk factors for development of flucloxacillin associated jaundice. BMJ 1993; 306: 233-235. Turnidge J. What to use instead of flucloxacillin [editorial]. Aust Prescriber 1995; 18: 54-55. Victorian Medical Postgraduate Foundation. Antibiotic guidelines 1996/97. 9th edition. Melbourne: The Foundation, 1996. (Received 19 Dec 1996, accepted 29 Apr 1997) Authors' details Department of Health and Family Services, Canberra, ACT. Peter McManus, BPharm, MMedSc, Secretariat, Drug Utilization Sub-Committee; John G Primrose, FRACR, Medical Advisor, Health Benefits Division. SmithKline Beecham (Aust), Melbourne, VIC. M Leigh Hammond, FRCPA, Medical Director. Therapeutics Unit, Royal Australian College of General Practitioners, Sydney, NSW. Susan D Whicker, PhD, Scientific Director. Drug and Alcohol Program, Eastern Sydney Area Health Service, Sydney, NSW. Andrea Mant, MD, FRACGP, Clinical Director. GPS Business Unit, Eli Lilly, Sydney, NSW. Steven R Fairall, BScAg, Associate Director. Reprints will not be available from the authors. Correspondence: Mr P McManus, Drug Utilization Sub-Committee, Department of Health and Family Services, GPO Box 9848, Canberra, ACT 2601. E-mail: peter.mcmanus @ health.gov.au Make a comment - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia. We appreciate your comments.

Peter McManus · John G Primrose · Andrea Mant · Steven R Fairall

The public health impact of dog attacks in a major Australian city Peter G Thompson 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 examine the impact of dog attacks by determining the incidence and risk factors for dog attacks. Design: Injury surveillance data on dog attacks for a major metropolitan hospital were converted to incidence rates using 1991 census figures for the hospital catchment area and combined with data on community attitudes and experiences derived from a large community survey. Setting: Queen Elizabeth Hospital (tertiary referral hospital), Adelaide, South Australia, January 1990 to July 1993. Participants: 356 victims of dog attacks who presented to the emergency department and 3093 respondents to the 1992 South Australian Health Omnibus Survey. Main outcome measures: Rates of dog attack by age and sex of the victim, hospital presentation and admission; differences in the representation of various dog breeds in attacks. Results: About 6500 people are injured in Adelaide each year as a result of dog attacks and about 810 seek hospital treatment (7.3 per 10 000 people per year). Children aged 0-4 years were attacked and required hospital treatment twice as often as adults aged 21-59 years, and men aged over 76 years twice as often as men aged 36-75 years. Males were more at risk of attack than females for all age groups. Hospital admission rates were five times higher for the elderly (95% confidence interval [CI], 2.3%-10.2%) and seven times higher for children 12 years and under (95% CI, 3.4%-15.1%) compared with people aged 13-59 years; 90% of children were admitted because of head and facial bites. The risk of attack from german shepherds, bull terriers, blue/red heelers, dobermans and rottweilers was four to five times higher than for other common breeds. Conclusions: The public health implications of dog attacks are significant and there needs to be increased awareness of the risks to young children. Potential interventions to reduce the incidence of dog attacks vary from strict controls on high-risk breeds to mandatory leashing to a "user pays" liability insurance proposal. MJA 1997; 167: 129-132 Introduction Dog attacks are a major cause of human injury in Australia. In 1991, it was estimated that there could be up to 30 000 people presenting to hospital annually as the result of dog attacks in Australia.1 Injury records from the Women's and Children's Hospital in South Australia show that dog attacks are the fourth most common reason for children being taken to hospital, after accidents from playground equipment, bicycles and motor vehicles.2 Studies from other States3,4 also report a high level of childhood injuries related to dog attacks, and a recent South Australian report5 confirmed that dogs were a significant cause of injury at all ages, including the elderly. In the United States, there has been a 37% increase since 1986 in dog bites that required medical attention, and dog attacks eclipse measles, mumps and whooping cough combined as a health threat to American children.6 To determine the impact of dog attacks and identify possible interventions to reduce their frequency, we examined surveillance data from a major metropolitan hospital in Adelaide and data from a large community survey. We report the rates of hospital treatment and admission for dog attacks, the severity of injuries, the groups most at risk of attack, community concern about dog attacks and a comparison of the relative risk between dog breeds. Methods Two data sources were used in this study: the South Australian Health Commission's Injury Surveillance System, and the 1992 South Australian Health Omnibus Survey. In both data sources, a "dog attack" was defined as an intentional bite by the dog, or direct aggression causing injury to the victim. 1991 Census population statistics were also used to determine the age- and sex-specific rates of dog attack, as well as the age-specific rates of admission to hospital resulting from dog attacks. Ethics approval was provided by the University of Adelaide. Injury Surveillance System The South Australian Health Commission's Injury Surveillance System automatically receives information from victims who present to selected metropolitan public hospitals for treatment. For the purposes of this study, it provided information about all victims of dog attacks (e.g., age and sex of victim, type of injury, location and description of incident and treatment) who presented to Queen Elizabeth Hospital in Adelaide between January 1990 and July 1993. This system, which includes all age groups, has the advantage of documenting the information at the time of treatment (in the hospital), which reduces the possibility of subsequent recall bias. Queen Elizabeth Hospital was chosen for this study because it has a well-defined catchment area with natural geographic boundaries on two sides. The other boundaries were determined by selecting the midpoint between adjacent public hospitals. Approximately 13% of the victims of dog attacks in the Adelaide metropolitan area who required hospital treatment between January 1990 and July 1993 presented to Queen Elizabeth Hospital. From a total of 356 attacks, the mean number by age and sex per year was calculated. The Injury Surveillance System provided the breed of dog (when it was known). We were confident that the breed names were accurate because in at least half of the attacks the victim was the dog's owner, a family member or a person who knew the dog well and the breeds named were common and easily recognised. Breeds that were unknown could have been a source of bias if their breed distribution was different. However, a comparison of victims who named the dog breed with those who did not failed to show any appreciable differences with regard to age, sex, dog ownership, body part injured and injury severity. The breed distribution of known breeds also largely agreed with other investigations.4,7-10 An indicator of the health impact of the injury on the person's life was whether the victim was admitted to hospital after initial examination in the emergency department. Those who were admitted were expressed as a proportion of the total number of people presenting to the emergency department. As data for all admissions came from the same hospital, the selection criteria for admission were likely to be consistent. The distribution of injury by body part was also examined. Health Omnibus Survey The 1992 South Australian Health Omnibus Survey11 contains information obtained from interviews with 3093 randomly selected persons in Adelaide in 1992.11 The annual Omnibus Survey is a population health survey that provides a large representative sample of the attitudes towards health issues and experiences of people aged over 15 years. For our investigation, 13 questions concerning dog attacks were incorporated into the Omnibus Survey, including: Does anyone in this household own a dog? What is the breed of the dog? Have you been attacked by a dog in the past three years? Whose dog was it? Where did the attack occur? To what extent do you fear being attacked or threatened by a dog? Respondents were also asked about injuries sustained and treatment received. Therefore, the Omnibus Survey provided data not only about victims of dog attacks who presented to hospital, but also data on victims of dog attacks who may have consulted a general practitioner as well as those who may not have been injured at all. The Omnibus Survey also provided information on the distribution of the dog population by breed. The frequency of breeds involved in attacks was converted to a representation ratio to compare the relative risks between breeds. The ratio was calculated by dividing the percentage of attacks per breed by the percentage of the total dog population represented by the same breed. Representation ratios allow confirmation of whether certain breeds of dog attack more frequently because they are more commonly chosen as pets (e.g., german shepherds may cause 25% of all attacks simply because they comprise 25% of the dog population). Population statistics from the Omnibus Survey as well as the 1991 Census were used to examine the demographics of the catchment area of Queen Elizabeth Hospital in comparison with metropolitan Adelaide. From an examination of the data on age, ethnicity and socioeconomic status, it was concluded that the catchment was representative of metropolitan Adelaide. Statistical analysis Ninety-five per cent confidence intervals [CIs] for admission rates were attributed to Lilienfeld and Lilienfeld,12 and 95% CIs for admission rate relative risks attributed to Rothman's analysis of crude data.13 Results Frequency of dog attacks: presentation to hospital Box 1 shows the age- and sex-specific rates of dog attack calculated from victims who presented to the emergency department of Queen Elizabeth Hospital from January 1990 to July 1993. The 356 dog attacks for this period equate to 7.3 attacks per 10 000 people per year requiring hospital treatment. The rate of dog attack for men over the age of 76 was nearly double the rate for men aged 36 to 75, but this was not statistically significant, possibly because of the small sample size of older men. Notably, the rate for children aged 0 to 4 years was twice that for adults aged 21 to 59 years. This rate was likely to be conservative because some children in the catchment area of Queen Elizabeth Hospital may have been taken directly to the Adelaide Children's Hospital. There was also a marked difference between the rates for men and women. Men had, on average, a 50% higher risk of attack at all ages ( Figure 1). Frequency of dog attacks: community survey Of the 3093 respondents to the Omnibus Survey, one in 20 reported that they had been attacked by a dog at least once in the past three years, and a third had been attacked more than once in the past three years. More than half (51%) reported that they had been attacked in a street or public place. Of the 88 people who reported in the Omnibus Survey that they had been injured by dogs and had required treatment, 35 people (40%) had consulted a doctor and 11 people (12.5%) had sought hospital treatment per year. The Omnibus Survey reported that 37.2% of households in metropolitan Adelaide owned at least one dog. The 1992 Dog Control Review Report estimated that there were about 190 000 dogs in metropolitan Adelaide.14 Admission to hospital Box 2 (above) shows the number of victims of dog attacks who were admitted to Queen Elizabeth Hospital between January 1990 and July 1993. The rates of admission to hospital, as an indicator of the health impact of dog attack, were five times higher for elderly people (95% CI, 2.3-10.2) and seven times higher for children (95% CI, 3.4-15.1) than for people aged 13-59 years. Nearly two-thirds (66%) of children aged up to 12 years received head and facial bites ( Figure 2); these injuries were responsible for 90% of admissions in this age group ( Figure 3). Relative risk of dog attack, by breed Box 3 (below) shows the proportion of dog attacks by various breeds, the representation of particular breeds in the total dog population, and the relative risk of attack by those breeds (representation ratio). The Injury Surveillance System provided the breed of dog in 43% of attacks (154). It can be seen that the first five breeds were responsible for 73% of all hospital-treated attacks, yet they represented only 31% of the dog population. The relative risk of attack by a german shepherd was about five times greater than a collie (2.5/0.5 = 5). Bull terriers, red/blue heelers and rottweilers presented a four-times-higher risk. The relative risk of attack by a doberman was even higher. It is possible that more dangerous dogs existed (e.g., the prohibited American pit bull terrier), but they did not feature in the Injury Surveillance System data because they comprised a small proportion of the dog population. Fear of dog attacks Half of the respondents to the Omnibus Survey felt threatened or feared being attacked by dogs (95% CI, 48.4%- 51.9%). Of those who were afraid, 28.4% said their concern was minor in that it did not affect their behaviour, 18.7% felt moderate concern which had had an effect on their behaviour (such as planning safer routes away from known dogs), and the remaining 3.1% expressed major concern which had had more dire consequences (such as deciding not to leave the house to go shopping). Incidence of dog attacks The total number of attacks represented a rate of 2.85% per year, which corresponds to about 29 000 attacks in metropolitan Adelaide each year, based on the 1991 Census population of 1 023 278. The total number of people injured and requiring treatment represented a rate of 0.63% per year, which corresponds to about 6500 people being injured and requiring treatment following dog attacks in Adelaide each year, with 2600 persons consulting a doctor and 810 seeking treatment at a hospital. If the overall rate of presentation to Queen Elizabeth Hospital following a dog attack (i.e., 7.3 per 10 000 people per year) is applied to the population of Adelaide, it corresponds to 750 persons presenting to hospital each year. This figure is close to the rate of 810 reported in the Omnibus Survey. If Adelaide is considered similar to most other Australian metropolitan areas, it could be expected that around 100 000 Australians will be injured and require treatment each year as a result of dog attack and that about 13 000 will seek treatment at a hospital. Discussion In this study, three-quarters of all hospital-treated dog attacks were caused by just five of the 160 or so available breeds. Limiting the availability of these breeds would be one way of reducing injury. Alternatively, ownership could be restricted to certified owners who accept responsibility to place specific controls on these breeds. These controls include obedience training and dog behaviour assessment, ensuring that the dog is on a leash at all times in public, the home property is securely fenced and warning signs have been erected for visitors. Owners should also be encouraged to join dog clubs to raise awareness of the responsibilities involved in owning a dog. More than half the attacks reported in this study occurred in a street or public place by loose uncontrolled dogs. It is reasonable to assume that if the dogs had been restrained these attacks would not have occurred. The Australian Capital Territory, the Brisbane City Council, and a number of Victorian councils have adopted the strategy of requiring all dogs to be on a leash at all times in public. Councils in those States that still consider dogs need only be under the verbal control of their master in public places should consider this safer option. Brisbane City Council also requires mandatory fencing to contain dogs within their owner's property. Data from the Injury Surveillance System clearly show that dogs and very young children frequently do not mix.1 Parents of young children would be wise to postpone purchase of a dog until their children are older, preferably more than five years of age. A nationwide publicity campaign is recommended to alert parents to the dangers, especially in view of the high level of attacks to the head and face of children found in this study. Another option to reduce dog attacks could be to adopt a "user pays" element into dog ownership by introducing a third party insurance scheme. The issue of a registration permit could be conditional on the presentation of a suitable insurance agreement. In 1993, a South Australian court awarded $380 000 to a garbage collector for injuries sustained when attacked by an unrestrained dog -- the dog's owners were found responsible for the damages.15 For low-risk breeds, it is anticipated that there would be no additional premium to standard home insurance cover, but for high-risk breeds an increased premium would be likely. The premium would ultimately be determined by the extent of the claims relevant to each particular breed (i.e., the performance of the insured determines the cost). The paying of an additional premium would have the effect of deterring "spur-of-the-moment" buyers by encouraging them to think more carefully when choosing a breed and perhaps buy a lower-risk breed. Another benefit would result from insurance companies insisting on better ownership practices for particular breeds (as outlined at the beginning of the Discussion) before issuing policies. The rates of dog attack in Adelaide were projected to the nation as a whole because most Australians live in metropolitan areas and large regional centres (similar to Adelaide) and it was therefore considered that dog attacks were a widespread public health problem. The finding that half of the population surveyed were concerned about being attacked by dogs indicates that strengthening of dog-control policies will be more acceptable to the community than previously thought. In view of rising community concern and increasing media reports on dog attacks, owners must take more responsibility and put in place measures to reduce the incidence of dog attacks. References South Australian Health Commission. Dog attacks. Inj Surveill Monthly Bull January 1991; 29: 1-2. Williams N. Women's and Children's Hospital. The perils of being a kid . The Advertiser (Adelaide) August 1995. Ashby K. Dog bites. Victorian Injury Surveillance System. Hazard 1996; 26: 7-13. Podberscer AL, Blackshaw JK, Nixon JN. The incidence of dog attack in children treated at a city hospital. Aust Vet J 1990; 67: 79-80. Langley A, Dantalis N, Edwards-Bert P. Environmental health in the home. Adelaide: South Australian Health Commission, 1996: 10-32. Wulf S. Man's best friend? Time 1997; June 23: 68. Greenhalgh C, Cockington R, Raftos I. An epidemiological survey of dog bites presenting to the emergency department of a children's hospital . J Paediatr Child Health 1991; 27: 171-174. Thomas PR, Buntine JA. Man's best friend? A review of the Austin Hospital's experience with dog bites. Med J Aust 1987; 147: 536-540. Langley J. The incidence of dog bites in New Zealand. Injury Prevention Research Unit, Preventive and Social Medicine. N Z Med J 1992; 105: 33-35. Avner JR, Baker MD. Dog bites in urban children. Pediatrics 1991; 88: 55-57. Harrison R. 1992 Health Omnibus Survey -- A research report. Adelaide: Harrison Market Research Pty Ltd; 1993: 11-21. Lilienfeld AM, Lilienfeld DE. Foundations of epidemiology. 2nd ed. New York: Oxford University Press, 1980: 336-337. Rothman KJ. Modern epidemiology. Boston/Toronto: Little, Brown and Company, 1986: 155-175. KJ McCann. Dog Control Review Report. Adelaide: South Australian Department of Environment and Planning, 1992. Revalk J. Dog scare garbo gets $380 000 for injuries. South Australian Advertiser March 1993. (Received 20 Aug 1996; accepted 26 May 1997) Authors' details Injury Surveillance and Control Unit, South Australian Health Commission, Adelaide, SA. Peter G Thompson, MPH, Injury Epidemiologist. Reprints will not be available from the author. Correspondence: Mr P G Thompson, Public and Environmental Health Service, South Australian Health Commission, PO Box 6, Rundle Mall, SA 5000. E-mail: somers.ronald@health.sa.gov.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter G Thompson

Burden and outcomes of hospitalisation for congestive heart failure Fiona M Blyth, Ross Lazarus, David Ross, Michael Price, Gary Cheuk and Stephen R Leeder For editorial comment see Krum 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 describe the hospital burden and health outcomes associated with admission for congestive heart failure (CHF). Design and setting: Descriptive follow-up study in a tertiary-level metropolitan teaching hospital. Patients: Acute adult inpatients with a clinical diagnosis of CHF for more than 24 hours admitted to Westmead Hospital, Sydney, during the four months from September 1993 to January 1994. At baseline, 122 patients were assessed; 88 patients were assessed at four-month follow-up. Interventions: Usual clinical care. Main outcome measures: Length of stay; hospital bed-days; readmissions; mortality; health related quality of life (SF-36); patient knowledge. Results: The average age of subjects was 73.4 years. Many were using informal domiciliary care before admission. Mean length of stay for the baseline admission was 13.8 days, accounting for 7.6% of hospital separations and 1683 hospital bed-days, or 4.2% of bed-days for all inpatients aged 65 years and over. Fifteen patients were readmitted for CHF during the following four months, with a total of 26 CHF-related admissions. Twenty-one patients (17.2%) died during the course of the study. Quality of life at baseline was poor compared with population normative data, with a slight improvement among survivors at four-month follow-up. Patient knowledge of CHF was poor in a subsample survey ( n = 24). Conclusions: CHF represents a significant burden to patients (through morbidity and mortality), their carers (through provision of daily care), and hospitals (through multiple admissions for acute decompensation). It is difficult to monitor the hospital burden of CHF using routine data sources. MJA 1997; 167: 67-70 Introduction Congestive heart failure (CHF) has been estimated to affect 3%-5% of those aged over 65 years, and 10% of those over 75 years.1 It is the fastest growing cardiovascular disorder in the United States,2 the only one increasing in incidence and prevalence,3 and the leading cause of hospital admission and readmission in Americans aged over 65 years.4 In 1990, CHF cost the US economy $US8 billion, and accounted for five million hospital bed-days.5,6 In Scotland, CHF hospital discharge rates have risen in a decade to be almost equal to those for myocardial infarction.7 In the United Kingdom, the National Health Service spends £360 million per year in diagnosis and management, on a par with spending on stroke or asthma. Most of this expenditure is on hospital admissions.8 As there is little information available on the outcomes of current hospital management of CHF patients,9,10 we describe the health outcomes of a cohort of patients hospitalised with CHF, and the impact of their hospitalisation on a health service. Methods All acute adult patients admitted to Westmead Hospital during four months (September 1993 to January 1994) with a clinical diagnosis of CHF, or who developed CHF of more than 24 hours' duration during an admission, were eligible for inclusion in the study. The diagnosis of CHF was made by medical staff on clinical grounds. Additional eligibility criteria were fluency in English and absence of significant cognitive impairment. Two cardiology-trained research nurses implemented an active daily case-finding strategy to overcome the difficulties encountered in identifying CHF patients from existing record systems. Diagnostic codes are generally not added to the patient's medical record until some time after discharge. Patients were identified by review of the computerised admissions log, medical record chart audit in the relevant ward areas, and consultation with medical staff. Potential subjects were assessed for their general condition and fluency in English and, if appropriate, screened for cognitive impairment by means of the Mini-Mental State examination.11 Informed consent was then sought. If patients were unable to participate fully, consent was sought to review their medical record and follow them up four months later to ascertain vital status. Baseline data were collected by interview, medical record review and self-administered questionnaires. Data were collected on demographic characteristics, domiciliary arrangements, current and past medical history, clinical severity of heart failure (according to the New York Heart Association [NYHA] criteria for grading functional incapacity of patients with cardiac disease), investigations, drug treatment, hospital resource use, formal and informal use of domiciliary care, and health-related quality of life (HRQOL) before admission (measured with the SF-36 [Medical Outcomes Study 36 Item Short Form Health Survey]).12 Patient knowledge about CHF was assessed by a short questionnaire in a subset of 24 consecutive patients. Four months after baseline admission, subjects were contacted by telephone to arrange follow-up by questionnaire. Data were sought on health status, HRQOL, current treatment, and domiciliary arrangements. The hospital's computer system was searched for any readmissions during the follow-up period. All analysis was performed using SAS version 6.08 for Windows.13 Two-sample t tests were used to assess the statistical significance of differences between groups, with adjustments made for multiple comparisons. SF-36 data were scored and subscales were calculated with the recommended scoring algorithm.12 Westmead Hospital Human Research Ethics Committee approved the study, and informed consent was obtained from all participating patients. Results There was no "gold standard" available for checking the accuracy and completeness of study case ascertainment methods. However, a list was assembled of all separations from Westmead Hospital during the study recruitment period with a principal diagnosis code for CHF (ICD-9 codes 428.0, 428.1, 428.9). These were then cross-checked against a list of study subjects. This list identified seven patients who were not identified by study case-finding methods. These were considered "missed" potential cases, but represented a small proportion of this group (4.3%). During the study recruitment period, 154 patients met the required clinical criteria and 122 (79%) consented to participate. Participation and follow-up are detailed in Box 1. Sample characteristics: Women made up 54.9% of the study participants. The mean age was 73.4 years (range, 24-97 years); women were older on average than men (76.8 compared with 69.4 years; P = 0.0001). Most patients had a history of established CHF; 35.2% were undergoing their first hospital admission for CHF. Only 1.8% of patients were NYHA grade I on baseline admission, 12.3% grade II, 64.4% grade III, and 17.5% grade IV (4% lacked data for NYHA classification). Thirty-eight patients had their ejection fraction measured at the baseline admission, with a mean value of 35% (range, 9%-74%). Ischaemic heart disease (58.2%) and hypertension (39.3%) were major aetiological factors in CHF. The cohort was cared for by cardiologists (n = 74; 60.7%), and geriatricians (n = 48; 39.3%). Admission diagnoses are shown in Box 2 (below). When admission diagnoses were compared with ICD-9 codings on the medical record, 39 (86.6%) of the 45 with heart-failure-specific admission diagnoses and 30 (78.9%) of the 38 with suggestive diagnoses had a CHF-related ICD-9 code (428, 428.0, 428.1, 428.9) in one of the first six ICD-9 coding positions. Preadmission characteristics: Data were available for 99 subjects: 88 lived in private accommodation, 50 reported needing regular help from family or friends with general housekeeping, and 23 reported needing help with supervision of medication. Length of stay: The study participants accounted for 7.6% of hospital separations (excluding day-only patients). The mean length of stay during the baseline admission was 13.8 days (SD = 12.1). Length of stay had a markedly skewed distribution (median, 10 days; range, 2-66 days). Overall, the sample accounted for 1683 bed-days during baseline admissions and 10.6% of hospital bed-days associated with the geriatricians and cardiologists who participated in the study. Of those patients aged 65 years and over admitted during the same period, the CHF cohort accounted for 4.2% of bed-days. Readmissions: During the follow-up period, there were 73 readmissions to Westmead Hospital from the study cohort, 26 due to a further episode of CHF in 15 patients. A total of 171 bed-days were used for CHF-related readmissions by the 14 patients for whom data were available. Deaths: Twenty-one patients died during the study (17.2%). Changes in domicile: Eight patients (8.1%) were discharged to a higher level of domiciliary care, suggesting a decline in independence and increased use of health and/or community services. Quality of life: Data on HRQOL before admission were obtained from 84 of the 85 subjects at baseline (Box 3). Mean SF-36 subscale scores for these subjects were generally low, particularly for subscales with physical health components. For each subscale there was a wide range of scores, indicating substantial variability in health-related quality of life before admission. Compared with Australian normative SF-36 data for men and women aged 65 years and over,14 the study cohort reported significantly lower mean HRQOL for all subscales. Follow-up SF-36 data were obtained for 58 subjects (Box 4). Patients with missing follow-up data had either died before follow-up (n = 15) or were too unwell to fill in the form (n = 6). In that sense, the SF-36 results at follow-up represent the "survivor" population within the study cohort. Mean follow-up subscale scores in survivors were somewhat higher compared with their baseline scores. The smallest improvements were in the subscales related to physical health. Improvements in the Social Function, Vitality and Mental Health subscales were statistically significant. Patient knowledge: The 24 patients who completed the questionnaire were similar to the CHF cohort in age, sex, length of stay, and type of treating specialist. Nineteen had been admitted to hospital previously for CHF. Only 11 knew that they had been diagnosed as having heart failure. Although 16 agreed that patients with heart failure would need to take medication permanently, six thought that CHF was unlikely to recur. Nineteen agreed that shortness of breath and 15 agreed that ankle swelling were important symptoms, but only four recognised that rapidly increasing weight was important. Discussion CHF has a significant impact on hospital services. The study cohort contributed significantly to adult bed-days attributable to participating clinicians. A substantial proportion (12.3%) of the cohort was readmitted with CHF within four months of their baseline admission, suggesting an annual readmission rate of around 36%. This compares with an annual readmission rate of nearly 20% in the SOLVD (Studies of Left Ventricular Dysfunction) registry study cohort, who were younger.10 CHF admissions show seasonal variations, with a winter peak that is probably associated with chest infection. Therefore, the impact of CHF on acute hospital services may be even greater at that time of year. The 48 subjects (39.3%) who were admitted under the care of geriatricians were, by hospital admission policy, those aged over 65 with serious comorbidity and/or likely to represent a placement problem after discharge. Many required substantial help with tasks essential for independent living, and most of this help was provided informally. This was clearly a group that would require increased resources with deteriorating health. HRQOL was generally poor in the study participants compared with normative data,14 probably reflecting the combined effects of disease severity and comorbidity. There was limited improvement between baseline and follow-up, particularly in the subscales related to physical health, perhaps indicating that at baseline the lower limits of some SF-36 subscales did not adequately reflect the subjects' condition (i.e., a "floor" effect was operating). The mean changes in scores over time were small, but underlying this was great variability between individuals. At the time of this study there were few educational resources for CHF patients. This is surprising, as CHF is a chronic condition with acute exacerbations that may be ameliorated by early recognition and intervention, and which requires compliance with medication. Some CHF patients may avoid hospital admission by timely intervention prompted by self-monitoring of signs and symptoms. Seventy-six subjects (62.3%) had a recorded history of acute deterioration lasting for more than 24 hours, suggesting a possible opportunity for early recognition and intervention. The patient knowledge survey was limited, but it demonstrated an apparent lack of understanding of key features of CHF. Recent acute illness could have contributed to this. That almost a quarter of the cohort required daily help with taking medications has implications for the targeting of educational interventions. For elderly patients experiencing readmissions for CHF, the risk of dying in the near future and the palliative nature of treatment are additional issues which may need to be explored. This study was constrained, for practical reasons, by reliance on a clinical diagnosis of CHF. In a larger study with more resources, verification of diagnosis and more detailed examination of diagnostic coding practices would be desirable, and would allow identification of subgroups of particular clinical interest. Diagnostic coding practices in routine record keeping do not facilitate monitoring of the public health impact of CHF. A hospital admission for CHF may be assigned a principal ICD-9 code which reflects the underlying cause of CHF, and secondary ICD-9 codes are sometimes used to identify a past medical history of CHF rather than a feature of the current admission. In this study, poor health represented a further barrier to study participation and monitoring outcomes. Most losses to follow-up resulted from death or worsening health. During the study 21 subjects (17.2%) died. This represents a poor survival rate, worse than for many malignancies of adulthood. Cause of death was not ascertained, but in the SOLVD registry cohort10 most deaths were due to progressive CHF. In addition, sudden death occurs in CHF patients at five times the rate in the general population of the same age.15 Chronic CHF represents a significant burden to patients (through morbidity and mortality), their carers (through provision of daily care), and the hospital system (through multiple admissions for acute decompensation). Acknowledgements We acknowledge the contribution of Moira Hewitt, RN, and Jeanette Bunn, RN, to the Westmead CHF Outcomes study, and study coinvestigator Dr Julia Lowe from the Newcastle Heart Failure Group. This study was funded by the NSW Health Department's Health Outcomes Program. References Failure to treat heart failure [editorial]. Lancet 1992; 330: 278-279. Mortality from congestive heart failure --United States, 1980-1990. MMWR Morb Mortal Wkly Rep 1994; 43: 77-81. Yamani M, Massie BM. Congestive heart failure: insights from epidemiology, implications for treatment. Mayo Clin Proc 1993; 68: 1214-1218. Gooding J, Jette AM. Hospital readmissions among the elderly. J Am Geriatr Soc 1985; 33: 595-601. National Centre for Health Statistics, Graves EJ. National Hospital Discharge Survey: Annual Summary, 1990. Vital Health Stat [13] 1992; 112: 28. Munoz E, Chalfin D, Birnbaum E, et al. Hospital costs, resource characteristics, and the dynamics of death for patients with a primary diagnosis of congestive heart failure. N Y State J Med 1989; 89: 60-63. McMurray J. Trends in hospitalisation for heart failure in Scotland 1980-1990. Eur Heart J 1993; 14: 1158-1162. McMurray J, Hart W. The economic impact of hearfailure on the U K National Health Service. Eur Heart J 1993; 14 Suppl: 133. Parameshwar J, Poole-Wilson PA, Sutton GC. Heart failure in a district hospital. J R Coll Physicians Lond 1992; 26: 139-142. Bourassa MG, Gurne O, Bangdiwala SI, et al. for the SOLVD investigators. Natural history and patterns of current practice in heart failure. J Am Coll Cardiol 1993; 22 Suppl A: 14A-19A. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189-198. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 health survey: manual and interpretation guide. Boston: The Health Institute, New England Medical Centre, 1993 . SAS for the Microsoft Windows Environment, Version 6. Cary, NC: SAS Institute Inc, 1993. Stevenson CE. SF-36: Interim norms for Australian data. Canberra: Australian Institute of Health and Welfare, 1996. Kannel WB, Ho K, Thom T. Changing epidemiologic features of cardiac failure. Br Heart J 1994; 72 Suppl: S3-S9. (Received 8 Oct 1996, accepted 10 Apr 1997) Authors' details Westmead Hospital, Sydney, NSW. Fiona M Blyth, FAFPHM, Registrar, Department of Public Health and Community Medicine. Ross Lazarus, FAFPHM, Senior Lecturer in Epidemiology, Department of Public Health and Community Medicine, University of Sydney at Westmead Hospital. David Ross, FRACP, Head, Department of Cardiology. Michael Price, FRACP, Head, Geriatric Medicine Unit. Gary Cheuk, FRACP, Registrar, Geriatric Medicine Unit. Stephen R Leeder, FRACP, PhD, FAFPHM, Professor of Public Health and Community Medicine, University of Sydney at Westmead Hospital. Reprints will not be available from the author. Correspondence: Dr F M Blyth, Department of Public Health and Community Medicine, Westmead Hospital, Westmead, NSW 2145. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Fiona M Blyth · Ross Lazarus · David Ross · Michael Price · Gary Cheuk · Stephen R Leeder

Troublesome lower urinary tract symptoms in the community: a prevalence study Carole B Pinnock and Villis R Marshall For editorial comment see Hirst & Ward 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 - Method - Population surveyed - Survey questionnaire - Results - Discussion - Key points of study - References - Authors' details - ©MJA1997 Abstract Objective: To determine the prevalence of troublesome lower urinary tract symptoms (LUTS) in men and women in the community. Design: Interview-based prevalence survey. Setting: Metropolitan and rural communities in South Australia, September, 1995. Subjects: Probability sample of 1204 men and 1686 women (aged over 18 years) weighted to reflect the age and sex distribution of the South Australian population. Data collected: Presence of storage (irritative) and voiding (obstructive) symptoms, based on the International Prostate Symptom Score questionnaire; satisfaction with urinary condition (quality-of-life measure); and visits to a doctor for urinary symptoms in the preceding 12 months. Results: The prevalence of one or more troublesome LUTS was 26% (318/1204) for men and 39% (662/1686) for women (all ages) and 48% (314/649) for men and women over 65. The most common troublesome symptoms in men and women were nocturia and frequency. Symptoms were significantly age-related in men, but less so in women, in whom symptom prevalence exceeded 30% for all age groups. Ten per cent of men (123/1204) and 15% of women (249/1686) had visited a doctor for a urinary problem in the previous 12 months. Nine per cent of men (104/1204) and 16% of women (274/1686) were substantially dissatisfied with their urinary condition. Symptom prevalence and dissatisfaction with urinary condition were significantly associated with visiting the doctor ( P < 0.0001), but only 28% (88/318) of men and 27% (179/662) of women with troublesome LUTS saw a doctor, and 63% (65/104) of men and 59% (162/274) of women dissatisfied with their urinary condition did not seek medical help. Conclusions: Although the prevalence of troublesome LUTS in the community is high, the number of people whose quality of life is substantially affected is much lower. The impact of these symptoms upon quality of life is a major reason for patients to see a doctor, yet many who are "bothered" by the symptoms do not do so. MJA 1997; 167: 72-75 Introduction As the community ages, conditions affecting the quality of life and activity of older people become of increasing concern. Lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) have been termed "prostatism" and may greatly affect the quality of life of older men;1-3 the consequent cost of treatment to the community is high.4 The prevalence of clinically demonstrated BPH is 20% in men aged 40-49 years and 40%-50% in those over 65 years.1,5,6 To document the prevalence of symptoms related to BPH, the International Prostate Symptom Score (IPSS)7 grades the presence of seven LUTS (nocturia, intermittency, urgency, weak stream, incomplete emptying, hesitancy, frequency) on a severity scale of 0-5. It also includes a disease-specific quality-of-life question. However, LUTS measured with the IPSS and related symptom scores may have a range of aetiologies. Urinary symptoms such as urgency and urge incontinence may be caused by idiopathic detrusor instability, changes in muscle contractility, and other non-obstructive causes related to ageing.8,9 The IPSS is thus a non-specific measure of LUTS possibly caused by BPH, and this is reflected by studies that have shown high symptom scores in men with other lower urinary tract conditions,10 and in women.11-13 In an Australian general practice survey, urological problems were given as 1.7% of reasons for encounter with a doctor (all ages, both sexes),14 while in older men 7%-14% of encounters were for urinary problems.15 But the number of people significantly "bothered" by LUTS appears to be very much greater than the number seeking medical help for the problem.5,6,15 Symptom prevalence varies between countries, but there is evidence that similar levels of symptoms have a similar impact on daily activities of living in different countries.16,17 The prevalence of LUTS has been measured with the IPSS or related indices in the Netherlands,18 Canada,19 the United Kingdom,5 France,20 Japan,21 Spain,22 New Zealand,23 Scotland and the United States;17 no community-based surveys of symptom prevalence have been undertaken in Australia. Because of this, we undertook a community survey to determine the prevalence of troublesome LUTS in men and women in South Australia. The symptoms surveyed are described as uncomplicated by the National Health and Medical Research Council.8 Our objective was not to derive a severity score, but to determine the presence or absence of troublesome symptoms, their impact on quality of life, and the proportion of individuals seeking medical help for such a problem. Method Population surveyed The Omnibus survey, a multiple-user household interview survey undertaken for health organisations in South Australia (SA), was used for the study. The methodology and results of its use in other studies have been reported.24-26 The sampling method provides a probability sample of the SA population: in the metropolitan sample, 10 dwellings are chosen from each of 320 census collection districts (1991 census) using a random starting point and selection is then based on every fourth household. One person aged over 15 years (the person whose birthday was last) is chosen per household. In the country sample, all cities/towns with a population of 10 000 or more are chosen, and the balance of the sample is chosen from centres with a population of 1000 or more, with weighting proportional to size. The sampling method was the same as for metropolitan dwellings. Sixty interviewers conducted 3016 interviews from the 4200 households selected. Data are weighted by the inverse of the individual's probability of selection, then reweighted to benchmarks derived from estimated resident population at 30 June 1993 by age, sex and local government area from the Australian Bureau of Statistics. The data analysed and presented have thus been weighted to represent the age and sex structure of the SA population. Survey questionnaire The questions were derived from the American Urological Association-7 BPH questionnaire,27 adopted by the World Health Organization (WHO) as the IPSS,7 and have been validated for test/retest reliability, validity and clarity. Respondents were asked if, in the previous 12 months, any of the following urinary symptoms were troublesome: a strong need to urinate (pass water) with little or no warning; needing to go again less than two hours after finishing urination; needing to get up twice or more at night to urinate; having a weak urinary stream; stopping and starting several times when urinating; wetting underclothes;20 and whether there were other troublesome urinary symptoms. Respondents were asked about the presence or absence of "troublesome symptoms" -- they were not asked to grade symptom severity. They were also asked about quality-of-life7 (level of satisfaction with their urinary condition, in seven categories: delighted, pleased, mostly satisfied, mixed, mostly dissatisfied, unhappy, terrible), and whether they had seen a doctor about any urinary problem in the past 12 months. Questions were piloted for ease of understanding, internal consistency and sensitivity in a group of 18 men, and subsequently in 50 further interviews with men and women. To ensure completeness and accuracy of recording, five per cent of each interviewer's work was selected at random and the respondent re-interviewed with selected questions. After data checking, any missing responses were followed up by telephone. Statistical analysis was done with SPSS for Windows version 6.1 (SPSS, Chicago, Ill, USA). Statistical significance was calculated with Pearson chi-squared tests, unless otherwise indicated. Results The initial sample drawn was 4200 houses, of which 4067 were occupied and defined as "households". Of these, 3016 households participated, a response rate of 74.2%. Of the 3016 people interviewed, 1734 were women (57.5%) and 1281, men (42.5%). The major reasons for non-response were refusal (601; too busy, not interested) and contact not established after six visits (293); 75.6% of interviews were in the metropolitan area and 24.4% in the country. Respondents were evenly spread across all age groups. Only adults aged over 18 years are included in the analysis reported here (1204 men, 1686 women). Twenty-six per cent of men (318/1204) and 39% of women (662/1686) reported one or more troublesome urinary symptoms, with no differences between rural and metropolitan respondents (men or women) (Box 1). The most common symptoms in both men and women were frequency and nocturia (Box 2). In men, nocturia increased significantly with age (from 4% in 18- to 24-year-olds to 33% in those over 65 years; P < 0.00001). Weak stream also increased, from 2% in 18- to 24-year-olds to 12% in men over 65 (P < 0.00001). Urgency, frequency and mild incontinence were reported more frequently by women than by men (all, P < 0.001), and, as stated above, the overall prevalence of troublesome urinary symptoms (i.e, prevalence of more than one symptom) was also higher in women (P < 0.00001). The prevalence of one or more storage (irritative) symptoms (i.e., urgency, frequency or nocturia) was 23% in men and 33% in women (P < 0.0001), with the prevalence of one or more voiding (obstructive) symptoms (i.e., weak stream and intermittency) being 6.7% and 6.4%, respectively (difference not significant). Under the category "other", the most common symptom was stress incontinence (n= 17/44; 38%) in women and medication side-effects in men (n= 4/16; 25%). Age-specific symptom prevalence varied between men and women. For men, there was a clear age dependence, with symptom prevalence exceeding 20% only after age 45. In women, the age-related increase was weaker, and symptom prevalence exceeded 30% in all age groups. For men and women over 65, symptom prevalence was 48% (314/649). While the percentage of respondents reporting troublesome urinary symptoms was high (Box 1), only 28% of men (88/318) and 27% of women (179/662) with troublesome LUTS had visited a doctor about a urinary problem during the preceding 12 months. Satisfaction with urinary condition seems to be a better predictor of visits to the doctor than symptom prevalence (one or more symptoms) -- only 6% (23/397) who were "pleased" with their urinary condition had visited a doctor for urinary symptoms, compared with 60% (39/65) who were "unhappy" with their urinary condition (P < 0.00001). Discussion This first study of LUTS in the Australian community shows a high prevalence of troublesome LUTS, which occurred across all ages, but particularly in older age groups (48% of men and women over 65 reported one or more symptoms). Other reports also show a high prevalence of urinary symptoms for older men, ranging from 35% in a United States study28 to more than 90% of men in a Canadian study.19 Specific symptom prevalence can also be high (e.g., 61% for urgency,6 and 51% for hesitancy5 ). Most studies show that the prevalence of mild symptoms is high, and that symptoms which substantially affect quality of life or trigger a visit to the doctor have a lower prevalence.3 The prevalence of severe or bothersome symptoms is often as low as 25% to 30% of the total symptom prevalence,5,29 suggesting that adaptation to mild symptoms may occur. A review of moderate to severe symptoms in four community-based studies reported prevalence rates of 14%-33% for men over 40 years,16 and agrees with the 37% (220/593) of men over age 45 reporting one or more troublesome urinary symptoms in our study. In our study the most common troublesome symptoms for men were nocturia and frequency. This agrees with studies in France,20 the Netherlands,29 and the United Kingdom,5 but not Scottish studies1,6 or a French study.3 Methodological differences, such as the wording of questions and framing of population sampling methods, may account for these differences. In our study, the prevalence of urinary symptoms associated with "prostatism" in men was the same for men and women aged 55 and over (Box 2). Other studies in clinical or selected populations have also reported high symptom scores in women.11-13 However, we found the prevalence of LUTS in women did not show the same age-specific trend as for men, and storage symptoms (urgency, frequency and nocturia) were more prevalent in women (33% [563/1686] for one or more symptoms) than men (23% [274/1204]), while voiding symptoms were similar in both groups. In a study of women with voiding symptoms undergoing urodynamic evaluation, relatively few women had outflow obstruction.11 While the overall prevalence of LUTS, particularly in those aged 55 and over, was similar in men and women in our study, the symptom profile (age-specific trend and individual symptom prevalences) differed, reflecting their potentially different aetiologies. For both men and women, impact on quality of life (measured by satisfaction with urinary condition) was strongly correlated with visits to the doctor, with this correlation being similar in men and women. This argues against some reports of men's "stoicism" in the face of urinary symptoms.1 However, the finding also suggests that men and women may be equally reluctant to seek medical assistance for LUTS. Sixty-three per cent (65/104) of men and 59% (162/274) of women substantially dissatisfied with their urinary condition were not visiting a doctor for the condition, which agrees with the substantial numbers not seeking help reported in other studies.1,5 Conversely, the small proportion of our participants who had seen a doctor despite being "delighted" with their urinary condition may represent preventive activity, such as checkups, or concern, for example, about prostate cancer. Other studies report a substantial impact of moderate to severe LUTS on quality of life. Activities of daily living were affected in 51% of men with clinically defined BPH,1 and working-age men reported symptoms as more bothersome than retirement-age men, despite experiencing them less frequently.6 People may be reluctant to seek help for LUTS because these symptoms are considered a normal part of ageing, because of the perceived stigma of the symptoms or fear of possible treatments,1 or (in men) because of stoicism.30 These possibilities need to be addressed in future studies, as does the possibility that rural men who were dissatisfied with their urinary condition were less likely than urban men to seek medical help (P = 0.057). The main reason patients visit doctors about their urinary condition may be to reduce its effect on their daily activities, and this is therefore an objective of treatment. Conservative measures such as bladder training, pelvic muscle exercises, diet and fluid-intake management as well as attention to functional factors may be helpful in achieving this when symptoms are mild. Key points of study High prevalence of troublesome lower urinary tract symptoms (LUTS) in Australian men (26%) and women (39%). Far fewer men and women are substantially dissatisfied with their urinary condition (9% men, 16% women) and seeking treatment (10% men, 15% women). But fewer than half of those who are substantially dissatisfied with their urinary condition seek medical help (38% men, 41% women). LUTS in men and women has different aetiologies and symptom profiles, although the prevalence of one or more symptoms in people over the age of 65 years is the same (48%). The impact on quality of life is the major reason for people to seek medical help. Conservative management strategies may reduce this impact when surgical or medical treatment is not indicated. References Garraway WM, McKelvie GB, Russell EBA, et al. Impact of previously unrecognised benign prostatic hyperplasia on the daily activities of middle-aged and elderly men. Br J Gen Pract 1993; 43: 318-321. Abramson ZH, Gofin J, Abramson JH. Obstructive prostatic symptoms: a community survey in Jerusalem. Int J Epidemiol 1994; 23: 797-804. Sagnier P, MacFarlane G, Teillac P, et al. Impact of symptoms of prostatism on level of bother and quality of life of men in the French community. J Urol 1995; 153: 669-673. Ahlstrand C, Carlsson P, Jonsson B. Estimated total costs of treating benign prostatic hyperplasia in Sweden. Scand J Urol Nephrol 1995; 29: 57-63. Jolleys JV, Donovan JL, Nanchahal K, et al. Urinary symptoms in the community: how bothersome are they? Br J Urol 1994; 74: 551-555. Tsang KK, Garraway WM. Prostatism and the burden of benign prostatic hyperplasia on elderly men. Age Ageing 1994; 23: 360-364. Mebust W, Bosch R, Donovan J, et al. Symptom evaluation, quality of life and sexuality. In: Second international consultation on benign prostatic hyperplasia. Paris: World Health Organisation, 1993: 131-143. National Health and Medical Research Council. Clinical practice guidelines. The managment of uncomplicated lower urinary tract symptoms in men. Canberra: AGPS, 1996. Yalla SV. Correlation of American Urological Association Symptom Index with obstructive and non-obstructive prostatism. J Urol 1995; 153: 674-680. Stoevelaar H, van de Beek C, Nijs H, et al. The symptom questionnaire for benign prostatic hyperplasia: an ambiguous indicator for an ambiguous disease. Br J Urol 1996; 77: 181-185. Chancellor MB, Rivas DA. American Urological Association symptom index for women with voiding symptoms: lack of index specificity for benign prostate hyperplasia. J Urol 1993; 150: 1706-1709. Chai TC, Belville WD, McGuire EJ, Nyquist L. Specificity of the American Urological Association voiding symptom index: comparison of unselected and selected samples of both sexes. J Urol 1993; 150: 1710-1713. Lepor H, Machi G. Comparison of AUA symptom index in unselected males and females between 55 and 79 years of age. Urology 1993; 42: 36-40. Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust 1992; 157: Suppl Oct 19: S1-S57. Ward J, Sladden M. Urinary symptoms in older men, their investigation and management: is there an epidemic of undetected morbidity in the waiting room? Fam Pract 1994; 11: 251-259. Bosch R. Use of the International Prostate Symptom Score (IPSS) in epidemiological studies and clinical practice -- a review. In: Third International Consultation on Benign Prostatic Hyperplasia. Monaco: World Health Organisation, 1995. Guess HA, Chute CG, Garraway WM, et al. Similar levels of urological symptoms have similar impact on Scottish and American men -- although Scots report less symptoms. J Urol 1993; 150: 1701-1705. Bosch JL, Niemer AQ, Kirkels WJ, Schroder FH. Signs and symptoms of benign prostatic hyperplasia in men screened for prostatic carcinoma. Prog Clin Biol Res 1994; 386: 97-107. Norman RW, Nickel JC, Fish D, Pickett SN. 'Prostate-related symptoms' in Canadian men 50 years of age or older: prevalence and relationships among symptoms. Br J Urol 1994; 74: 542-550. Sagnier PP, MacFarlane G, Richard F, et al. Results of an epidemiological survey using a modified American Urological Association symptom index for benign prostatic hyperplasia in France. J Urol 1994; 151: 1266-1270. Tsukamoto T, Kumamoto Y, Masumori N, et al. Prevalence of prostatism in Japanese men in a community-based study with comparison to a similar American study. J Urol 1995; 154: 391-395. Hunter D, Berra-Unamuno A, Martin-Gordo A. Prevalence of urinary symptoms and other urological conditions in Spanish men 50 years old or older. J Urol 1996; 155: 1965-1970. Nacey J, Morum P, Delahunt B. Analysis of the prevalence of voiding symptoms in Maori, Pacific Island and Caucasian New Zealand men. Urology 1995; 46: 506-511. Wilson D, Wakefield M, Taylor A. The South Australian Health Omnibus Survey. Health Prom J Aust 1992; 2: 47-49. MacLennan A, Wilson D, Taylor A. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. MacLennan A, Taylor A, Wilson D. Changes in the use of hormone replacement therapy in South Australia. Med J Aust 1995; 162: 420-422. Barry MJ, Fowler F, O'Leary M, et al. The American Urological Association Symptom index for benign prostate hyperplasia. J Urol 1992; 148: 1549-1557. Diokno AC, Brown MB, Goldstein N, Herzog AR. Epidemiology of bladder emptying symptoms in elderly men. J Urol 1992; 148: 1817-1821. Bosch JL, Hop WC, Kirkels WJ, Schroder FH. The International Prostate Symptom Score in a community-based sample of men between 55 and 74 years of age: prevalence and correlation of symptoms with age, prostate volume, flow rate and residual urine volume. Br J Urol 1995; 75: 622-630. McCallum J. Older Men's Health: Stoicism versus successful ageing. Proceedings of the National Men's Health Conference. Melbourne: AGPS, 1995. (Received 24 June 1996, accepted 17 Feb 1997) Authors' details Repatriation General Hospital Daw Park, South Australia Carole Pinnock, PhD, Principal Research Scientist, Division of Surgery; Villis R Marshall, MD, FRACS, Professor and Head, Department of Surgery, Flinders Medical Centre, and Division of Surgery, Repatriation General Hospital Daw Park. Reprints: Dr CB Pinnock, Division of Surgery, Repatriation General Hospital Daw Park, Daws Road, Daw Park, SA 5041. E-mail: spinncb AT rgh.sa.gov.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Carole B Pinnock · Villis R Marshall

Abstract Objectives: To estimate the number of pregnant women in New South Wales who had not been tested for gestational diabetes mellitus (GDM) during the period 1991-1994. Design: The number of women not tested for GDM was estimated from the recorded data available in the NSW Midwives Data Collection (MDC) annual reports and compared with three incidence surveys. Main outcome measure: The number of pregnant women not tested for GDM. Results: Over the four-year period, the average annual recorded MDC incidence of GDM was 2.2%. This percentage was adjusted up to 3.3% after review of the MDC validation study and an incidence study. However, the expected incidence of GDM from three incidence surveys was 6.6%. Thus, half of the pregnant women in NSW do not appear to have been tested for GDM. Conclusion: For the four-year period 1991-1994, an estimated 50% of women in NSW were probably not tested for GDM. MJA 1997; 167: 14-16 Introduction Gestational diabetes mellitus (GDM) is carbohydrate intolerance of variable severity with onset or first recognition during the current pregnancy.1 Undiagnosed, and therefore untreated, diabetes is a serious disorder of pregnancy with an increased perinatal mortality rate.2,3,4 Following the Australasian Diabetes in Pregnancy Society's (ADIPS) 1991 recommendation that all pregnant women should be tested for GDM in every pregnancy,5 the NSW Midwives Data Collection (MDC) recorded a gradual increase in the number of women with GDM from 1.5% in 1991 to 2.7% in 1994. In contrast, from surveys in other Australian centres since 1991, the incidence of GDM ranges from 5.5%-8.8%.4,6-8 The difference between these rates and those recorded by the MDC suggests that many women are still not being tested for GDM in NSW and are at risk of complications which could either be prevented or substantially reduced. The purpose of our study was to estimate the extent of undiagnosed GDM in NSW for the period 1991-1994 by estimating the number of pregnant women who had not been tested for GDM. Methods We obtained data from the NSW MDC annual reports for 1991-1994. It is a statutory requirement under the Public Health Act 1991 (NSW) that all births (including home births) are reported to the MDC, which records information on maternal medical and obstetric conditions, delivery and infant characteristics. Incidence of GDM recorded on the MDC was compared with the incidence of GDM found in three different Australian surveys. The sources of these data are shown in Box 1. The three surveys used the 75 g oral glucose tolerance test for the diagnosis of GDM based on the ADIPS criteria.5 According to these criteria, GDM is diagnosed if the fasting plasma glucose level is ≥ 5.5 mmol/L and/or the two-hour plasma glucose level is ≥ 8.0 mmol/L. By combining these data, we obtain an average incidence of GDM, which we refer to as the expected incidence. At the Mercy Hospital for Women in Melbourne, a 50 g glucose load is used and capillary blood samples taken for plasma glucose measurement; a diagnosis of GDM is made if the glucose level at one hour is ≥ 9.0 mmol/L and the glucose level at two hours is ≥ 7.0 mmol/L. The incidence of GDM during the period 1991-1994 was 8.8%.4 While the glucose load and diagnostic criteria are different, a comparison of the Mercy Hospital and ADIPS criteria found that they diagnosed similar women and in the same proportion.9 While the incidence of GDM will vary depending on the ethnic composition of the population being examined, these surveys all included a majority of people of European extraction. Validation of the NSW Midwives Data Collection A 1990 validation study of the MDC, using a 1% sample, found that the recording of data relating to GDM had a sensitivity of 66.7% and a specificity of 99.6%.10 That is, when a case of GDM was recorded it was accurate, but only two-thirds of the known cases were recorded. Therefore, by increasing the recorded MDC incidence by 50% (representing the underestimation of GDM according to the sensitivity data), we are likely to obtain the actual MDC incidence, which we refer to as the estimated incidence. A 1993 survey carried out in the Wollongong area to determine the incidence of GDM was compared with the recorded MDC incidence of GDM in the area.6 The MDC recorded a rate of 5.0%, while the survey found a rate of 7.2%. A 50% addition to the recorded MDC incidence (as indicated by the validation study) gave a figure of 7.5%, which is similar to the 7.2% found in the survey. Therefore, the addition of a 50% correction factor to the recorded MDC incidence of GDM is a reasonable approximation. Results The proportion of women with a diagnosis of GDM recorded by the MDC for each different Area Health Service in NSW between 1991 and 1994 is shown in Box 2. It was assumed that the accuracy of data recording in all Area Health Services was equal and had not changed over the four-year period. For the whole of NSW, the percentage of women diagnosed with GDM increased from 1.5% in 1991 to 1.9% in 1992 (P < 0.001) and from 1.9% in 1992 to 2.6% in 1993 (P < 0.001). There was no significant change between 1993 and 1994. For the four-year period, the overall recorded MDC incidence of GDM was 2.2%. In the Sydney metropolitan area, the incidence of GDM ranged from a high of 3.1% in the Central Sydney Area Health Service to a low of 1.5% in the Northern Sydney Area Health Service. The incidence of GDM in the main metropolitan areas of Sydney, Newcastle and Wollongong was 2.4%, which was significantly higher than the country areas (1.6%) (P < 0.001). Some country areas also showed marked changes over the four-year period. For example, the proportion of women diagnosed with GDM increased from 0.8% to 2.7% in the Mid West Area Health Service and declined from 3.4% to 0.8% in the Far West Area Health Service. By applying the 50% correction factor to the recorded MDC incidence of 2.2%, the estimated incidence of GDM is 3.3%. However, the expected incidence of GDM is 6.6% (Box 1). Therefore, half of the pregnant women in NSW during the period 1991-1994, or 173 534 women, were probably not tested for GDM. Discussion The expected incidence of GDM was derived from pooled incidence data from the three surveys where the diagnosis had been based on the ADIPS criteria. The lowest incidence was reported in the two surveys which used data gathered from prenatal clinics.7,8 A higher incidence was reported in the survey which included private patients in the data collection.6 The higher rate found in the survey which included private patients could be anticipated, as private patients are older than clinic patients and increasing age is a high risk factor for developing GDM.4 Thus, the expected incidence of GDM of 6.6% is likely to be conservative. The recorded MDC incidence of GDM for 1991-1994 was lower than the expected incidence. With the application of the 50% correction factor to the recorded MDC incidence (as suggested by the MDC validation study and by data collection in the Wollongong area6 ) and a conservative estimate for the expected incidence of GDM, it is possible that half of all the women who delivered in NSW between 1991 and 1994 were not tested for GDM. Some women may have decided not to be tested for GDM. Others may not have been able to tolerate the glucose solution. In most cases, however, the decision not to test would have undoubtedly been made by the clinician responsible. Box 2 shows that testing for GDM is not evenly distributed, with a recorded MDC incidence range of 0.7%-3.2%. Of particular concern is that lower than average rates of testing were found in areas where a higher than average rate of GDM could be anticipated. In metropolitan Sydney, the lowest number of recorded cases of GDM were from the Northern Sydney Area Health Service. The MDC has shown that this is also the Area Health Service with the highest proportion of women aged 35 years or over at the time of delivery, a risk factor for GDM. An incidence of GDM of at least 10%4 could be anticipated in this age group. Women with an Aboriginal background have a high incidence of GDM.8 The New England and Macquarie Area Health Service, with a high proportion of Aboriginal Australians, had a rate of GDM less than the non-metropolitan average. The Far West Area Health Service also has a high proportion of Aboriginal Australians, and the recorded incidence of GDM there fell over the four-year period from 3.4% to 0.8%. Observational studies of women with untreated GDM have found a higher perinatal mortality rate than that found in glucose-tolerant women.2,3 At the Mercy Hospital for Women in Melbourne, Beischer et al. showed that, despite a steady reduction in the overall perinatal mortality rate, women who were not tested for GDM (and therefore not treated) had a significantly higher perinatal mortality rate than women who were tested.4 An estimate can be made of the excess perinatal mortality rate for women in NSW who have not been tested for GDM ( Box 3). Although the recorded incidence of GDM has increased (particularly in the two years after the ADIPS recommendation for universal testing was made), our results confirmed our belief that not all pregnant women in NSW are being tested for GDM. This may have implications for perinatal mortality rates. References Metzger BE. Summary and recommendations of the Third International Workshop-Conference on Gestational Diabetes Mellitus; 1991 Dec. Diabetes 1991; 40 Suppl 2: 197-201. O'Sullivan JB, Charles D, Mahan CM, et al. Gestational diabetes and perinatal mortality rate. Am J Obstet Gynecol 1973; 116: 901-904. Pettitt DJ, Knowler WC, Baird R, et al. Gestational diabetes: infant and maternal complications of pregnancy in relation to third-trimester glucose tolerance in the Pima Indians. Diabetes Care 1980; 3: 458-464. Beischer NA, Wein P, Sheedy MT, et al. Identification and treatment of women with hyperglycaemia diagnosed during pregnancy can significantly reduce perinatal mortality rates. Aust N Z J Obstet Gynaecol 1996; 36: 239-247. Martin FIR. The diagnosis of gestational diabetes. Med J Aust 1991; 155: 112. Moses R, Griffiths R, McPherson S. The incidence of gestational diabetes in the Illawarra area of New South Wales. Aust N Z J Obstet Gynaecol 1994; 34: 425-427. Martin FIR, Ratnaike S, Wootton A, et al. The 75 g oral glucose tolerance in pregnancy. Diabetes Res Clin Pract 1995; 27: 147-151. Yue DK, Molyneaux LM, Ross GP, et al. Why does ethnicity affect prevalence of gestational diabetes? The underwater volcano theory. Diabet Med 1996; 13: 748-752. Henry OA, Shelley-Jones DC, Oats JN, et al. Comparison of the 50 g capillary plasma glucose tolerance test with the 75 g venous plasma glucose tolerance test in pregnancy. J Obstet Gynecol Res 1996; 22: 215-219. Epidemiology and Health Services Evaluation Branch, Public Health Division, NSW Health Department. Validation Study of the New South Wales Midwives Data Collection 1990. Public Health Bull 1993; 4 Suppl 8: S5. (Received 15 Jan, accepted 8 May, 1997) Authors' details Illawarra Area Health Service, NSW. Robert G Moses, FRACP, Clinical Director of Diabetes Services. Prince of Wales Hospital, Sydney, NSW. Stephen Colagiuri, FRACP, Director of Diabetes Services.

Robert G Moses · Stephen Colagiuri

Incidence of bloodborne virus infection and risk behaviours in a cohort of injecting drug users in Victoria, 1990-1995 Nick Crofts and Campbell K Aitken 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 assess changes in risk behaviours for transmission of bloodborne viruses and incidences and prevalences of these viruses in a field-recruited cohort of injecting drug users. Design: Prospective longitudinal cohort study. Setting: Metropolitan and rural Victoria, June 1990 to December 1995. Subjects: 626 current injecting drug users (i.e., who had injected drugs within the previous 12 months). Main outcome measures: Seroconversion to HIV and hepatitis B and C viruses (HBV and HCV); risk behaviours for infection. Results: HIV incidence was very low (0.2 per 100 person-years). HCV incidence was high (10.7 per 100 person-years), but fell throughout the study, although the downward trend did not reach statistical significance. HBV incidence was moderate (1.8 per 100 person-years) and did not fall. Prevalence of risk behaviours, notably sharing needles and syringes, decreased significantly. Conclusions: Significant change has occurred in the risk behaviours of the cohort, confirming results of cross-sectional studies of injecting drug use. This change may be responsible for the apparent decline in HIV and HCV incidence. Further studies are needed to monitor the incidence of bloodborne viruses in injecting drug users. Efforts to decrease risk of transmission should continue. MJA 1997; 167: 17-20 Introduction Bloodborne viruses, especially the human immunodeficiency virus (HIV) and hepatitis viruses B and C (HBV, HCV), pose major risks to the health of people who inject illicit drugs.1 This is largely because of transfer of blood through sharing of contaminated injecting equipment or of environmental contamination in injecting settings, which in turn depends on the behaviour of injecting drug users (IDUs).2 The Victorian Injecting Drug Users Cohort Study (VICS) is the first longitudinal cohort study of IDUs carried out in Australia. At the inception of VICS in 1989, there was little Australian research into injecting drug use, and most studies were small, cross-sectional and retrospective.3 Information was needed about changes in IDU behaviour and their impact on the incidence of infection with bloodborne viruses among IDUs. The aims of VICS were: To develop methods for follow-up of active, field-recruited IDUs; To measure incidences of HIV, HBV, HCV and other bloodborne and sexually transmitted diseases among IDUs, and to investigate risk factors; To examine risk behaviour, behaviour change and influences on behaviour over time among IDUs; and To describe the natural history of injecting drug use in this cohort. This article describes the incidence of three bloodborne viruses (HIV, HBV and HCV) in the cohort, the prevalences of some important risk behaviours for transmission of these viruses and relationships between the two. Methods Subjects and assessment Subjects were current IDUs (i.e., who had injected drugs in the previous 12 months) and were recruited between June 1990 and March 1995. Because we wished to study a cohort of IDUs not necessarily in treatment and because of the difficulties in recruiting and following up IDUs over any length of time, novel methods were developed. These have been outlined previously.4,5 Subjects were recruited by peer outreach workers (former or continuing IDUs with extensive experience of the IDU "scene"), primarily through their own social networks and, to a lesser extent, from agencies (such as needle exchange programs and prisons). These outreach workers undertook all interviews, blood sampling and follow-up, after training in HIV counselling at the Melbourne Sexual Health Centre. Follow-up continued until December 1995. Interviews and collection of blood samples were initially intended to be at six-month intervals, but difficulties in tracking participants meant that interviews occurred opportunistically. The interview questionnaire included questions on demographics, frequency of drug injection, injecting history, needle-sharing, and other injecting practices. The full questionnaire is available from the authors on request. A blood sample was collected after interview if the situation allowed and the participant was willing. Inevitably, samples were not collected at every interview and fewer IDUs provided samples than were interviewed. Blood was tested for antibodies to HIV, HCV and HBV core antigen. Statistical analyses For calculating incidences, we assumed that seroconversion occurred on the date halfway between a seroconverter's last negative and first positive test. Confidence intervals for incidences were calculated using an exponential-error formula.6 The chi-squared trend statistic (2TR) was used to measure significance of trends in incidences and behaviours over time.7 Ethical approval The original study design and sub sequent modifications (including venepuncture, delivery of serological results, and pre- and post-test counselling by the peer outreach workers) were approved by the Institutional Ethics Committee of Fairfield Hospital, Melbourne, Victoria. Results Cohort description Data were obtained from 716 IDUs, but were insufficient for this analysis for 90. The remaining 626 IDUs provided contact and background data at an initial interview and detailed data at one or more follow-up interviews (maximum, 11). A total of 1663 follow-up interviews were conducted, with 267 IDUs (42.7%) completing only one follow-up questionnaire and 359 (57.3%) completing two or more, at an average interval of 259 days. Subjects were recruited from the community (431; 70%), agencies (134; 22%) and prisons (51; 8%). The prisoners were recruited between May and September 1994. Descriptive information was collected at the first interview. Of the 626 participants, 39% were women and 60% were men (one respondent was transsexual). Median age was 27.7 years (range, 14.9-63.2), and median age of first injection was 18 years (range, 10-60). Of 512 participants who had injected drugs in the previous month, 63.9% specified heroin as the drug most often injected and 33.6% specified amphetamines. For 420 participants who had injected in the previous week, median injection frequency was four times per week (range, 1-210). One hundred and eighty-eight participants (30%) reported injecting with a shared needle or syringe in the previous month. Prevalence of bloodborne viruses Nearly 6000 serological tests were performed on blood samples from 531 participants. Prevalences of HIV, HBV and HCV are shown in Box 1. On their first blood test, almost two-thirds of IDUs (62.4%) were found to have been infected with HCV, almost half (45.2%) with HBV and 3% with HIV. Between 1990 and 1995, the prevalence of HIV antibodies among those tested in each year declined significantly, from 6.3% to 0.7% (2TR = 12.49; P < 0.005). The prevalences of antibodies to HCV and HBV core antigen also varied over this period but with no discernible trend. Incidence of bloodborne viruses Only one person converted from HIV-seronegative to HIV-seropositive during the 599.8 person-years at risk captured by the study, an overall HIV incidence of 0.2 per 100 person-years (95% confidence interval [95% CI], 0.0-1.4). Seroconversions and incidences of HBV and HCV infection are shown in Box 2. Five participants seroconverted to HBV during 276.3 person-years at risk, an overall HBV incidence of 1.8 per 100 person-years (95% CI, 0.8-4.3). However, HBV incidence increased between 1992-1993 and 1994-1995, when four of the seroconversions occurred. However, first-test HBV prevalence did not vary significantly from year to year. Nineteen participants seroconverted to HCV during 177.6 person-years at risk, an overall HCV incidence of 10.7 per 100 person-years (95% CI, 6.8-16.8). One hundred and sixty-five participants remained HCV-seronegative throughout the study. Although there was a downward trend in HCV incidence between 1990-1991 and 1994-1995, comparison of 95% confidence intervals showed it did not reach statistical significance. Prevalence of risk behaviours The Figure shows prevalences of four risk behaviours over the 11 six-month periods of data collection. Bingeing (a period of heavier than usual drug use for the individual which may impair the ability to maintain safe behaviour) was common, with 41% of participants reporting at least one binge; however, the percentage who reported bingeing declined significantly over time (2TR = 4.5; P < 0.03). There were also significant downward trends in the percentage of current IDUs who shared needles and syringes (2TR = 5.5; P < 0.02), shared rinsing or mixing water (2TR = 12.8; P < 0.001) and were sometimes injected by others (2TR = 15.1; P < 0.001). Mean frequency of injecting in the cohort varied over time, ranging from five to nine times per week, without any significant trend. Figure: Prevalences of risk behaviours for transmission of bloodborne viruses in a cohort of Victorian injecting drug users, 1990-1995. Association between risk behaviours and incidence For the 202 participants who completed at least three interviews and reported continuing to inject, an attempt was made to relate the major risk behaviour -- sharing needles and syringes -- to HCV infection status (see Box 3). A gradient in both prevalence and incidence of HCV infection was apparent, related to the frequency that sharing was reported, although 95% confidence intervals for the incidences and a 2 test for the prevalences showed that these gradients were not statistically significant (2TR = 2.5; P = 0.28). However, 43 who were HCV-positive and two who seroconverted never reported sharing needles or syringes. Discussion We found that incidence of HIV among a cohort of Victorian IDUs was very low (0.2 per 100 person-years at risk), while incidence of HCV was high (10.7 per 100 person-years) and incidence of HBV was moderate (1.8 per 100 person-years). There was evidence that HCV incidence has decreased among Victorian IDUs, from 16.6 per 100 person-years in 1990-1991 to 8.1 per 100 person-years in 1994-1995, although the small number of seroconverters meant that the downward trend did not reach statistical significance. We also found significant declines in prevalence of risk behaviours, notably sharing of needles and syringes. There are several possible explanations for this apparent decline in risk behaviours. Firstly, it may be a real decline, as a similar decrease in risk behaviour was seen between the Melbourne arms of two cross-sectional national IDU surveys, in 19898 and 1994,9 respectively. Prevalence of sharing of injecting equipment (in the previous month) fell from 38%8 to 13% 9 of respondents, a statistically significant difference. These surveys had sample groups largely independent of the VICS cohort. Another explanation is that participants became less likely to report risk behaviour with time; this change in social desirability bias might also have been responsible for the difference between the results of the two national surveys.3 However, in our study, participants' increasing trust in their peer workers -- the basis for continued follow-up -- makes this unlikely. It is also possible that the cohort experienced greater attrition over time among IDUs whose behaviour was relatively risky. This might also explain the decreasing HCV incidence, with those most at risk of HCV infection seroconverting first. To evaluate this possibility, the study was kept open to new recruits until March 1995; the rise in HBV incidence in 1994-1995 reflects enrolment of a group at heightened risk of bloodborne viruses, most of whom were already exposed to HCV. Lastly, these results might simply reflect the natural history of injecting drug use (e.g., a move away from being injected by others with longer use) and have nothing to do with changes in the environment (such as educational campaigns). If so, cross-sectional studies would find a higher prevalence of risk behaviour among younger IDUs. However, such a difference was not apparent in a major national cross-sectional study of 812 IDUs.9 If the decline in risk behaviour is real, then it may indicate that information campaigns about modes of HCV transmission are having an effect among Victorian IDUs. As there is evidence that reduced needle-sharing reduces HCV transmission,10 this change in behaviour may be responsible for a decline in HCV incidence. Other studies of Australian IDUs have also found a high incidence of HCV infection, but our study is the first to note a fall in incidence.11 However, a decline in first-test HCV prevalence was seen among IDUs at a major methadone maintenance clinic in Melbourne.12 We have documented a phenomenon which needs further investigation -- new HCV infections in IDUs who report no needle-sharing. This raises the possibility that infection is being spread in other ways. Several key risk behaviours for transmission of bloodborne viruses among IDUs have been documented.13 Sharing needles and/or syringes is thought to offer the greatest potential for transmission of HBV and HCV because of the relatively large volumes of blood which can be exchanged. However, equipment such as mixing spoons and filters, as well as rinsing water and the environment (such as surfaces and hands), can also become contaminated and are potential vehicles for transmission. Alternatively, respondents may have unwittingly shared needles or been reticent about disclosing sharing behaviour. If routes of infection other than needle-sharing are involved in HCV transmission, they are likely to be substantially less efficient, as HCV incidence among IDUs who reported sharing at half or more of their interviews was almost four times greater than among those who reported no sharing. These data confirm that HIV is not spreading among Australian IDUs (in our cohort, HIV prevalence significantly declined) and that rates of risk behaviours for HIV transmission among this group are low.14 This difference in epidemiology of HIV and HCV is probably due to the much higher prevalence of HCV among IDUs and the much smaller volume of blood necessary, on average, to transmit HCV compared with HIV. Nevertheless, we found that risk behaviours for HCV transmission are continuing and that HBV, which is vaccine-preventable, is spreading. While HCV transmission may already be decreasing among IDUs, our results suggest that further and sustained behaviour change is possible and necessary if the spread of HCV among Australian IDUs is to be controlled. The results also indicate yet again the failure of our current policies on hepatitis B vaccination and the need for vaccination targeted to IDUs and prisoners.15,16 Acknowledgements The authors are grateful for the hard work of Jenny Kelsall, Michael Kerger, John Meade, Franz Hernberger, Vicky Hunt and the multitude of others associated with the Victorian Injecting Drug Users Cohort Study. We also gratefully acknowledge the support of the Victorian Health Promotion Foundation, the Drug and Alcohol Research and Education Advisory Council and the Commonwealth Department of Health and Family Services. Nick Crofts was supported by the Research Fund of the Macfarlane Burnet Centre for Medical Research. References Crofts N, Hopper JL, Bowden DS, et al. Hepatitis C infection among a cohort of Victorian injecting drug users. Med J Aust 1993; 159: 237-241. Saxon AJ, Caslyn DA, Jackson TR. Longitudinal changes in injection behaviours in a cohort of injection drug users. Addiction 1994; 89: 191-202. Crofts N, Webb-Pullman J, Dolan K. An analysis of trends over time in social and behavioural factors related to the transmission of HIV among injecting drug users and prison inmates. Canberra: AGPS, 1996. Crofts N, Hopper JL, Bowden DS, et al. Hepatitis C infection among a cohort of Victorian injecting drug users. Med J Aust 1993; 159: 237-241. Aitken CK, Crofts N. Effectiveness of peer interviewers in a cohort study of injecting drug users. In: Gooding R, Whelan G (editors). Proceedings of the Autumn School of Studies on Alcohol and Drugs. 1996 May 9; Melbourne. Melbourne: St Vincent's Hospital, 1996: 15-26. Clayton D, Hills M. Statistical models in epidemiology. Oxford: Oxford Science Publications, 1993: 6. Daly LE, Bourke GJ, McGilvray J. Interpretation and uses of medical statistics. Oxford: Blackwell Scientific Publications, 1991. Monheit B, Mijch A, Lewis V. Australian national AIDS and injecting drug use study: Melbourne 1989. Melbourne: Fairfield Hospital, 1991. Loxley W, Carruthers S, Bevan J. In the same vein: first report of the Australian Study of HIV and injecting drug use (ASHIDU). Perth: National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology, 1995. Crofts N, Jolley D, Kaldor J, et al. The epidemiology of hepatitis C virus infection among injecting drug users in Australia. J Epidemiol Community Health. In press. Hagan H, Des Jarlais DC, Friedman SR, et al. Reduced risk of hepatitis B and C among injection drug users in the Tacoma syringe exchange program. Am J Public Health 1995; 85: 1531-1537. Crofts N, Nigro L, Oman K, et al. Methadone maintenance and hepatitis C virus infection among injecting drug users. Addiction. In press. Lenaway DD, Guilfoile A, Rebchook G. Multiple HIV-risk behaviors among injection-steroid users. AIDS Public Policy J 1992; 7: 184-186. Crofts N, Ballard J, Chetwynd J, et al. Involving the communities: AIDS in Australia and New Zealand. AIDS 1994; 8 Suppl 2: S45-S53. Thompson SC, Oman K. Why should Australia adopt universal infant hepatitis B vaccination? Aust N Z J Public Health 1996; 20: 436-439. Crofts N, Stewart T, Hearne P, et al. Spread of bloodborne viruses among Australian prison entrants. BMJ 1995; 310: 285-288. (Received 10 Jan, accepted 16 May, 1997) Authors' details Epidemiology and Social Research Unit , Macfarlane Burnet Centre for Medical Research, Melbourne, VIC. Nick Crofts, MPH, FAFPHM, Head; Campbell K Aitken, PhD, Senior Research Officer. Reprints: Dr N Crofts, Epidemiology and Social Research Unit, Macfarlane Burnet Centre for Medical Research, PO Box 254, Fairfield, VIC 3078. E-mail: crofts @ mbcmr.unimelb.edu.au - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nick Crofts · Campbell K Aitken

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". Abstract - Introduction - Methods - Data source - Study design - Analysis by demographic characteristics - Results - Discussion - Acknowledgements - References - Authors' details Abstract Objective: To examine patterns of surgical management of breast cancer among Australian women. Design: Retrospective survey of Medicare records (a national dataset of all services rendered on a "fee-for-service" basis for which a Medicare benefit has been paid). Patients: All Australian women (4683) who underwent surgery consistent with being for breast cancer in 1993 and for which Medicare benefits were paid. Main outcome measures: Proportions of women undergoing different forms of mastectomy, breast-conserving surgery and axillary surgery by patient age and State and region (urban or rural) of residence. Results: Modified radical mastectomy was the most common surgery, performed in 2097 of the 4683 women (44.8%), while 1868 (39.9%) had breast-conserving surgery. Frequency of breast conservation decreased significantly with age and varied significantly between States and region of residence. It ranged from 34% in Western Australia to 49% in South Australia and the Northern Territory, and from 34% among rural women to 42% among urban women. Axillary surgery was recorded for 83% of all women studied. Conclusions: There was substantial geographical variation in patterns of surgical management for breast cancer. The tendency for rural women to undergo mastectomy rather than breast-conserving surgery may reflect the relative lack of access to postoperative radiotherapy. We are unable to explain the variation between States. MJA 1997; 166: 626-629 Introduction Breast cancer is the commonest malignancy among Australian women after non-melanocytic skin cancer and is the commonest cause of cancer deaths in women.1 Until recently, the optimal management of breast cancer that is limited to the primary site (with or without axillary nodal involvement) was unclear, with some advocating routine mastectomy and others advocating a breast-conserving approach for selected patients. After randomised controlled clinical trials, a consensus has emerged that most patients with Stage I and II carcinoma of the breast (comprising about 80% of patients presenting with breast cancer) can be managed with a breast-conserving approach, with rates of local and regional control and survival equivalent to those obtained with mastectomy.2-6 Breast-conserving treatment also seems less disturbing to perceived body image and sexuality than mastectomy.7 Surgical management of breast cancer has been found to vary significantly between different population groups in the United States.8,9 We investigated surgical management of Australian women treated for breast cancer by analysing Medicare records, and assessing variations in management by patient age and State and region (urban or rural) of residence. Methods Data source Medicare statistics were obtained from the Commonwealth Department of Health and Family Services. They contain details of services rendered on a "fee-for-service" basis for which Medicare benefits were paid. They exclude services to public patients in hospitals and to Veterans' Affairs patients, and services for injuries that are eligible for compensation, unless an interim Medicare benefit is paid. Study design All women who received at least one Medicare benefit for surgical items on the Medicare Benefits Schedule (MBS) consistent with breast cancer surgery during the 1993 calendar year were included. These items comprised mastectomy -- simple, partial, extended simple, subcutaneous, modified radical an d radical -- and excision of a breast lump if followed by axillary dissection and/or radiotherapy. Medicare records for the first two quarters of 1994 were also examined to ensure that all subsequent episodes of breast surgery or radiotherapy were captured. It was assumed that very few patients would receive these treatments for non-malignant breast disease. Women who had had only excision of a breast lump but no radiotherapy or axillary dissection were excluded. Data recorded in addition to surgical procedure(s) were the date of service, and patient's personal identification number (PIN), date of birth, sex and postcode of residence. The identity of each person in the study was protected by a PIN which could not be decoded by the investigators. Analysis by demographic characteristics Patient age in 1993 was determined from year of birth, and State and region of residence from postcode. Postcodes were classified into regional zones according to the Rural, remote and metropolitan areas classification 1991 census edition.10 When a postcode extended into two regions, a factor based on population density was used to determine in which region it would be placed. To provide sufficient numbers for analysis in each State group, data were combined for the Australian Capital Territory (ACT) and New South Wales (NSW) and for the Northern Territory (NT) and South Australia (SA). Proportions were compared with the chi-squared test. Logistic regression analysis was performed with SPSS version 6.1.11 Results We identified 4683 women who received at least one Medicare benefit for surgical items consistent with breast cancer surgery in 1993. These represented 58% of the 8100 expected incident cases of female breast cancer in Australia in this year.1 Surgical procedures performed are summarised in Box 1 (below). Some form of total mastectomy was performed in 2815 women (60.1%), while surgery consistent with breast conservation was performed in 1868 (39.9%). The most frequently identified definitive surgical procedure was radical or modified radical mastectomy, with 2097 services recorded. It was the only surgical therapy in 1265 women, but was accompanied by other surgical items in 832. Patterns of surgery in different patient age groups are summarised in Box 2 (below). Breast-conserving surgery was most frequent in women aged less than 60 years, with the frequency falling to 32% in women aged 70 to 79 years. Variation in type of surgery by age was highly significant (chi-squared for trend = 16.3; P < 0.001). Frequency of breast-conserving surgery was significantly higher among women resident in urban regions than among those resident in rural regions (comprising large rural towns, rural areas and remote areas). Breast conservation was undertaken in 1462 of 3483 urban women (41.9%), but in only 397 of 1170 rural women (33.9%) (chi-squared = 23.3; P < 0.001). The frequency did not differ between women resident in large rural towns, in rural areas and in remote areas. The residential area of 30 women could not be classified. Patterns of surgery also varied significantly between States (Box 3), with breast-conserving surgery performed in 49.2% of those resident in SA and the NT, but in only 33.8% of those resident in Western Australia (WA). Multivariate analysis showed that this variation was not caused by State differences in population distribution between urban and rural areas. The axilla was treated surgically, either as part of a mastectomy or under specific axillary dissection MBS items, in 3889 women (83.0%). Frequency of axillary surgery was similar in most age groups, except those aged 80 years or older (Box 2). In this group, only 62.8% of women underwent axillary dissection versus 84.1% of women aged less than 80 years (chi-squared = 70.0; P < 0.001). Frequency of axillary surgery varied slightly between States, with WA having the highest rate and Tasmania the lowest (Box 2), but did not differ between urban and rural residents (2892 of 3483 [83.0%] urban residents and 970 of 1170 [82.9%] rural residents). Discussion We found that breast-conserving surgery was performed in almost 40% of Australian women undergoing breast cancer surgery reimbursed by Medicare in 1993. However, the proportion who underwent breast-conserving surgery tended to decrease with patient age and varied significantly beween States and between rural and urban women. Our results are similar to those of other studies of surgical care for breast cancer in Australia. In WA, Byrne et al. found that breast-conserving surgery was used in 29.4% of all women treated for breast cancer in 1989, and in 31.3% of those with "potentially eligible" tumours,12 compared with a figure of 33.7% for WA in our study. In NSW in 1988-1991, breast-conserving surgery was used to treat 40% of a series of 105 mammographically detected tumours,13 while a six-month survey of Victorian surgeons in 1990 found that breast conserving surgery was performed in 42% of cases of operable breast cancer.14 We found significant geographical variation in the proportion of women receiving breast-conserving surgery reimbursed by Medicare. Women living in rural or remote locations were more likely to undergo mastectomy. Breast conservation usually necessitates postoperative radiotherapy, and, as radiotherapy services are often not conveniently located for rural populations, this treatment can involve considerable social and financial costs to patients, which may influence the decision to undergo mastectomy. The proportion of women undergoing breast-conserving surgery also varied between States. This variation was not explained by differences between populations, such as proportions of women living in rural and urban regions. The reasons for this are unclear, but preference for mastectomy versus breast-conserving surgery among surgeons and women may vary between States, explaining the observed differences. Older women were less likely to have breast-conserving treatment. Similar patterns have been observed in surveys of breast cancer management.7 Some older women might reasonably prefer to avoid radiotherapy and be relatively less concerned about mastectomy. Alternatively, as the study could not detect women with breast cancer who had had only excision of the primary tumour but neither axillary dissection nor radiotherapy, if this treatment was more common in older patients, then the frequency of breast conservation may have been underestimated. The rates of axillary surgery were generally high and relatively uniform across age groups and between States and regions. Treatment of the axilla is not recommended for in-situ disease15 and may reasonably be withheld for a small invasive cancer, particularly in older women, possibly explaining the omission of axillary dissection for a proportion of study patients.16 Our study, using data collected routinely for administrative purposes, has several advantages over special purpose surveys. These include timeliness, economy, objectivity and standardisation of data recording. In addition, such a study offers the possibility of examining trends in service delivery over time by means of repeated reviews. Special purpose surveys usually rely on healthcare providers to donate their own, or staff, time to complete the survey instrument, which can be a problem for both researchers and healthcare providers. However, a review based on administrative datasets has some limitations. It can provide only descriptive information and does not give insight into the reasons for disease management decisions. As subjects were identified by interpreting MBS items from Medicare records, the presence of an underlying diagnosis of breast cancer was inferred and not independently verified -- for example, by data matching. Therefore, no information was available about clinical or pathological features of the tumours (e.g., stage and size of primary tumour), which would have influenced the choice of surgical management. In addition, some women who underwent surgery for a breast neoplasm other than carcinoma, or for benign disease, may have been included as subjects. We believe that these instances would be rare, and that the vast majority of cases represented women with primary carcinoma of the breast or carcinoma-in-situ. It was also assumed that patients who had one procedure performed on a private "fee-for-service" basis would have subsequent related services provided on the same basis. However, if substantial numbers of women with breast cancer moved to the public hospital system for part of their surgical management, then this study would have underestimated the frequency of subsequent, more extensive, surgery. This might have led to underestimation of the frequency of mastectomy and axillary dissection, and could have had a variable effect between regions because of differences in private health insurance rates. Guidelines for the treatment of early breast cancer have been published recently and are expected to improve standards of care and treatment,6 and to reduce variability in clinical practice. However, the optimal ratio of mastectomies to breast conserving-surgery in Australia remains unknown. Ultimately, the choice of treatment is a decision taken by each individual, informed by advice from her surgeon and information from other sources. Secondary analyses of data collected for reimbursement purposes, such as in our study, can shed no light on such decisions. Detailed surveys of patterns of care should be undertaken and deserve the support of the medical community. Acknowledgements We wish to thank the Medicare Statistics Section of the Department of Health and Family Services for the data supplied within this report. Special thanks to David Wong for his assistance in supplying data. References Jelfs P, Coates M, Giles G, et al. Cancer in Australia 1989-1990 (with projections to 1995). Canberra: Australian Institute of Health and Welfare, 1996: 7-16. Cancer Series No. 5. Jamrozik K, Byrne MJ, Fitzgerald CJ, et al. Breast cancer in Western Australia in 1989. I. Presentation. Aust N Z J Surg 1993; 63: 617-623. Fisher B, Bauer M, Margolese R, et al. Five year results of a randomised clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985, 312: 665-673. Veronesi U, Luini A, Del Vecchio M, et al. Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med 1993; 328: 1587-1591. Blichert-Toft M. A Danish randomised trial comparing breast conservation with mastectomy in mammary carcinoma. Br J Cancer 1990; 62 Suppl 12: S15. National Health and Medical Research Council. Clinical practice guidelines. The management of early breast cancer. Canberra: AGPS, 1995: 46-50; 133-162. Kiebert GM, de Haes JCJM, van de Velde CJH. The impact of breast-conserving treatment and mastectomy on the quality of life of early-stage breast cancer patients: a review. J Clin Oncol 1991; 9: 1059-1070. Samet JM, Hunt WC, Farrow DC. Determinants of receiving breast-conserving surgery. The surveillance, epidemiology and end results program 1983-1986. Cancer 1994; 73: 2344-2351. Nattinger AB, Goottlieb MS, Veum J, et al. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 1992; 326: 1102-1107. Department of Primary Industries and Energy and Department of Human Services and Health Rural, remote and metropolitan areas classification 1991 census edition. Canberra: the Departments, 1994. SPSS Inc. Statistical package for the social sciences [computer program]. Version 6.1. Chicago, III: SPSS Inc, 1994. Byrne MJ, Jamrozik K, Parsons RW, et al. Breast cancer in Western Australia in 1989. II. Diagnosis and primary management. Aust N Z J Surg 1993; 63: 624-629. Harrison RI, Glenn DC, Niesche FW, et al. Surgical management of breast cancer. Experience of the Central Sydney Health Service Breast X-ray Programme, 1988-1991. Med J Aust 1994; 160: 617-620. Hill DJ, White VM, Giles GG, et al. Changes in the investigation and management of primary operable breast cancer in Victoria. Med J Aust 1994; 161: 110-122. Balch CM, Singletary E, Bland KI. Clinical decision-making in early breast cancer. Ann Surg 1993; 217: 207-255. Silverstein MJ, Gierson ED, Waisman JR, et al. Axillary lymph node dissection for T1a breast c arcinoma. Cancer 1994; 73: 664-669.(Received 6 Sep 1996, accepted 3 Mar 1997) Authors' details Medical Oncology Unit, Canberra Hospital, Canberra, ACT. Paul S Craft, MPH, FRACP, Director. Commonwealth Department of Health and Family Services, Woden, ACT. John G Primrose, FRACR, Senior Medical Advisor; Julie A Lindner, Computer Analyst, Drug Utilization Sub-Committee Secretariat; Peter R McManus, BPharm, MMedSc, Secretary, Drug Utilization Sub-Committee of the Pharmaceutical Benefits Advisory Committee. No reprints will be available. Correspondence: Dr P S Craft, Medical Oncology Unit, Canberra Hospital, Canberra, ACT 2607. E-mail: PAUL_CRAFT@dpa.act.gov.au

Paul S Craft · John G Primrose · Julie A Lindner · Peter R McManus

Factors in accessibility of general practice in rural Australia John S Humphreys, Shari Mathews-Cowey and Herbert C Weinand 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 ascertain the importance rural Australians attribute to different factors of accessibility in their decision to consult a general practitioner. Design: Survey by interview or delivery-and-collection questionnaire (participant's choice) based on the method of paired comparisons. Setting and participants: All residents of 10 small rural communities in north-west New South Wales aged over 16 years in July and August 1996. Main outcome measures: Rank order and relative importance of residents' preferences for choosing to consult a particular doctor. Results: Social accessibility or acceptability considerations were more important than geographical proximity in the choices of rural residents to consult a particular doctor. Elderly people, in particular, attributed most significance to acceptability and continuity of care. Geographical proximity ranked most highly for young and middle-aged people and men living in isolated communities. Conclusions: For rural inhabitants, geographical distance is not the sole or even the most important determinant in their choice of general practice care; rather, they will seek the services of a GP with whom they feel comfortable. Incentives programs designed to recruit and retain more GPs in rural practice must acknowledge the importance of attracting acceptable doctors. This requires that rural doctors acquire suitable clinical and communication skills to meet the diverse needs of their patients, as well as an understanding of rural culture. MJA 1997; 166: 577-580 Introduction The overwhelming importance attributed to health services, particularly medical services, by rural residents has been clearly demonstrated.1,2 Rural general practitioners, with their traditional involvement in cradle-to-grave activities, have assumed the role of healer, carer, counsellor and friend. Moreover, general practice is the first point of contact with the health care system, with 80% of Australians visiting a GP at least once each year, and 5.5 general practice attendances per capita in 1994-95.3,4 Compared with their urban counterparts, rural GPs see more patients but see them less often.5 The importance attributed to rural doctors, in particular, is influenced by two factors. Firstly, most rural dwellers (like most Australians) take health for granted. Invariably, their prime concern is with illness and sickness, so that the focus has traditionally been on the availability of curative treatment. Secondly, inaccessibility of GPs remains the greatest source of disuse and disadvantage for most rural residents. It is problems associated with lack of accessibility, combined with the shortage and mal distribution of GPs within rural Australia, that have contributed to the establishment of the General Practice Rural Incentives Program,3,6 designed to overcome the problem of lack of access to rural general practitioners and to improve their recruitment and retention in rural and remote areas. The importance of good access to health care services is not in dispute. However, we need a better understanding of specific criteria for measuring accessibility. Penchansky and Thomas identified five distinct factors underpinning access to a doctor.7 These were: availability (the existence of services in relation to patients' needs); accessibility (measured in terms of distance, time, cost and availability of transport); accommodation (how the service is organised to accept patients, measured in ways such as waiting time); affordability (in terms of economic access to the service); and acceptability (in terms of patients' attitudes towards a particular doctor). The issue of accessibility in relation to the decisions of rural people to consult a doctor has not been thoroughly investigated in Australia. As a result, ac cessibility is simply equated with geographical proximity. However, consumer perceptions of accessibility to health services are important considerations for policies designed to increase the availability and location of doctors in sparsely populated rural and remote areas. Here, we report some findings from a major study investigating ways of facilitating the provision of health care services to people in small rural and remote communities.8 In particular, we sought to identify the importance that consumers attribute to different factors of accessibility in their decision to consult a doctor. Methods The study area comprised ten small rural and remote communities located around Moree and Narrabri in the Barwon region of north-west New South Wales (see Box 1). The communities were Bellata, Boomi, Burren Junction, Croppa Creek, Garah, Gravesend, North Star, Pallamallawa, Warialda Rail, and Yetman. These communities, with populations of 50-300 residents, have neither a resident nor visiting doctor. To obtain medical services, residents must travel to larger regional centres (such as Moree and Narrabri in New South Wales or Goondiwindi in Queensland) or smaller intervening centres (like Warialda and Wee Waa in New South Wales). During July and August 1996, residents aged over 16 years from all occupied dwellings in these communities were invited to participate in a survey, either by interview or delivery-and-collection questionnaire. This choice was offered to maximise the response rate and to avoid inconvenience to participants. We asked respondents to consider the following five factors relating to social, geographical and economic factors of accessibility that were relevant to their decision to consult a doctor: A doctor who bulk bills; A doctor you can call any time; A doctor who is close or easy to get to; A doctor you feel comfortable with; and Being able to see the same doctor each visit. We chose these five factors on the basis of the importance attributed to them in the rural health literature,7,9 their ability to indicate the relative importance of geographical, social and economic factors of accessibility, and the constraints imposed by the paired comparison technique.10 We used paired comparisons to elicit respondents' attitudes relating to their decision to consult a doctor. The method involves presenting participants with pairs of stimuli, with instructions to choose one member of each pair on the basis of some criterion.10-12 Each factor is paired with every other factor in all possible combinations. The number of alternatives must be constrained as too many can result in fatigue for both respondents and researcher. The paired comparison method gives not only a rank order for the stimuli, but also an estimate of the interval separating the importance attributed to each, enabling a good deal of information to be obtained from a limited amount of material. The scale values for each of the factors reflect the characteristics of the data, and hence the origin is arbitrary. However, for purposes of comparison, the scaling is transformed to a base of zero. Thus, in this study, respondents were asked to choose, for each possible combination of our five factors, which of the two was more important in their decision to consult a doctor. To reduce bias, the pairs of alternatives were arranged so that each alternative appeared equally on the right and left (to control for space error), was alternated from right to left, and did not appear in consecutive pairs (instead, being spaced as far apart as conditions would permit).13,14 To ascertain any differences in the pattern of preferences, the data were broken down by age groups and the degree of isolation of the community. Consistent with previous research, the age groups used were: young (less than 35 years); middle age (35-54 years); and old age (55 years and over).1 A community's isolation was determined by the distance to the nearest doctor and the conditions of the roads. Isolated communities were designated as those located at least half an hour's drive from the nearest doctor (ranging between 55 and 100 kilometers), and whose residents were required to negotiate unsealed or minor roads regularly closed after rainfall. Results It was not possible to ascertain exactly from census data the total eligible population for this survey because of Australian Bureau of Statistics' confidentiality and anonymity regulations associated with small populations. However, of an estimated potential population of 455 people, 14% (63) refused to participate, 2% (8) were too sick to complete the interview, and a further 5% (25) failed to return the questionnaire. Overall, a total of 359 questionnaires were completed (response rate, 79%). Of these, 27 were eliminated from statistical analysis because of missing data, leaving 332 questionnaires. Box 2 shows the sex, age and degree of residential isolation of the participants, and the results of the paired comparison analysis together with the co- efficient of agreement (a measure of variation in responses) in each case.10 In all cases the coefficient of agreement was significant at the 99% confidence level, indicating that, within groups, the respondents showed significant agreement in the factors they considered most important in the decision to consult a doctor. The most important factor in deciding to consult a doctor was having a doctor with whom participants felt comfortable. Being able to see the same doctor generally ranked a close second. For people over 55 years, being able to see the same doctor was most important, especially for those whose place of residence was isolated. Being able to call a doctor at any time was the third most important factor, ahead of geographical proximity. This factor was very important for young and middle-aged people and for men living in more isolated communities (see Box 2). Geographical proximity to the doctor was consistently rated more highly for people living in isolated communities, and was the most important consideration for men from isolated communities. The significance of bulk billing (an indicator of economic access) did not rate highly among the five factors for any population subgroup. The importance attributed to the factors influencing participants' decisions to consult a doctor varied across age groups. For example, while geographical proximity to the doctor decreased in importance with increasing age, the significance of acceptability and continuity of care increased. Discussion It is important to recognise that the concept of accessibility comprises closely related factors that can influence both health care behaviour and use of general practice services. Geographical proximity is undoubtedly an important issue, more so at times when acute and emergency care are needed than in relation to more discretionary health care. It is interesting to note our finding that men from isolated communities rank geographical access to doctors as the most important consideration. This is consistent with recent studies that suggest rural men generally neglect their health, often choosing only to consult a doctor for acute medical care and invariably visiting the closest doctor to minimise work disruption.15 However, our findings show that, overall, rural residents consider social accessibility (or acceptability) and continuity of care to be more important than geographical proximity in both their decision to consult and their choice of a doctor. Rural Australians are prepared to travel further than necessary, often bypassing the closest GP, to consult a doctor with whom they feel more comfortable.16 This finding is also consistent with results of earlier research which showed that less than one-third of patients indicated proximity as the main reason for choosing their usual doctor.17 These results are particularly significant in regard to the rural elderly population. While it is commonly believed that elderly people are most disadvantaged by geographical distance (and hence that this factor might be the one they identify as most important), our results confirm findings from other studies showing that continuity of care and acceptability, rather than geographical proximity, are the more important aspects in explaining where rural elderly people seek medical care.7,18 The importance of acceptability and continuity of care over geographical accessibility has significant implications for recruitment and retention schemes, such as the General Practice Rural Incentives Program, as well as for rural general practice training programs generally. Our findings support the recommendations made at the 1994 Undergraduate Rural Curriculum Conference, which highlighted the importance of social factors, community issues and communication skills in developing a curriculum for rural general practice.19 It follows that a critical component of the evaluation of the effectiveness of the Rural Incentives Program should be the extent to which the program is attracting doctors who understand rural culture, the background and health needs of rural patients, and who appreciate and develop the personal skills and attitudes necessary to practise medicine effectively in rural communities. While acceptability is unquestionably an important factor in the decision to consult a doctor, exactly what determines acceptability requires further research. Results from a hospital-based consumer satisfaction survey undertaken in 1993-94 indicated information and communication, concern, respect and personalised attention, attention to the patient's condition, and skill were the most important variables affecting patients' satisfaction with doctors.20 One of the few Australian rural case studies into patients' attitudes to general practice services found that the most important qualities sought in a doctor were compassion and an ability to communicate.21 The authors of this study acknowledged that these priorities were not reflected in undergraduate medical education at the time. However, more focused and comprehensive research is required to identify the particular attributes patients value most highly from rural general practitioners. People use and choose health and medical services on the basis of not only their need for them, but also their perceptions of them and the value they place on them. A knowledge of the importance people attribute to the various factors associated with access to health services will assist policymakers in planning how best to allocate scarce resources, and the form those resources should take if they are to result in improved health outcomes in the community. References Humphreys JS, Weinand HC. Health care preferences in a country town. Med J Aust 1991; 154: 733-737. Humphreys JS, Weinand HC. Evaluating consumer preferences for health care services in rural Australia. Aust Geog 1991; 22: 44-56. Commonwealth Department of Health and Family Services. General practice in Australia 1996. Canberra: General Practice Branch of the Department, 1996. Australian Medical Workforce Advisory Committee. Australian medical workforce benchmarks. North Sydney: Australian Institute of Health and Welfare, 1996. Australian Medical Workforce Advisory Committee. The medical workforce in rural and remote Australia. North Sydney: Australian Institute of Health and Welfare, 1996. (AMWAC Report No. 1996.8.) Holub L, Williams B. The General Practice Rural Incentives Program, development and implementation: progress to date. Aust J Rural Health 1996; 4: 117-127. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care 1981; 19: 127-140. Humphreys JS, Mathews-Cowey S, Rolley F. Health service frameworks for small rural and remote communities -- issues and options. Armidale: University of New England, 1996. Buetow SA. What do general practitioners and their patients want from general practice and are they receiving it? A framework. Soc Sci Med 1995; 40: 213-221. Edwards A. Techniques of attitude scale construction. New York: Appleton Century Crofts Inc., 1957. Guildford JP. Psychometric methods. New York: McGraw-Hill, 1954. Kerlinger FN. Foundations of behavioral research. London: Holt Rinehart and Winston, 1970. Ross RF. Optimum orders for the presentation of pairs in the method of paired comparisons. J Educ Psychol 1934; 25: 375-382. Ross RF. Optimal orders in the method of paired comparisons. J Exp Psychol 1939; 25: 414-424. O'Hehir B. Men's health -- uncovering the mystery. Mt Gambier: SE Kingston Leader, 1995. Humphreys JS, Weinand HW. Health status and health care in rural Australia: a case study. Community Health Stud 1989; 13: 258-275. Humphreys JS, Rolley F. Health care behaviour and service provision in rural Australia. Armidale: University of New England, 1993. Williams SJ, Calnan M. Key determinants of consumer satisfaction with general practice. Fam Pract 1991; 8: 237-242. Commonwealth Department of Human Services and Health. Undergraduate Rural Curriculum Conference Report. Canberra: AGPS, 1995. Draper M, Hill S. The role of patient satisfaction surveys in a national approach to hospital quality management. Canberra: AGPS, 1995. Cymbalist Y, Wolff A. Patient attitudes to general practice services . Aust Fam Physician 1988; 17: 789-794 . (Received 14 Nov 1996, accepted 4 Apr 1997) Authors' details Department of Geography and Planning, University of New England, Armidale, NSW. John S Humphreys, PhD, Associate Professor; Shari Mathews-Cowey, BA(Hons), Junior Research Fellow; Herbert C Weinand, MS, Senior Lecturer. No reprints will be available from the author. Correspondence: Professor J S Humphreys, School of Health and Human Sciences, La Trobe University Bendigo, PO Box 199, Bendigo, VIC 3522. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

John S Humphreys · Shari Mathews-Cowey · Herbert C Weinand

The risk of transmitting HCV, HBV or HIV by blood transfusion in Victoria Gordon S Whyte and Helen F Savoia 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 - Incident rates - Risk estimation - Results - Hepatitis B virus - Hepatitis C virus - HIV - Discussion - Acknowledgements - References - Authors' details - ©MJA1997 Abstract Objective: To report the incidence rate of hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV in Victorian repeat blood donors and to derive the residual risk of transmission of the viruses by screened blood transfusion. Design: The interval from the previous whole blood donation was extracted retrospectively from Victorian Red Cross Blood Bank records for each of the 358 332 repeat donations given between March 1994 and December 1995. Records of repeat donors found positive for the viruses in this period were traced to the previous seronegative donation and accepted if screened by the same test. For each virus, the number of previous donations screened by the same test was calculated and the sum of all donation intervals used to derive the incidence of infection in the repeat donor population. Published intervals after infection (when a donation can be infective although seronegative) were used to calculate the risk of release of a seronegative unit which would be infective. Participants and setting: Homologous blood donors at the Red Cross Blood Bank of Victoria. Main outcome measures: Incidence rate of HBV, HCV and HIV in regular blood donors and risk of infective donations being seronegative. Results: The incidence of infection in repeat donors was: HBV: 1.67 per 100 000 person-years; HCV: 1.89 per 100 000 person-years; and HIV: 1.31 per 100 000 person-years. The risk of a seronegative repeat donation being infective was: HBV: 2.71 per million donations (adjusted to 6.45 to account for viraemias which remain seronegative); HCV: 4.27 per million donations; and HIV: 0.79 per million donations. Conclusion: The risk of transmitting HCV, HBV or HIV by repeat blood donors is low and compares favourably with overseas data. Repeat donors have an incidence rate of HIV and HBV comparable to that of the general population, but the incidence rate of HCV is lower for repeat donors than in the general population. MJA 1997; 166: 584-586 Introduction There are no current Australian estimates of the risks of transmission by blood of hepatitis B virus (HBV) or hepatitis C virus (HCV), although the theoretical risk of HIV transmission has been estimated to be less than 1 in 903 000.1 Accurate estimates of the risk of transfusion-transmitted viral infections are important data for the risk-benefit analysis of homologous blood transfusions and in assessing the cost-effectiveness of new screening tests or methods of donor assessment. Schreiber et al. recently reported estimates of the risk of transfusing blood collected during the infectious "window period" (the time between a non- reactive blood donation and a repeat blood donation confirmed positive by the same test) at five United States blood centres.2 We used a method similar to that of Schreiber et al. to estimate the incidence of HBV, HCV and HIV in repeat Victorian blood donors and the risk of collecting blood infective for the viruses but seronegative by screening tests. Window-period collections are responsible for most transmissions of these three viruses. Methods A glossary of terms is shown in the Box. The donation interval was extracted from Victorian Red Cross Blood Bank records for all repeat whole blood donations given in Victoria in the 22-month period 1 March 1994 to 31 December 1995. This period was chosen because an algorithm was finalised in March 1994 to decide whether a donor reactive to a second generation HCV screening test was truly positive, liable to transmit HCV and liable to the sequelae of infection.3 Patients attending for autologous, directed or therapeutic donations were excluded, as were donors returning for repeat testing or counselling only. Plasma donors were not analysed because they are selected from repeat donors, there are no seroconversions and plasma undergoes virucidal procedures in fractionation. In the study by Schreiber et al., seroconversion intervals all lay within a three-year period.2 In contrast, in our study, seroconversion intervals were not required to commence in the same period, but were taken back to the year of the introduction of the screening test for each virus that was used in 1994-1995 in order to increase the number of seroconversions available for study. Therefore, the study period was different for different tests, but required that the reactive donation was given between March 1994 and December 1995. HBV: Seroconverting donors were identified whose seroconversion interval lay between the introduction of the current HBV surface antigen test (Auszyme Monoclonal, Abbott Laboratories, Illinois, USA) in January 1994 and the end of the study in December 1995. HCV: Seroconverting donors were identified whose initial (negative) donation was given after the introduction of the current second generation screening test (Abbott HCV EIA 2nd generation, Abbott Laboratories, Wiesbaden, Germany) in December 1991 and whose second (reactive) donation was given between March 1994 and December 1995. HIV: Seroconverting donors were identified whose initial (negative) donation was given after the current screening test for HIV antibody (Genelavia MIXT. Screening kit for the detection of antibodies to HIV-1 and HIV-2 in serum/plasma by enzyme immunoassay. Sanofi Pasteur, Marne la Coquette, France) was introduced in July 1992 and whose second (reactive) donation was given between March 1994 and December 1995. The repeat donor population screened by the same test was calculated to match the seroconversion study period for each disease by assuming that all repeat donors in the study period gave blood on 31 January 1995 (midpoint of the study period). For HBV, the number of donors was found whose previous donation was less than 53 weeks before (January 1994); for HCV, the interval was 165 weeks (December 1991); and, for HIV, the interval was 134 weeks (July 1992). Incident rates The incident rate was calculated as the number of incident cases (i.e., the number of seroconversions) divided by the sum of the interdonational intervals, in person-years, as described by Busch et al.,3 of all the donors in the study period. Risk estimation To derive the residual risk of transmission of each virus, the number of seroconversions were multiplied by the reported window periods before seroconversion, expressed in fractions of a year. The product is the probability that a seroconverting donor gave an infectious unit of blood during the window period that was not detected as seropositive by the screening tests currently in use and could therefore have been given in a blood transfusion.2 Results Repeat whole blood donors gave 358 332 donations in which the interdonational interval lay between March 1994 and December 1995. Half of the interdonational intervals were 12-15 weeks, with none less than 12 weeks. Ninety per cent of interdonational intervals were less than 54 weeks. Hepatitis B virus There were two seroconversions in the interval covered by the same screening test. There were 325 534 interdonational intervals after January 1994, calculated as 53 weeks before the end of January 1995, representing 6 221 761 person-weeks. The incidence rate of HBV was therefore 2 in 6 221 761 person-weeks, or 1.67 per 100 000 person-years. Interdonational intervals for the two seroconvertors were 77 and 178 days. The HBV window period is thought to be 59 days (range, 37-87),5 so the previous donation of each of the two seroconvertors could have been falsely negative for a total window period of 118 days (range, 74-174) in 6.22 million person-weeks, or 2.71 per million donations. The risk of giving blood infective for HBV (i.e., in the window period) was therefore 2.71 per million donations (range, 1.70-4.00). Hepatitis C virus There were three seroconverting whole blood repeat donors whose seronegative donation was after December 1991 and whose second (reactive) donation was between March 1994 and December 1995. Interdonational intervals for the three seroconvertors were 96, 651 and 1369 days, respectively. Of the 358 332 repeat donations in the 22 months from March 1994, the first donation of 349 226 interdonational intervals was given after December 1991, calculated as 165 weeks before the end of January 1995. The intervals represent 8 221 189 person-weeks, giving an incidence rate of HCV of 1.89 per 100 000 person-years. The HCV window period for second generation antibody tests is considered to be 82 days (range, 54-192).3,6 The risk of donating blood infective for HCV but seronegative was therefore 246 days (range, 162-576) in 8 221 189 person-weeks, or 4.27 per million donations (range, 2.82-10.01). HIV There were two seroconverting whole blood repeat donors whose seronegative donation was after July 1992 and whose reactive donation was between March 1994 and December 1995. Interdonational intervals for the two seroconvertors were 279 and 223 days. There were 347 076 interdonational intervals after July 1992, calculated as 134 weeks before January 1995. The donations represent 7 951 347 person-weeks, or 152 911 person-years, giving an incidence rate of HIV of 1.31 per 100 000 person-years. The HIV window period for second generation tests is considered to be 22 days (range, 6-38).7 The risk of donating blood infective for HIV but seronegative was therefore 44 days (range, 12-76) in 7 951 341 person-weeks, or 0.79 per million donations (range, 0.22-1.37). Discussion The effect of modifying the model used by Schreiber et al.3 depends on the length of the interdonational intervals of the study population compared with the intervals for seroconvertors. If long interdonational intervals are characteristic of seroconvertors, there will be a progressive overestimation of incidence in our model compared with that of Schreiber et al. This is because the total population of intervals is skewed strongly towards 12-15 weeks, and long intervals are under-represented in this study. HBV: Schreiber et al. argued that the true risk of a seronegative donation which is nevertheless infective is higher than that identified by HBV surface antigen because only 42% of HBV incident infections persist to be detected by the HBV surface antigen assay.2 Application of this adjustment to the risk in Victoria yields a window-period risk of 6.45 per million donations (range, 4.05-9.52). The comparable figure in the United States is 15.83 per million (range, 6.82-31.97)2 and, in France, 8.45 per million (range, 2.8-25.2).8 In our study, the unadjusted incidence of HBV in Victorian repeat volunteer donors was 1.67 per 100 000 person-years, comparable to the unadjusted incidence in the Australian general population of 2.4 per 100 000 person-years.9 The similarity of the two figures suggests that the critical factors for community transmission of HBV have not been identified well enough to assist in donor selection. During the study period, each time they donated blood donors signed a form stating that they had not engaged in male-to-male sex or used intravenous drugs. HCV: A current estimate of the incidence of HCV in Australia is 7.6 per 100 000 person-years.10 The estimate has been considered unreliable because of the unlikeliness that mild cases would be detected, although most of the individuals tested were more likely to be at high risk. Locarnini et al. hypothesised that if the number of incident cases were underestimated by a factor of three, and that 75% were intravenous drug users, then the true rate could be extrapolated to 22.2 per 100 000 per year.11 In our study, the 10-times-lower incident rate of HCV in repeat donors of 1.89 per 100 000 person-years is evidence of the low-risk behaviour of repeat volunteer blood donors. The risk of transmission of HCV by blood transfusion in Victoria in the window period was 246 days in 8 221 189 person-weeks, or 1 in 234 000 donations (range, 100 000-355 000). The comparable United States figure is 1 in 103 0002 and, in France, 1 in 223 000.8 HIV: The incidence of HIV in Australia is thought to be 480 per year from 1993, or 2.7 per 100 000 person-years.12 Our study shows that repeat Victorian blood donors have an incidence of HIV of 1.31 per 100 000 person-years. The limited reduction in the incidence of HIV in repeat volunteer donors is evidence of an increasing proportion of seroconversions caused by activity not identified as high risk. The risk of collecting a seronegative but HIV-infected donation in the window period is 1 in 1.27 million, similar to the calculation by Dax et al.1 The comparable United States figure is 1 in 493 0002 and, in France, 1 in 571 000.8 The incidence rate of HBV and HIV in regular blood donors is comparable to that of the general population. This suggests that donor assessment is ineffective in repeat donors, presumably because those who contract HBV or HIV do not regard themselves as at risk by the criteria applied by the blood bank. The incidence rate of HCV is lower for regular blood donors than the general population. The relative effectiveness of HCV discrimination presumably reflects the lack of experimentation by regular donors with intravenous drugs. The risk of window-period transmission of HBV, HCV and HIV in Victoria is low and compares favourably with overseas figures. The risk is probably overestimated for HIV because of the long seroconversion intervals. Care should be exercised when generalising from these figures because of the small number of seroconversions. However, the medical community and the general public should be reassured by this evidence that the blood supply is very safe. Acknowledgements We wish to thank John Butler, Christine Carroll, Phil Keily and Tony Chan at the Red Cross Blood Bank Victoria for data collation and processing, and John McNeil of Monash University for critical review of the manuscript. References Dax EM, Healey DS, Crofts N. Low risk of HIV-1 infection from blood donation: a test-based estimate. Med J Aust 1992; 157: 69. Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion-transmitted viral infections. N Engl J Med 1996; 334: 1685-1690. Busch MP, Korelitz JJ, Kleinman SH, et al. Declining value of alanine aminotransferase in screening of blood donors to prevent posttransfusion hepatitis B and C virus infections. Transfusion 1995; 35: 903-910. Strasser SI, Smith BC, Watson KJR, et al. Evaluation of blood donors with equivocal hepatitis C serological results. Med J Aust 1995; 162: 459-461. Mimms LT, Mosely JW, Hollinger FB, et al. Effects of concurrent acute infection with hepatitis C on hepatitis B virus infection. BMJ 1993; 307: 1095-1097. Lelie PN, Cuypers HT, Reesink HW, et al. Patterns of serological markers in transfusion transmitted hepatitis C infection using second generation HCV assays. J Med Virol 1992; 37: 203-209. Busch MP, Lee LL, Satten GA, et al. Time course of detection of viral and serological markers preceding human immunodeficiency virus type 1 seroconversion: implications for screening blood and tissue donors. Transfusion 1995; 35: 91-97. Courouce A-M, Pillonel J. Transfusion transmitted viral infections. N Engl J Med 1996; 335: 1609-1610. Kaldor JM, Plant AJ, Thompson SC, et al. The incidence of hepatitis B infection in Australia: an epidemiological review. Med J Aust 1996; 165: 322-326. Andrews R, Curran M. Enhanced surveillance for incident cases of hepatitis C in Australia, 1995. Communicable Diseases Intelligence 1996; 20: 384-388. Locarnini S, McAnulty. Hepatitis C surveillance [editorial]. Communicable Diseases Intelligence 1996; 20: 388-389. Feachem RGA. Valuing the past -- investing in the future: evaluation of the National HIV/AIDS Strategy 1993-94 to 1995-96. Canberra: Commonwealth Department of Human Services and Health, 1995: 29-40. (Received 5 Dec 1996, accepted 16 April 1997) Authors' details Red Cross Blood Bank, Southbank, VIC. Gordon S Whyte, FRACP, FRCPA, Director; Helen F Savoia, MB BS, Registrar. No reprints will be available from the author. Correspondence: Dr G S Whyte, PO Box 354, South Melbourne, VIC 3205. E-mail: gwhyte @ rcbbv.org.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Gordan S Whyte · Helen F Savoia

Urinary diagnosis of gonorrhoea and chlamydia in men in remote Aboriginal communities Steven J Skov, Penny Miller, Wayne Hateley, Ivan B Bastian, Jenny Davis and Peter W Tait MJA 1997; 166: 468 For editorial comment see Waddell 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 Aims: (1) To evaluate the acceptability and validity of an intervention based on urine tests for diagnosis and treatment of gonorrhoea and chlamydia in men in remote Aboriginal communities. (2) To provide a prevalence estimate of these infections in the male population in the surveyed communities. Methods: First-void urine samples from 460 men in remote communities and 33 men in the Alice Springs Gaol were tested for gonorrhoea and chlamydia with at least one of polymerase chain reaction (PCR), enzyme immunoassay (EIA) and culture (gonorrhoea only). Results: One hundred and three men (20.9%) were infected with gonorrhoea or chlamydia. The prevalence of infection for gonorrhoea only was 11.7%, for chlamydia only 4.1% and for dual infection 5.1%. Eighty-eight infected men and 45 of their sexual partners were recorded as having been treated within two months of testing. PCR tests detected the largest number of infections and were the easiest to use. Conclusions: The prevalence of these infections was higher than anticipated. Urine PCR tests were acceptable to men and are well suited to the remote-community setting. As an effective alternative to urethral swabs, they permit a range of community-based strategies to address high rates of infection with gonorrhoea and chlamydia. MJA 1997; 166: 468-471 Introduction The rates of sexually transmitted diseases (STDs) in central Australia, particularly gonorrhoea and chlamydia, are among the highest in Australia and indeed the world,1,2 despite a modest decline in gonorrhoea over the past 15 years (according to notifiable diseases data from the health departments of South Australia, Western Australia and the Northern Territory). Although these infections are more common in this region than in the rest of Australia among both Aboriginal and non-Aboriginal people, most of the excess morbidity occurs among Aboriginal people (health departments' data). Many factors contribute to this situation. Dispossession, unemployment and their sequelae are the fundamental determinants of the poor health of Aboriginal people and also underlie the observed high levels of STDs. The serious under-resourcing of central Australian health services, the difficulty in maintaining confidentiality in small communities, the stigma attached to STDs, the unpleasant nature of urethral and endocervical swabs and, in particular, the frequent lack of male health care workers -- all militate against effective STD programs.3-5 Urine tests for the detection of gonorrhoea and chlamydia are now commercially available. Enzyme immunoassay (EIA) tests have sensitivities above 80% and specificities above 93%,6-9 while polymerase chain reaction (PCR) tests have reported sensitivities of 90%-100% and specificities of 98%-100%.10-14 These technologies offered exciting possibilities to address some of the difficulties in delivering STD services, so, after receiving approval from the Alice Springs Institutional Ethics Committee, the Tri-State STD/HIV Project (TSP), in collaboration with Nganampa Health Council (NHC) and the Central Australian Aboriginal Congress (CAAC), both organisations controlled by Aboriginal communities, undertook the programs described in this article. Methods The study was undertaken in four parts. Phase I: NHC provides health services to several remote Aboriginal communities and conducts annual syphilis serology screening programs in these communities. NHC maintains a population register, and all persons between the ages of 12 and 40 years who are in the communities during the screening programs are sought out and asked to participate. In April 1995, 189 men participating in this program in three communities serviced by NHC were asked to give a first-void urine sample in addition to the blood sample for the syphilis test. Phase II: In June 1995, another 218 men in the remaining three NHC communities had urine tests only; all males over the age of 12 who were present in the communities at the time were asked to participate. Phase III: In October 1995, a further 53 men were tested who had not been previously tested. Phase IV: CAAC, as part of its many functions, provides the health service to the Alice Springs Gaol. In June 1995, 33 new inmates were asked to give a first-void urine sample as part of their comprehensive health check on admission. Diagnostic tests used for gonorrhoea were culture, EIA (Abbott Gonozyme, Chicago, IL) and PCR (Roche Amplicor CT/NG, Branchburg, NJ) and for chlamydia were EIA (SYVA MicroTrak II, Palo Alto, CA) and PCR (Roche Amplicor, Branchburg, NJ) (Box 1, below). If there was insufficient urine for all tests, the order of priority was to do PCR first, then culture, chlamydia EIA and finally gonococcal EIA. To check for cross-contamination between PCR specimens, all Phase III specimens that provided sufficient urine were divided before any PCR procedures were performed. When a positive result was obtained the other half of the original sample was retested. Chocolate and/or Thayer-Martin agar plates incubated in candle jars or CO2 gaspacks were used for gonococcal culture. BioCult GC tubes (Orion Diagnostica, Espoo, Finland), which contain a modified Thayer-Martin dipslide and a CO2-generating tablet, were also trialled. Culture media were inoculated with sediment from 10 mL of centrifuged urine and incubated for up to 72 hours at 35oC on-site and/or at Western Pathology in Alice Springs. Neisseria gonorrhoeae was identified by standard methods: typical morphology of colonies, oxidase paper test, microscopy with Gram stain, and latex agglutination (Phadebact GC, Boule Diagnostics AB, Huddinge, Sweden). Urine samples for EIA and PCR were prepared on-site according to the test manufacturer's specifications and then sent to Western Pathology in Alice Springs for processing. Male Aboriginal health workers and registered nurses in each clinic were responsible for liaison with the community and collection of specimens. Each man was asked to give 25-40 mL of first-void urine in a sterile collection jar. No urethral swabs were sought. Initial preparation of urine specimens for transport to the laboratory was completed within three hours of collection. A diagnosis of infection was made and treatment was initiated if any test was positive. Resident clinic staff were responsible for offering treatment, further investigation and safe-sex education to infected men and their sexual partners. Results Study population We tested urine samples from 493 men, of whom 460 lived in six remote communities and 33 were gaol inmates. Acceptability to clients was high, with fewer than 10 men (exact count not possible) declining testing. The 460 men from remote communities represented about 60% of the male population over the age of 12 in the area serviced by the participating clinics (Box 2, below). The proportion of men tested in different communities varied from 28% to 85%. The rate of infection Based on all methods of diagnosis combined, 103 of the men tested (20.9%) were found to be infected with either gonorrhoea or chlamydia. The rate of infection in different communities varied between 14.5% and 26%. Among the gaol inmates, who originated from all parts of the southern NT, seven (21.2%) were infected. Most infections (90.3%) occurred in men aged 15-39 years and the five-year age-specific prevalence of infection in this group varied from 22% to 27% (Box 2, above). Treatment and follow-up Eighty-eight men were treated within two months of testing. The average delay between testing and treatment was 18 days. Forty-five sexual partners of infected men were also recorded as having been treated. Performance of the tests used Different combinations of tests were used in different phases. The volume of urine received from each man varied, so it was not always possible to do all the intended tests. A summary of the numbers of specimens subjected to the various tests and their relative performance is shown in Box 3 (below). During Phase II, culture for gonorrhoea using both BioCult GC tubes and standard Thayer-Martin plates was performed on 193 urine specimens. Thirteen diagnoses were made with the BioCult GC tubes and only seven were made with standard Thayer- Martin plates: all cases positive on Thayer-Martin plates were also positive on the BioCult GC tubes. During Phase III, 19 of the 20 initially positive PCR results were retested (in one case there was insufficient urine). In 18 of these cases there was complete agreement between the first and second test. One chlamydia-positive specimen was negative on the second testing. However, because of delays in transport, the tests on this specimen were done at six and eight days after collection, well in excess of the four days maximum recommended by the test manufacturers. Discussion These results highlight the need for improvements in current STD control, including surveillance programs. Based on routine clinic activity and notifications, NHC reported only 38 men with either gonorrhoea or chlamydia during the whole of 1994 (health departments' notifiable diseases data), compared with the 96 cases detected in this study. Other regions of Australia that have comparable notification rates of these infections1 may have similar problems in underdetection. The variation in participation rates in different communities and age-groups was largely attributable to the numbers of people who happened to be present at the time of the study (people in these remote communities being highly mobile), the working relationship between community members and the health staff, and the assiduousness of the health staff in conducting the program. In central Australia it is often considered, without specific evidence, that people who do not participate in such programs may be at higher risk of infection. Recent work by NHC showed no difference in rates of syphilis infection between those tested during the main body of a screening program and those tested later as part of an effort to test non-participants (Dr Penny Miller, unpublished data). The screening programs in our study were intended to identify the most effective and practical tests for everyday use in remote clinics. Collection of urethral swabs was avoided because it would not have been acceptable to the community. Hence, the study lacked a diagnostic "gold standard" and could not formally evaluate sensitivities and specificities. The published specificities of all the tests were high -- above 98% for urine PCR tests.10-14 The procedures used in Phase III demonstrated no problems with cross-contamination in PCR testing. Several studies have suggested that urine PCR tests for chlamydia are more sensitive than urethral-swab culture and highly specific.10-13 Less work has been done on urine PCR for diagnosing gonococcal infection, but two studies indicate sensitivities above 90% and specificities of 100%.13,14 In ideal conditions, the sensitivities of urethral-swab microscopy and culture are 90%-98%,15,16 but are likely to be much less in remote communities because of high staff turnover, the use of non-nutritive transport media, and frequently prolonged transport times. In such circumstances, urine PCR may be as good as or better than urethral-swab microscopy and culture for diagnosis of gonorrhoea. In any event, according to local management protocols,17 all men presenting to clinics with urethritis are offered immediate treatment for both gonorrhoea and chlamydia. In terms of practical application, PCR was superior to culture for gonorrhoea and EIA for both infections. PCR tests detected more infections with either organism than did the other tests (Box 3). Assuming that the high published specificities for the PCR tests held under field conditions, this increased rate of detection would be attributable to a superior sensitivity. The PCR test was also the easiest to use: urine is simply stored and transported at 4¡-8¡C in the same jar used to collect it. The urine must then be processed in the laboratory within four days (test manufacturer's instructions), which is usually feasible in most remote situations. In contrast, both EIA tests used require centrifuging before transport, and the SYVA MicroTrak II EIA required addition of a transport buffer. However, PCR tests do not provide information about antibiotic susceptibility. If PCR technology is to be used as the principal diagnostic tool for gonorrhoea, there would need to be accompanying sentinel systems for gonococcal culture and antibiotic susceptibility. We found that culture of first-void urine was positive in 72% of diagnoses of gonorrhoea. Sensitivities of 70%-100% for urine culture of gonorrhoea have been reported.18,19 On this basis, urine culture in addition to urine PCR for diagnosis of gonorrhoea could be performed routinely at sentinel sites and during similar programs to those reported here in order to maintain antibiotic-sensitivity surveillance. In the field situation, the BioCult GC tubes detected more gonorrhoea than standard Thayer-Martin plates and were easier and more convenient to use. The accuracy, ease of use and acceptability to men of urine PCR tests suggest several strategies to make clinical services more accessible to people, reduce the amount of disease in the community and identify individuals who are in need of safe-sex education. The use of urine tests for routine diagnosis may encourage more men to present with an STD, even if there is no male practitioner present. Health services could adopt active case-finding strategies such as opportunistic testing when people present for other reasons, including annual comprehensive health checks or community surveys. Such strategies are under consideration by health services in central Australia. For example, CAAC is seeking funding to establish an outreach program via a mobile clinic to make comprehensive well-men's check-ups, including STD checks, accessible to Aboriginal men in Alice Springs. We also examined screening as an STD control strategy. With fewer than 10 men refusing to participate, these programs resulted in 88 men who had either gonorrhoea or chlamydia and at least 45 of their sexual partners being treated. We did not have the resources to determine whether the men were symptomatic at the time of the test. However, none of them had presented to the clinic for treatment. When these findings are considered in the light of routine notifications and our own local experience, it is likely that most of these people would not have been diagnosed and treated outside these programs. Health services catering to remote Aboriginal communities in other parts of Australia may wish to consider this new technology and its usefulness in comprehensive STD education and control programs. Acknowledgements The Tri-State STD/HIV Project (TSP) is jointly funded and managed by the Commonwealth Department of Health and Family Services, Territory Health Services, the South Australian Health Commission and the Western Australian Health Department. The work would not have been possible without the support of the clinical staff of Nganampa Health Council (NHC) and the Central Australian Aboriginal Congress (CAAC). Technical advice and material resources were contributed by the TSP, NHC, CAAC, Western Pathology, Alice Springs Hospital laboratory, the Australian Army, the Northern Territory AIDS/STD Unit, Roche Diagnostics, and the Institute of Medical and Veterinary Science. John Kaldor, Russell Waddell, Frank Bowden and John Boffa all commented on earlier drafts of this paper. References National Notifiable Diseases Surveillance System. Annual report of the National Notifiable Diseases Surveillance System. Commun Dis Intell 1994; 18: 518-548 . De Schryver A, Meheus A. Epidemiology of sexually transmitted diseases: the global picture. Bull World Health Organ 1990; 68 (5): 639-654. Scrimgeour D, Rowse T. Evaluation of STD control activities in central Australia. Menzies School of Health research report. Alice Springs: Menzies School of Health, 1992. Warchivker I. Variations in health care expenditure in the Alice Springs Rural District in 1993-94. Aust N Z J Public Health 1996; 20: 11-13. McDermott R, Beaver C. Models of horizontal equity in resource allocation in Aboriginal health. Aust N Z J Public Health 1996; 20: 13-15. Roongpisuthipong A, Lewis JS, Kraus SJ, Morse SA. Gonococcal urethritis diagnosed from enzyme immunoassay of urine sediment. Sex Trans Dis 1988; 15: 192-195. Schachter J, Pang F, Parks RM, et al. Use of gonozyme on urine sediment for diagnosis of gonorrhoea in males. J Clin Microbiol 1986; 23: 124-125. Moncada J, Schachter J, Shafer MA, et al. Detection of Chlamydia trachomatis in first catch urine samples from symptomatic and asymptomatic males. Sex Trans Dis 1994; 21: 8-12. Sanders JW, Hook EW, Welsh LE, et al. Evaluation of an enzyme immunoassay for detection of Chlamydia trachomatis in urine of asymptomatic men. J Clin Microbiol 1994; 32: 24-27. Jaschek G, Gaydos CA, Welsh LE, Quinn TC. Direct detection of Chlamydia trachomatis in urine specimens from symptomatic and asymptomatic men by using a rapid polymerase chain reaction assay. J Clin Microbiol 1993; 31: 1209-1212. Bianchi A, Scieux C, Brunat N, et al. An evaluation of the polymerase chain reaction Amplicor Chlamydia trachomatis in male urine and female urogenital specimens. Sex Trans Dis 1994; 21: 196-200. Bauwens JE, Clark AM, Loeffelholz MJ, et al. Diagnosis of Chlamydia trachomatis urethritis in men by polymerase chain reaction assay of first-catch urine. J Clin Microbiol 1993; 31: 3013-3016. Mahony JB, Luinstra KE, Tyndall M, et al. Multiplex PCR for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in genitourinary specimens. J Clin Microbiol 1995; 33: 3049-3053. Komeda H, Deguchi T, Yamamoto H, et al. Detection of Neisseria gonorrhoeae in first-voided urine sediments from male urethritis patients by polymerase chain reaction. Kansenshogaku Zasshi 1992; 66: 1209-1212. Judson FN. Gonorrhoea. Med Clin North Am 1990; 74: 1353-1366. Lind I. The laboratory diagnosis of gonorrhoea. In: Facklam R, Laurell G, Lind I, editors. Recent developments in laboratory identification techniques. Amsterdam: Excerpta Medica, 1979. Central Australian Rural Practitioners' Association. The CARPA Standard Treatment Manual. 2nd ed. Alice Springs: Institute for Aboriginal Development, 1994. Woods ER, Galvez LM, Talis AL, Jean Emans S. First catch urine sediment for Chlamydia trachomatis and Neisseria gonorrhoeae in adolescent males with pyuria. J Adolesc Health 1991; 12: 329-334. Feng WC, Medeiros AA, Murray ES. Diagnosis of gonorrhoea in male patients by culture of uncentrifuged first-voided urine. JAMA 1977; 289: 896-898. (Received 24 June, accepted 17 Oct, 1996) Authors' details Tri-State STD/HIV Project, Alice Springs, NT. Steven J Skov, MPH, FAFPHM, Medical Officer, Tri-State STD/HIV Project. Nganampa Health Council, Alice Springs, NT. Penny Miller, MB BS, STD/HIV Program Coordinator. Wayne Hateley, STD/HIV Aboriginal Health Worker. Royal Darwin Hospital, NT. Ivan B Bastian, MB BS, MSc, Microbiology Registrar. Australian Army, Darwin, NT. Jenny Davis, Medical Technician. Central Australian Aboriginal Congress, Alice Springs, NT. Peter W Tait, MB BS, DipRACOG, FRACGP, Acting Senior Doctor. Reprints will not be available. Correspondence: Dr Penny Miller, Nganampa Health Council, PO Box 2232, Alice Springs, NT 0871. - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Steven J Skov · Penny Miller · Wayne Hateley · Ivan B Bastian · Jenny Davis · Peter W Tait

The Hobart Salt Study 1995: few meet national sodium intake target Trevor C Beard, David R Woodward, Peter J Ball, Helen Hornsby, Richard J von Witt and Terence Dwyer MJA 1997; 166: 404 For editorial comment see Beilin 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 - Statistical analysis - Results - Sodium and potassium excretion - Discretionary use of salt - Discussion - Public health implications - Conclusion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objective: To estimate 24-hour sodium and potassium excretion in an urban Australian population. Design and setting: Cross-sectional survey of an urban population in Hobart, Tasmania, in 1995. Participants: Systematic sample (87 men, 107 women) from the Commonwealth Electoral Roll of people aged 18-70 years on 30 June 1995 whose residential address was within 10 km of the Hobart General Post Office. Main outcome measure: Conformity with the national target for sodium intake for the year 2000 of ≤100 mmol/day. Results: The target was met by 6% of men and 36% of women. This difference between the sexes was significant ( P < 0.001), while differences between age groups and socioeconomic levels were not significant. Conclusion: Our findings confirm the low level of conformity with the national sodium target reported by the handful of Australian studies over the past decade. Given the major community costs associated with hypertension, our results highlight the need for effective and properly monitored action to reduce sodium intakes. MJA 1997; 166: 404-407 Introduction Many health problems are associated with the current sodium intake of people in Western societies.1 In 1988, an Australian target for a lower sodium intake was set for the express purpose of reducing the prevalence of hypertension.2 Although other factors, such as excess body weight, inadequate exercise, excess alcohol, low dietary potassium and "psychological influences", may contribute to hypertension,3 Australia's national target for sodium intake (≤100 mmol/day)2 is accepted internationally.4-6 Further, it is supported by the discovery that the usual human salt intake in Western diets induces hypertension in chimpanzees, and that this is reversed when they return to their natural diet.7 The effect of low dietary potassium on health has received less attention, but there is good evidence that potassium intake should at least equal sodium intake in molar units.8,9 Potassium predominates in unsalted foods because it is the major intracellular cation in the living tissues of both plants and animals. Thus, virtually all the natural foods available to mammals have a molar sodium to potassium ratio of less than 1.0. The human body must have evolved on this dietary ratio; its inversion is recent in phylogenetic terms, unnecessary and probably unsafe.8,9 Published data on current intakes of sodium and potassium among Australians are very few, and usually based on small samples10-12 We report electrolyte excretion data obtained from 194 Hobart residents for a behavioural study in 1995. Our estimates are based on 24-hour excretion of these electrolytes in the urine (widely accepted as the preferred method of assessment of intake).13,14 Methods People aged 18-70 years on 30 June 1995 and residing within 10 km of the Hobart General Post Office were selected from the Commonwealth Electoral Roll (revised to February 1995) as follows. Every 500th person on the roll was selected for contact or, if ineligible, replaced by the next eligible person. A letter inviting participation was mailed to each person, outlining the study (including the need to attend for interview and to provide a 24-hour urine sample) and enclosing a reply-paid envelope. Those failing to reply were sent a second letter two weeks later, followed, if necessary, by a telephone call within a further 10 days. Unpredictable variability in sodium excretion (a confounder in the behavioural study) was reduced by excluding volunteers with serious intercurrent illness, pregnancy, breast-feeding or use of potassium supplements, diuretics or other drugs likely to affect sodium excretion. We estimated socioeconomic status by the postcode of the participant's address, using the Index of Relative Socioeconomic Disadvantage (IRSD);15 data for specific postcodes were supplied by the Australian Bureau of Statistics. Suburbs whose postcodes had an IRSD ≤ 1000 (the national mean score) were classified as "lower socio economic status", and those with an IRSD ≥ 1000 as "higher socioeconomic status". Two subjects listed a GPO box address and were not assigned a socio economic status rating. At interview, we collected demographic and anthropometric data and a short medical history. Participants completed a food-frequency questionnaire and answered behavioural and cognitive questions, which will be reported elsewhere. Each participant received detailed verbal and written instructions on how to make a complete 24-hour collection of urine; all were asked to collect urine on weekdays, and women of reproductive age were asked to avoid collection during the premenstrual week, when sodium retention may occur.16 Participants collected urine in 2 L plastic containers containing 20 mL of 6 molar hydrochloric acid and returned them promptly. Urine volume was estimated by weighing. For 82 of the 194 samples the estimated volume was adjusted to 24 hours because of longer or shorter actual collection times; the maximum adjustment was 175 minutes over the 24 hours (12.2%), and only five adjustments exceeded 5%. The samples, identified only by code numbers, were diluted with neutral pH buffer and analysed for sodium and potassium by ion-selective electrodes on a Kodak Ektachem 750 XRC analyser (Johnson & Johnson Clinical Diagnostics, Rochester, NY, USA) and, for creatinine, by the Ektachem method also. Laboratory results were sent to those participants who requested them. A duplicate of every tenth sample was sent for analysis under a different code number for quality assurance. We calculated imprecision of laboratory measurements from the differences between results for duplicate samples using the formula published for the Intersalt study.17 The coefficients of variation for laboratory imprecision were 0.6% for sodium, 1.1% for potassium and 5.4% for creatinine. The protocol was approved by the University of Tasmania Committee on Ethical Aspects of Human Experimentation, and all subjects gave written informed consent. Statistical analysis We used SPSS18 to analyse the data; P< 0.05 was used as the criterion of statistical significance. Differences between sexes, age groups and socioeconomic status levels were assessed by t tests (for mean sodium and potassium excretion rates) and by chi-squared tests (for compliance with targets for sodium and sodium to potassium ratio). Results Of 619 individuals originally selected, 167 (27%) were uncontactable despite active follow-up, 80 (13%) were ineligible because they had moved out of the target area, 151 (24%) declined to take part, 18 (3%) were eliminated by our exclusion criteria (nine for medications, five for illness, and four for pregnancy or lactation), and nine participated incompletely. The remaining 194 (31% of the initial sample, or 52% of those known to be eligible) were interviewed and provided a 24-hour urine collection. Box 1 (below) compares sociodemographic characteristics for these 194 participants with those of the other 425 people originally selected. The two groups had a similar sex distribution, but participants were significantly older and had higher socioeconomic status. For participants, the sex ratio was similar in both age divisions (43% men in the 18-44 years group and 46% men in the 45-70 years group), and in both socioeconomic groups (47% and 44% men in the lower and higher socioeconomic status groups, respectively). While we do not have birthplace data for the non-participants, most participants were born in Australia (83%) or in the United Kingdom or Ireland (12%). Sodium and potassium excretion Twenty-four-hour sodium excretion was greater in men (range, 39-337 mmol) than in women (26-241 mmol), and the mean sodium intake (as reflected by this excretion rate) was 52 mmol higher in men than in women, a highly significant difference (P< 0.001). Only 6% of men, compared with 36% of women, met the Australian national target (≤ 100 mmol/day), represented by the vertical line in the Figure, and this difference was also significant at P< 0.001. Differences between age groups and socioeconomic status groups were not significant at the P< 0.05 level (Box 2, below). The mean potassium intake in men was 9 mmol higher than in women (P = 0.03), but differences between age groups and socioeconomic status groups were not significant (Box 2, above). Only 5% of men and 19% of women met the recommendation8,9 that the sodium to potassium ratio should not exceed 1.0 (diagonal line in the Figure); this sex difference was significant (P = 0.002). Differences were not statistically significant between younger and older participants (P = 0.33), and were on the margin of significance for socioeconomic status levels (P = 0.05). Discretionary use of salt Most of our 194 participants claimed that they never or rarely added salt at the table (51% of men and 73% of women), and that they never or rarely cooked with salt (54% of men and 61% of women). Compliers and non-compliers with the sodium target gave similar answers about the use of salt: 66% of compliers and 62% of non-compliers rarely or never added salt at the table, and 57% of compliers and 58% of non-compliers rarely or never cooked with salt. Discussion Despite our relatively low response rate, Box 1 shows that our participants had a similar sex ratio to that of a systematic sample from the Hobart electoral roll, and we found that sex differences in electrolyte excretion were significant. Although our sample was biased in terms of age and socioeconomic status, the effect of age and socioeconomic status on electrolyte excretion in the participants barely reached significance (Box 2), and hence these biases are unlikely to have influenced our findings. If the participants were unrepresentative in some other way -- more health-conscious, for example -- our data could underestimate sodium excretion and overestimate compliance with the sodium target. It is difficult to be certain of the completeness of 24-hour urine collections. Para-aminobenzoic acid has been used as a marker in overseas studies,19 but is not approved for use with healthy volunteers in Australia. Creatinine excretion is a customary indicator of completeness, but no standard cut-off points exist.19 As both undercollection and overcollection could have affected our results, we repeated the t-test analyses of Box 2 after excluding subjects whose creatinine outputs were in the lowest and highest 2.5% for men and women. For both sodium and potassium the changes in means and standard deviations were negligible, indicating no serious problem with outliers. Moreover, the range of excretion rates of each electrolyte in each sex remained unaltered. Accuracy and imprecision of assays are also important determinants of data quality. As reported in our Methods, duplicate assays indicated acceptable imprecision -- the laboratory is a participant in the Royal College of Pathologists of Australasia-Australian Association of Clinical Biochemists Quality Assurance Scheme and is accredited by the National Association of Testing Authorities. Few other Australian studies have been reported. In one, estimates based on food-frequency questionnaires were somewhat lower than ours,12 but urinary excretion is considered a more valid indicator of intakes.13,14 A Hobart study in 1989, with a similar protocol for sample selection and urine collection,10 found mean sodium and potassium excretion rates in men of 160 mmol/day and 77 mmol/day, respectively, compared with 124 mmol/day and 66 mmol/day in women. In Sydney, in 1992, Notowidjojo and Truswell11 found mean sodium and potassium excretion rates of 164 mmol/day and 74 mmol/day in men and 133 mmol/day and 66 mmol/day in women. These two studies support our conclusion that average intakes in Australia -- especially among men -- are substantially above the national target. Public health implications Meta-analysis by Law et al. indicates that a 50 mmol decrease in community sodium intake could reduce mortality from heart disease by 16% and from stroke by 22%.20 The annual cost to Australia of heart disease, stroke and hypertension was recently estimated at $1198 million, $666 million and $546 million, respectively.21 If a lower salt intake reduced prevalence as much as it reduced mortality, the saving from 16% less heart disease and 22% less stroke and hypertension would be $458 million annually, with added savings from reduced prevalence of other conditions.1 In the United Kingdom the complete elimination of table salt and cooking salt would reduce mean sodium intake by only about 15%.22 This figure might be even lower in Australia, as this and other studies show that most people already avoid adding salt to their food.23,24 The main source of dietary sodium -- at least 75% of the total -- is processed foods, and a major reduction depends on changing their composition.21 Government initiatives have been limited to recommending a lower salt content in processed foods,25 setting a national target for sodium intake of ≤100 mmol/day,2 and publishing the dietary guideline Choose low salt foods and use salt sparingly.26 Food manufacturers have made some commendable initiatives, but they depend on consumer demand, and little has been done to inform the public about the national target for sodium intake. Although some low-salt processed foods are available and labelled in accordance with the food regulations, shoppers receive little specific advice or encouragement to reduce their sodium intake by choosing them. Conclusion By setting a national sodium-intake target, Australian health authorities have accepted that excessive dietary sodium is an important health issue, with significant morbidity, mortality and economic costs. Our results indicate the need for an active campaign to promote and monitor the nation's sodium target effectively. Acknowledgements This study was carried out with an educational grant from the National Heart Foundation of Australia, and financial assistance towards the purchase of computer equipment was received from Sizzler Restaurants and from Salt Skip Incorporated. We are indebted to Leigh Blizzard, statistician at the Menzies Centre, for statistical advice. References Antonios TFT, MacGregor GA. Deleterious effects of salt intake other than effects on blood pressure. Clin Exp Pharmacol Physiol 1995; 22: 180-184. Health Targets and Implementation (Health For All) Committee. Health for all Australians. Canberra: AGPS, 1988: 38. WHO/ISH Statement Committee. Prevention of hypertension and associated cardiovascular disease: a 1995 statement. Clin Exper Hypertension 1996; 18: 581-593. National Research Council. Committee on diet and health. Implications for reducing chronic disease risk. Washington DC: National Academy Press, 1989: 16-17. World Health Organization. Diet, nutrition, and the prevention of chronic diseases. WHO Technical Report No. 797. Geneva: WHO, 1990: 61. Committee on Medical Aspects of Food Policy. Nutritional aspects of cardiovascular disease. Department of Health and Social Security. Report on health and social subjects No. 46. London: HMSO, 1994: 138. Denton D, Weisinger R, Mundy NI, et al. The effect of increased salt intake on blood pressure of chimpanzees. Nature Med 1995; 1: 1009-1016. Truswell AS. Potassium. In: Truswell AS, Dreosti IE, English RM, et al., editors. Recommended nutrient intakes: Australian papers. Sydney: Australian Professional Publications, 1990: 191-198. Stamler J, Rose G, Stamler R, et al. Intersalt study findings: public health and medical care implications. Hypertension 1989; 14: 570-577. Beard TC, Eickhoff R, Mejglo ZA, et al. Population-based survey of human sodium and potassium excretion. Clin Exp Pharmacol Physiol 1992; 19: 327-330. Notowidjojo L, Truswell AS. Urinary sodium and potassium in a sample of healthy adults in Sydney, Australia. Asia Pacific J Clin Nutr 1993; 2: 25-33. Baghurst KI, Crawford D, Worsley A, et al. The Victorian nutrition survey: a profile of the energy, macronutrient and sodium intakes of the population. Community Health Studies 1988; 12: 42-54. Caggiula AW, Wing RR, Nowalk MP, et al. The measurement of sodium and potassium intake. Am J Clin Nutr 1985; 42: 391-398. Hunter D. Biochemical indicators of dietary intake. In: Willett W, editor. Nutritional epidemiology. New York: Oxford University Press, 1990: 143-216. Australian Bureau of Statistics. Socio-economic indexes for areas. Canberra: ABS, 1990. MacGregor GA, Markandu ND, Roulston JE, et al. Is idiopathic oedema idiopathic? Lancet 1979; 1: 397-400. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ 1988; 297: 319-328. SPSS for Windows, release 6.1 [computer program]. Chicago: SPSS Inc, 1994. Bingham SA, Cummings JH. The use of creatinine output as a check on the completeness of 24-hour urine collections. Hum Nutr Clin Nutr 1985; 39C: 343-353. Law MR, Frost CD, Wald MJ. By how much does dietary salt lower blood pressure? III. Analysis of data from trials of salt reduction. BMJ 1991; 302: 819-823. National Heart Foundation of Australia. Heart and stroke facts report. Canberra: The Foundation, 1995. James WPT, Ralph A, Sanchez-Castillo CP. The dominance of salt in manufactured food in the sodium intake of affluent societies. Lancet 1987; 1: 426-429. Bennett SA, Magnus P. Trends in cardiovascular risk factors in Australia. Med J Aust 1994; 161: 519-527. Thomson A, Rundle S, Singh BB, et al. Regional differences in cardiovascular risk factor prevalence in Tasmania: are they consistent with the increased cardiovascular mortality? Aust N Z J Med 1995; 25: 290-296. National Health and Medical Research Council. Report of the working party on sodium in the Australian diet. Canberra: AGPS, 1984: 4. National Health and Medical Research Council. Dietary guidelines for Australians. Canberra: AGPS, 1992: 70-83. (Received 24 Jun, accepted 4 Nov, 1996) Authors' details Menzies Centre for Population Health Research, University of Tasmania, Hobart, TAS. Trevor C Beard, OBE, MB BChir, MPH, Senior Research Fellow; Helen Hornsby, BA(Hons), Research Assistant; Terence Dwyer, MD, MPH, Director. Division of Biochemistry, University of Tasmania, Hobart, TAS. David R Woodward, PhD, Senior Lecturer. Department of Psychology, University of Tasmania, Hobart, TAS. Peter J Ball, BSc, MA, Senior Lecturer. Department of Clinical Chemistry, Royal Hobart Hospital, Hobart, TAS. Richard J von Witt, FRCPath, FRCPA, Director. Reprints: Dr T C Beard, Menzies Centre for Population Health Research, 17 Liverpool Street, Hobart, TAS 7000. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Trevor C Beard · David R Woodward · Peter J Ball · Helen Hornsby · Terence Dwyer

Evaluation of sexual health services within Australia and New Zealand Caron Marks, Robin L Tideman and Adrian Mindel MJA 1997; 166: 348-352 For comment see Fairley 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 - Figure 1 - Figure 2 - - ©MJA1997 Abstract Objective: To examine and compare specialised services for patients with sexually transmitted diseases (STDs) in Australia and New Zealand. Design: Postal questionnaire survey. Participants and Setting: All STD facilities in Australia and New Zealand in 1993. Main Outcome Measures: Patient numbers and demography; staffing levels; the role of nurses; diagnostic and treatment protocols; contact-tracing policies; and the availability of specialist medical services and community and education programs. Results: 83 of 100 clinics responded; 52 were urban, 21 rural, and nine remote. 95% were open to men and women. Staffing levels were similar in Australia and New Zealand and there was considerable consistency in diagnostic techniques and treatment among clinics. Australian clinics more often used ciprofloxacin or ceftriaxone as the treatment of first choice for gonorrhoea; New Zealand clinics were more likely to test for Chlamydia using direct immunofluorescence; and Australian clinics were more likely to test for hepatitis A and offer hepatitis B vaccination to a broader range of patients. 88% of clinics always traced contacts for gonorrhoea, 86% for syphilis and 77% for Chlamydia . 98% of clinics offered HIV test counselling, and 78% STD health education. Conclusions: The number of sexual health services has increased over the past decade. Other improvements include most clinics being open to both men and women, and consistency in the diagnosis, treatment and contact tracing of STDs. However, given the lack of adequate comparative data and the variable quality of national surveillance data, it is difficult to determine whether current facilities are meeting service needs. MJA 1997; 166: 348-352 Introduction The control of sexually transmitted diseases (STDs) depends on health promotion, education, the provision of adequate facilities for the diagnosis, treatment and contact tracing of STDs, and ongoing research.1 One of the more comprehensive national STD services (involving more than 200 standardised clinics) is in the United Kingdom.2,3 By contrast, Australia currently has a fragmented STD control system in which each State and Territory works independently and with different health policies. There are no nationally agreed guidelines for the diagnosis, treatment and tracing of contacts of patients with STDs,4 availability of different tests varies across the continent, and treatment protocols may vary according to antibiotic resistance patterns and financial constraints. A 1983 survey of public STD facilities throughout Australia found that almost all clinics were located in major cities, leaving large areas of rural Australia unserviced by public clinics.5 Other deficiencies identified included inadequate opening times, lack of facilities in some clinics for treating both men and women, insufficient staff, inadequate contact tracing, limited use of facilities for teaching purposes, and inadequate maintenance of their role as reference centres for other practitioners and agencies. This survey included all 20 public STD facilities Australia-wide, and concluded that these facilities were "inadequate to meet the needs of the population".5 Over the past decade there have been many changes to sexual health care, including more clinics and better training for staff. Consequently, we felt that it was timely to establish what STD services were available from public and private STD clinics and Family Planning Clinics (FPCs); whether STD clinical services were adequately staffed; to determine the range of diagnostic, treatment, and contact-tracing services; and whether clinics were providing the community with education, counselling and other specialist services. Finally, we compared services in Australia and New Zealand and noted geographic differences in the provision of services within Australia. Methods In 1993 we identified all STD treatment facilities in Australia and New Zealand. These included all known public and private sexual health clinics, and the main Family Planning Clinic (FPC) in each State. Most facilities were identified through the National Venereology Council of Australia and the Family Planning Association of New South Wales, with the remainder found when clinics identified centres in their area which had been overlooked. A questionnaire and prepaid addressed envelope were posted to the director (senior doctor or nurse) of each clinic. The 65-item questionnaire sought information about the geographic location and physical structure of clinics, as well as staffing, diagnosis, treatment and contact tracing for the various STDs, specialist medical services, and community and educational programs run by the facility. Non-respondents were sent a second questionnaire two months after the first. Statistical analysis The results were analysed using the Statistical Package for the Social Sciences (SPSS).6 Descriptive statistics, frequency distributions, χ2 and Fisher's exact test were used. There was no weighting of the data by size of clinic. Chi-square tests, when used to compare therapies for the various STDs, involve all treatments, ranging from "most commonly used" to those "never used". When reporting significant differences the χ2 takes into account all these modalities. However, the figures reported show only a description of where the differences lie. The rural/remote areas classification system was used to classify Australian facilities into rural and remote areas by means of postcodes,7 while the New Zealand Yearbook was used to classify those in New Zealand.8 Results We identified 101 STD facilities, one of which had closed down. From the remaining 100 clinics, 83 questionnaires were returned (72 on the first mailout and an additional 11 on the second). Geographic distribution and type of facility Fifty-six clinics were in Australia and 27 were in New Zealand. Sixty-three per cent were in inner-city and suburban areas, 26% in rural areas and 11% in remote areas (Box 1). Seventy-nine clinics (95%) were public and four (5%) were private. There were 71 STD clinics and five FPCs. One private facility identified itself as a specialist venereology practice, and three as general practices specialising in STDs and HIV. The remaining three clinics identified themselves as "other". Seventy-nine clinics (95%) were open to both men and women. Staffing Box 2 shows that the median number of patients seen per year decreased as the facilities became more remote. Clinics in Australia saw a greater median number of patients per year and had more doctors, nurses, laboratory and clerical staff than those in New Zealand. However, the only significant difference was for full-time equivalent clerical staff, with a median of 1 (range, 0-4.3) for Australia, compared with 0 (range, 0-2.4) for New Zealand (P = 0.002). The most common duties of nurses at STD facilities included history taking, clinical examination and testing for STDs. Only 26% of clinics allowed nurses to prescribe treatment; more nurses in rural and remote areas were allowed to prescribe treatment than those in urban areas (36% v. 16%), but this difference was not significant. Nurses took histories "sometimes" (options were "always", "sometimes" and "never") in over 80% of clinics in New South Wales, compared with 39% in Victoria (P = 0.02), and examined patients at 70% of NSW clinics, compared with 22% in Victoria (P = 0.02). There were no significant differences in nursing duties between New Zealand and NSW. However, comparing New Zealand with Victoria showed that New Zealand nurses were more likely to take histories (P = 0.003), examine patients (P = 0.005), and test patients for STDs (P = 0.002). Diagnosis and treatment Gonorrhoea: Eighty-one clinics (99%) used culture, and 77 (94%) used Gram stain to diagnose gonorrhoea. The three most common treatments for gonorrhoea were amoxycillin plus probenecid, ciprofloxacin, and ceftriaxone, used in 63%, 24% and 12% of clinics, respectively (Box 3). New Zealand clinics were more likely than Australian clinics to use amoxycillin plus probenecid as first-line therapy for gonorrhoea (93% v. 49%; P = 0.01). Urban clinics in both Australia and New Zealand were more likely to use ciprofloxacin than rural and remote clinics (51% v. 21%; P = 0.02). Syphilis: Forty-seven clinics (57%) used dark-ground microscopy for diagnosing primary syphilis. For screening, 61 (74%) used the rapid plasma reagin (RPR) test, 58 (71%) the Treponema pallidum haemagglutination antibody (TPHA) test, and 25 (31%) the Ven ereal Disease Research Laboratory (VDRL) test. Fifty Australian clinics (91%), compared with 11 New Zealand clinics (41%), used the RPR test for screening (P < 0.001). The fluorescent treponemal antibody test (FTA) was used by 61 (75%) clinics to confirm the diagnosis. Procaine and benzathine penicillins were the first-choice treatments in all facilities. Chlamydia and non-gonococcal urethritis: Chlamydia was most commonly diagnosed by direct immuno fluorescence (DIF), which was used by 44 clinics (54%), followed by: enzyme immunoassay (EIA) from swabs, 39 clinics (48%); culture from swabs, 35 clinics (43%); and EIA from urine, 10 clinics (12%). Australian clinics were more likely to use culture to diagnose chlamydial infection than New Zealand clinics (58% v. 11%; P < 0.001), while New Zealand clinics were more likely to use DIF than Australian clinics (74% v. 44%; P = 0.01). Urban centres were significantly more likely to use culture to diagnose Chlamydia than rural and remote centres (58% v. 17%; P < 0.001). Most clinics used doxycycline as first-line treatment for Chlamydia and non-gonococcal urethritis (92% and 91%, respectively). Genital herpes: Herpes simplex virus (HSV) was diagnosed by viral culture (79 clinics [96%]), EIA (16 clinics [20%]), and serological testing (10 clinics [12%]). Acyclovir was used to treat primary HSV infections by 79 clinics (98%), for long term suppression by 70 clinics (86%), and for recurrences of HSV infection by 58 clinics (72%). Human immunodeficiency virus (HIV): All the clinics surveyed routinely offered counselling and voluntary HIV testing to all persons considered to be at risk of HIV infection. Fifty-two clinics (64%) had facilities to manage HIV- positive patients. Forty-one clinics (51%) provided antiretroviral therapy and prophylaxis and treatment of opportunistic infections. Genital warts: Cryotherapy was the first-line treatment for human papillomavirus infection in 55 clinics (69%), and podophyllin was the second most common treatment option, used in 17 clinics (21%). Australian clinics were more likely to use podophyllin than New Zealand clinics (16/53 [30%] v. 3/27 [11%]; P = 0.03). Trichomoniasis and bacterial vaginosis: To diagnose trichomoniasis, wet-film microscopy was the most common technique, used in 67 clinics (83%), while culture was used by 39 clinics (48%). Gram staining was the most common diagnostic technique for identifying bacterial vaginosis (74 clinics [93%]). Alternative diagnostic techniques used included culture to identify Gardnerella vaginalis and other anaerobes (56 clinics [70%]), vaginal pH testing (44 clinics [55%]), and the potassium hydroxide test (which identifies volatile amines) (41 clinics [51%]). Most clinics used metronidazole to treat trichomoniasis (53/80 [66%]) and bacterial vaginosis (50/79 [63%]). Viral hepatitis: Forty-four clinics (55%) offered antibody testing for hepatitis A and 79 (98%) for hepatitis C. Australian clinics were significantly more likely to offer antibody testing for hepatitis A than New Zealand clinics (36/54 [67%] v. 8/26 [31%]; P = 0.003). When screening for hepatitis B infection, 65 clinics (81%) meas ured surface antigen (HBsAg), 57 (71%) measured core antibody (HBcAb), and 48 (60%) measured surface antibody (HBsAb). Figure 1 shows clinic policies for hepatitis B vaccination. Vaccination was recommended for health care workers by 52/53 (98%) Australian clinics, compared with 19/27 clinics (70%) in New Zealand (P < 0.001); for heterosexuals with multiple partners, these figures were 44/53 (83%) and 15/27 (56%), respectively (P = 0.01); and for intravenous drug users (IVDUs), 52/53 (98%) and 21/27 (78%), respectively (P = 0.002). Contact tracing Seventy-one clinics (87%) offered contact tracing for patients with STDs. Many centres employed multiple techniques. In 67 clinics (94%), staff negotiated with patients to advise their own contacts, 53 clinics (75%) used face-to-face discussions between contacts and clinic staff, 45 (63%) had staff visit contacts at home, and 38 (54%) traced contacts by phone. Twenty-one of the 71 clinics (30%) employed specially trained contact tracers. Doctors were involved in contact tracing in 22 clinics (28%), counsellors in 23 (32%), and nurses in 44 (62%). Patients were encouraged to inform their own contacts in 28 clinics (39%). All 21 clinics in NSW stated that they undertook contact tracing, compared with 9/13 (69%) clinics in Victoria (P = 0.01), and NSW clinics were significantly more likely to involve counsellors in contact tracing than Victorian clinics (62% v. 8%; P = 0.002). There were a number of differences in contact-tracing policies between Australia and New Zealand. Australian facilities were more likely than New Zealand clinics to involve doctors (22/55 [40%] v. 1/27 [4%]; P = 0.001), less likely to trace contacts by telephone (21/55 [38%] v. 18/27 [67%]; P = 0.02), and less likely to trace contacts by having staff visit them (22/55 [40%] v. 23/27 [85%]; P < 0.001). Box 4 summarises the contact-tracing practices for each STD. Most clinics always traced contacts of patients with gonorrhoea, syphilis, Chlamydia , HIV and trichomoniasis. Only one of the five FPCs (20%) provided contact tracing, compared with 65 of 66 (98%) sexual health clinics (Fisher's exact test, P < 0.0005). Additional services provided by STD clinics The facilities surveyed offered a range of additional services. Eighty-one facilities (98%) offered counselling before and after HIV testing, 78 (95%) functioned as a referral service for further specialist counselling, 68 (84%) offered family planning advice, and 48 (59%) offered relationship counselling. Other services are outlined in Figure 2. Sixty-eight (82%) of the responding clinics offered education programs to other health professionals, schools or youth groups, while 46 (55%) offered some form of higher education/university courses. Discussion Our findings show that the number of STD facilities in Australia increased considerably over the past decade, and that facilities in New Zealand and Australia were broadly comparable (although, in Australia, there was still a marked urban predominance of clinics). Other improvements were that most clinics were open to men and women, and offered a wide range of teaching and other special services. Relative to the 1983 survey of Australian STD services by Bradford and Philpot,5 we found an increase in the number of nurses and doctors, while the number of patients seen annually was similar. However, over the past decade clinics have become more involved in managing patients with complex medical problems, including HIV, hepatitis B and C, disseminated herpes simplex virus infection, and cervical intraepithelial neoplasia.4,9 Increased availability of services does not necessarily lead to improvement in the sexual health of the community. The best measure of improvement is a reduction in the incidence of sexually transmitted diseases. In Australia, disease patterns have been difficult to in terpret because the collection of epidemiological data for most STDs (with the exception of gonorrhoea) from the States and Territories is uneven.4 None the less, there is considerable evidence to suggest that there has been a dramatic reduction in reported cases of gonorrhoea, syphilis and chlamydial infections since 1981,10-12 with the most marked improvements in the large metropolitan centres. By contrast, the incidence of gonorrhoea, syphilis, Chlamydia and donovanosis remained extremely high in many rural Aboriginal communities, particularly in the Northern Territory, far north Queensland, and the Pilbara and Kimberley regions of Western Australia.13-15 These areas all have a limited number and quality of sexual health facilities, and improvements in clinical services and intervention programs are urgently needed. Our findings show considerable consistency in diagnosis and treatment of STDs throughout Australia and also between Australia and New Zealand, with most facilities following the diagnostic and treatment guidelines produced by the United States Centers for Disease Control (CDC)16 or those of the Venereology Society of Victoria.17 However, we did identify some differences between Australia and New Zealand in the treatment of first choice for gonorrhoea, the method of detecting chlamydial infection, and in the likelihood that hepatitis A tests would be requested. There were also differing policies on hepatitis B vaccination and on tracing contacts of patients with STDs. Varying patterns of antibiotic resistance in strains of the organism that causes gonorrhoea (penicillinase-producing Neisseria gonorrhoeae ) were more common in Australia, particularly along the east coast,18 than in New Zealand, and resistance to quinolones occurs in strains infecting a sizeable minority of travellers from the Philippines and neighbouring countries;19 this may explain the difference in antibiotic treatment. Other factors contributing to the differences in practice include local availability of diagnostic tests, variation in populations attending clinics (travellers,20,21 sex-industry workers22,23 and homosexual men24-26 ) and local variations in clinical practice. The differences in hepatitis A testing policy and hepatitis B vaccination policy are intriguing, and may include differing financial arrangements between the clinical services in the two countries, availability of testing and vaccination from other sources (in particular, the recommendation for universal HBV vaccination in New Zealand),27 and differing populations28,29 and perceptions of risk.30 Differences in contact-tracing policies probably reflect availability of staff, local working practices, or variation in the understanding of contact tracing. There are a few minor differences between urban clinics and those in rural and remote settings, with a greater proportion of urban clinics using ciprofloxacin to treat gonorrhoea, using culture to diagnose Chlamydia , and requesting hepatitis A testing. This also reflects differences in the population groups attending different clinics (urban centres attract a higher proportion of overseas travellers, sex workers and homosexual and bisexual men than rural and remote centres), antibiotic sensitivities and local availability of tests. Overall, the availability of contact-tracing services was excellent. However, it is of some concern that 4% of clinics never and 9% only sometimes traced contacts for gonorrhoea, 8% never traced contacts for syphilis and 2% never traced contacts for Chlamydia . Although we surveyed only five FPCs, our finding that only one of these five provided contact tracing is of concern, particularly with Chlamydia , which is often diagnosed within these facilities.31 Barriers to contact-tracing services within FPCs should be explored and solutions considered. One possible solution would be to encourage closer links between sexual health and family planning services. Our findings in this survey should be of assistance in future sexual health service planning. In addition, the remarkable consistency in the diagnosis, treatment and contact tracing of STDs in Australia and New Zealand should encourage the development of national guidelines. Acknowledgements We thank Professor G Berry and Associate Professor B Donovan for their assistance with this manuscript. References Adler MW. Sexually transmitted diseases. In: Holland WW, Detels R, Knox G, editors. Oxford textbook of public health. Vol. 21. 2nd Ed. Oxford: Oxford University Press, 1991: 345-357. Bingham JS. Genitourinary medicine should remain a separate specialty. Genitourin Med 1996; 27: 312. Adler MW, Belsey EM, O'Connor BH, et al. Facilities and diagnostic criteria in sexually transmitted disease clinics in England and Wales. Br J Vener Dis 1978; 54: 2-9. Mulhall BP, Hart G, Harcourt C. Sexually transmitted diseases in Australia: a decade in change. Epidemiology and surveillance. Ann Acad Med Singapore 1995; 24: 569-578. Bradford DL, Philpot CR. A survey of sexually transmitted disease centres in Australia. Br J Vener Dis 1983; 59: 330-334. SPSS: Statistical package for the social sciences [computer program], version 7.0. Chicago, Ill: SPSS Inc, 1995. Rural/remote areas classification. Canberra: Department of Human Services and Health, 1994. New Zealand Official Yearbook 1993. 96th Ed. Wellington: New Zealand Department of Statistics, 1993. Donovan B, Finlayson RJ, Mutimer K, et al. HIV infection in sexually transmissible disease practice in Sydney: the effects of legislation, public education and changing clinical spectrum. Int J STD AIDS 1990; 1: 21-27. The Australian gonococcal surveillance programme. The incidence of gonorrhoea and the antibiotic sensitivity of gonococci in Australia, 1981-1991. Genitourin Med 1993; 69: 364-369. Hart G. STD epidemiology in Australasia; Syphilis and gonorrhoea. Venereology 1992; 5: 115-120. Garland SM, Gertig DM, McInnes JA. Genital Chlamydia trachomatis infection in Australia. Med J Aust 1993; 159: 90-96. Annual report of the national notifiable diseases surveillance system, 1992 - part 2. Syphilis. Commun Dis Intell 1993; 17(22): 507-508. Bowden FJ. Surveillance of sexually transmitted diseases in the Northern Territory of Australia. Venereology , 1995; 8(1): 21-25. Main J, Patel A, Bowden FJ. Surveillance of donovanosis in the Northern Territory. Venereology 1995: 8: 16-19. sexually transmitted diseases treatment guidelines. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1993; 42(RR-14): 1-102. Management guidelines for sexually transmissible diseases and genital infections. 4th ed. Melbourne: Venereology Society of Victoria, 1995. Anonymous. The incidence of gonorrhoea and the antibiotic sensitivity of gonococci in Australia, 1981-1991 . The Australian Gonococcal Surveillance Programme. Genitourin Med 1993; 69(5): 364-369. Tapsall JW, Schultz TR, Philip EA. Characteristics of Neisseria gonorrhoeae isolated in Australia showing decreased sensitivity to quinolone antibiotics. Pathology 1992; 24: 27-31. Mulhall BP, Hu M, Thompson M, et al. Planned sexual behaviour of young Australian visitors to Thailand. Med J Aust 1993; 158: 530-535. Mulhall BP. Sexually transmissible diseases and travel. Br Med Bull 1993; 49(2): 394-411. O'Connor CC, Berry G, Rohrsheim R, Donovan B. Sexual health and use of condoms among local and international sex workers in Sydney. Genitourin Med 1996; 72: 47-51. Philpot CR, Harcourt JM, Edwards JM. A survey of female prostitutes at risk of HIV infection and other sexually transmissible diseases. Genitourin Med 1991; 67: 384-388. Rowbottom JH, Tapsall JW, Plummer DC, et al. An outbreak of a penicillin-sensitive strain of gonorrhoea in Sydney men. Genitourin Med 1994; 70: 196-199. Forsyth JRL, Sherrard J, Traynor P. Resurgent gonorrhoea in homosexual men [letter]. Lancet 1990; 336: 878. McNulty A. Anorectal gonorrhoea revisited. Venereol 1993; 6(4): 109-111. Goldwater PN. History of hepatitis B vaccination in New Zealand: lessons for Australia? Aust J Pub Health 1993; 17: 221-225. Stewart T, Crofts N. An outbreak of hepatitis A among homosexual men in Melbourne. Med J Aust 1993; 158: 519-521. Stokes ML. Infectious diseases: hepatitis A survey results. NSW Public Health Bull 1992; 3: 7-12. Anderson B, Bodsworth NJ, Rohrsheim R, Donovan B. Hepatitis B virus infection and vaccination status of high risk people in Sydney: 1982 and 1991. Med J Aust 1994; 161: 368-371. Garland SM, Gertig DM, McInnes JA. Genital Chlamydia trachomatis infection in Australia. Med J Aust 1993, 159: 90-96. (Received 9 Apr, accepted 1 Nov, 1996) Authors' details Academic Unit of Sexual Health Medicine, Sydney Hospital, Sydney, NSW. Caron Marks, BSc, MA, Research Assistant; Robin L Tideman, MB BS, Clinical Research Coordinator; Adrian Mindel, FRACP, MD, Professor of Sexual Health Medicine. Reprints: Ms C Marks, Academic Unit in Sexual Health Medicine, Sydney Hospital, GPO Box 1614, Sydney, NSW 2001. E-mail: cmarks AT extro.ucc.su.oz.au - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Caron Marks · Robin L Tideman · Adrian Mindel

Hepatitis C transmission on the north coast of New South Wales: explaining the unexplained Tim J Sladden, Alan R Hickey, Therese M Dunn and John R Beard MJA 1997; 166: 290 For comment see Wodak 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 - Exposures - Transmission to sexual partners and offspring - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objective: To determine the routes of hepatitis C virus (HCV) transmission in an Australian community. Design: Questionnaire-based, cross-sectional survey of notified HCV cases. Subjects and setting: All cases notified to the New South Wales North Coast Public Health Unit between 1 January 1993 and 30 September 1994. Outcome measures: Frequency of potential transmission exposures (parenteral and sexual); most likely primary exposure; HCV infection rates in sexual partners and offspring. Results: 467 subjects responded (47% of resident cases). Of these, all but one reported actual or potential blood exposures (injecting drug user [IDU], 85%; IDU with sharing of injection equipment, 76%; pre-1990 blood transfusions, 6%; other blood exposures, 8%). Most subjects reported multiple exposures and none reported sexual contact as the only potential exposure. Of 233 sexual partners tested for HCV, 83 were positive; 54 of these were questioned and all had other parenteral exposures. Only three children out of 91 children tested were positive for HCV (two expressing maternal antibodies). Conclusions: In contrast with previous studies, possible HCV transmission modes were identified for almost all respondents. Most respondents in this community were IDUs. Non-parenteral transmission appeared minimal. Novel approaches to preventing HCV transmission in IDUs are needed. MJA 1997: 166; 290-293 Introduction Few studies have investigated transmission of hepatitis C virus (HCV) in representative, population-based samples.1-3 Most previous studies have examined patient series,4-6 those at risk (e.g., transfusion recipients and injecting drug users [IDUs])7-9 or other particular groups (e.g., blood donors, pregnant women and prisoners).10-12 Previous studies have also failed to identify exposures in significant numbers of cases (up to 45% of respondents).1-5,8 HCV transmission is predominantly parenteral13 (via shared drug injection equipment, infected blood products [almost entirely before screening was introduced in February 1990], unsterile skin penetration practices [e.g., tattooing, ear/skin piercing, acupuncture], needlestick and "sharps" injuries and shared personal items, such as toothbrushes and razors14 ). However, patient-to-patient transmission (via contaminated anaesthetic circuitry)15 and surgeon-to-patient transmission (via percutaneous injury)16 have both been demonstrated. Sexual transmission without blood contact appears rare,5,6,8,13 but the risk of blood exposure may be increased by sexual contact during menstruation and anal intercourse. Vertical transmission also appears rare.8,13,17 Both sexual and vertical transmission appear viraemia-dependent,8,9,13,17 and may be facilitated by genital lesions.6,17 Nipple trauma may enable postnatal transmission.18 Household transmission is probably restricted to infected personal items.19 Arthropod vectors have not been identified. Despite evidence that there is no risk of transmission via casual contact, community concern about hepatitis C transmission remains evident in the discrimination reported anecdotally by people with HCV. Clarification of how HCV is transmitted is needed both to allay this concern and to allow the development of new prevention strategies.20 One focus of the current Australian hepatitis C epidemic is the north coast of New South Wales (NSW), where the notification rate (201/100 000 residents) is double the NSW rate (103/100 000 residents),21 and nearly three times the Australian average (74/100 000 residents).22 We investigated the mode of transmission in notified cases in residents on the NSW north coast over a 21-month period. Methods All people diagnosed with HCV infection (through duplicate second generation anti-HCV antibody tests) who were notified to the North Coast Public Health Unit between 1 January 1993 and 30 September 1994 were invited to participate. Subject name, diagnosis and contact address were verified with attending doctors. Questionnaires were mailed to subjects with covering letters, consent statements, and reply-paid return envelopes. Non-respondents were recontacted by mail six weeks later. Data, with identifying codes removed, were entered into a restricted-access database. We developed a questionnaire that included demographic questions, a checklist of possible ways the subject may have contracted hepatitis C (see Box 1) and questions about the HCV status of the subject's current sexual partner and, for women, of their children. The questionnaire was pilot-tested on clients of a local sexual health service. The study and questionnaire were approved by the North Coast Region Health Service Ethics Committee. For subjects with multiple potential exposures, exposures were ranked according to expected risk, and the exposure with the highest risk was considered the most likely primary exposure. Parenteral exposures were assumed to be higher risk than sexual exposure and ranked as: High risk -- (in descending order of risk) injecting drug use (IDU) (with and without reported sharing of injection equipment), receipt of pre-1990 blood products, dialysis and transplants; Medium risk -- needlestick injuries, tattooing, or blood splashes into a cut, eye or mouth (i.e., during an accident or fight); and Potential or low risk -- origin from countries where medical services have used inadequate infection control procedures in the past (such as reuse of needles) or where unsterile tattooing or scarification is common (including the Mediterranean area, Eastern Europe, Asia, South America, Africa and the Middle East),23 post-1989 blood transfusion, ear or skin piercing and other clinical procedures. Transmission between study subjects and their current sexual partners was investigated; a modified questionnaire which included only the checklist of potential transmission routes was mailed to all HCV-positive partners. Household and social contact were examined when no other exposure was reported. Subjects with only low-risk or no parenteral exposures were offered testing for HCV RNA by polymerase chain reaction (PCR) to confirm their hepatitis C status. Demographic characteristics of respondents and non-respondents were compared with chi-squared tests and t tests, and sharing of injection equipment by current and former IDUs was compared with chi-squared tests. Results Of 1487 notified cases, 487 were excluded (395, temporary residents or non-residents; 67, with address unknown; seven, aged under 18 years; 18, other reasons), leaving a study population of 1000. Questionnaires were returned by 467 (46.7%). Respondents differed significantly from non-respondents in sex and age distributions: respondents included a significantly higher proportion of women than non-respondents (respondents: 219/467 [47%]; non-respondents: 212/533 [40%]; chi-squared = 4.42, P = 0.035) and were significantly older (respondents: mean age, 37.4 years; 95% confidence interval [CI], 36.6-38.3; range, 18-86; non-respondents: mean age, 34.9 years; 95% CI, 34.4-35.5; range, 18-62); t [unequal variances] = 4.70; df = 852, P < 0.001). Exposures Potential HCV exposures are shown in Box 1. Almost all 467 respondents reported at least one potential transmission exposure and most reported multiple exposures. The potential exposure with the highest expected risk was classified as the most likely primary exposure. Most respondents (398 [85%]) were IDUs (222 men, 176 women), including 287 (72%) former IDUs (although 45 [11%] of these reported stopping during the survey period). None of the 19 subjects aged over 60 years were IDUs. Of the IDUs, 354 (89%) reported having shared injection equipment. Frequency of sharing injection equipment by IDU status is shown in Box 2 (below). Current IDUs reported sharing significantly less than former IDUs ( chi-squared = 5.82; df = 1; P= 0.016). Hepatitis B infection was reported by 184 subjects (39%); 175 of these (95%) were IDUs. All but 11 sharers of injection equipment and all non-sharer IDUs reported other parenteral exposures (Box 1). Among subjects who were not IDUs, the most likely primary exposure (Box 1) was pre-1990 blood transfusion for 30 (6%), dialysis for two (0.4%), needle-stick injuries for six (1%) (including three health care workers, one with a known exposure to hepatitis C virus, a garbage collector and the partner of an IDU), tattooing for four (0.9%), blood splashes for four (0.9%), origin in a "high-risk" country for three (0.6%), post-1989 blood transfusion for two (0.4%), skin piercing for 13 (3%) and medical procedures for four (0.8%). About a third of subjects (151 [ 32%]) reported past or current HCV-positive sexual partners. However, 147 (97%) also had potential blood exposures (141, IDU; three, blood transfusion; and one each, tattoos, needlestick injury and blood splash). The remaining four had low-risk potential blood exposures (pierced ears or skin for three and a clinical procedure for one). Thus, sexual contact did not occur without concurrent or potential blood exposure(s). Sharing of personal items (e.g., toothbrushes) also could not be excluded for subjects reporting sexual contact. For 15 subjects, no sexual exposure and only low-risk potential parenteral exposures were reported. Another subject reported no risk factors. Polymerase chain reaction (PCR) was offered to these 16 to confirm their anti-HCV antibody test results. Ten were lost to follow-up (including the subject with no risk factors), three were confirmed HCV-positive (all had had clinical procedures, two had pierced ears and the third had social contact with an HCV-positive person) and three were HCV-negative, indicating either resolved infections or false positive initial antibody results. Transmission to sexual partners and offspring Three-hundred-and-twenty subjects (69%) had current sexual partners. Of 233 partners who had been tested for HCV, 83 (36%) were positive, 138 negative and 12 had unknown results. Of the positive partners, 80 (96%) were partners of IDUs, with independent parenteral exposures determined for 54 (68%) and unknown for the rest. Of the negative partners, 70 (51%) practised "unsafe" sex (defined as unprotected oral, anal or vaginal sex) with study subjects. Among the 219 women subjects, 173 had had children; 56 had had one child tested for HCV and 35, a second child. Only three children were anti-HCV positive -- two infants expressing maternal anti-HCV antibodies, and a three-year old. Discussion Many studies have investigated HCV transmission in limited patient series or specific groups,4-12 and full identification of exposures has been difficult.1-5,8 Our study was a population-based survey, and we were able to identify potential blood exposures for 99% of respondents. However, the response rate was low (47%), reflecting the difficulties of community-based surveys and, possibly, community sensitivities about bloodborne viruses. In addition, there were small but statistically significant age and sex differences between respondents and non-respondents, with a higher proportion of women among respondents and most older subjects responding. However, none of the 19 subjects aged over 60 years were IDUs. We suggest that non-IDUs would be more likely to respond than IDUs, and that a higher response rate in non-IDUs accounted for the age difference between respondents and non-respondents. Questionnaire comprehension was not thought to be a problem as the north coast population is predominantly English-speaking (96%).24 The high proportion of subjects declaring use of illicit drugs in the 60 years and under age group (89%) implies they were reporting truthfully. Therefore, we postulate that the respondents were representative of those infected with HCV in this community. If more respondents had denied injecting drugs, selection bias due to non-response of IDU subjects might have been a legitimate concern. Our results suggest that, on the NSW north coast, injecting drug use with sharing of injection equipment accounted for transmission in 76% of all people with hepatitis C. Transmission during injecting drug use remained possible in a further 9% who denied sharing injection equipment, as unrecognised contamination of such equipment (e.g., spoons, filters, water or swabs), poor recall or denial of sharing may have occurred. Apart from IDU, other high- or medium-risk blood exposures appeared to be responsible for a further 10% of respondents, and all but one of the remaining 5% had low-risk or potential blood exposures, with 1% of these also having sexual contact. While rates of IDU (past or current) may be relatively high on the NSW north coast, we suggest that almost all HCV transmission is via blood exposure, with varying proportions of different types of blood exposure in different populations. Thus, there appeared to be minimal HCV transmission via sexual, perinatal, household, occupational or social contact, provided blood exposures were avoided. Supplemental testing identified some false positives among the few subjects without obvious blood exposures. While a third of subjects had had sexual contact with HCV-positive partners, all of these had additional blood exposures (high risk for 95%, medium risk for 2% and low risk for 3%). Our results should help allay community concern about HCV transmission via casual contact. Sexual transmission appears to be minimal, but the risk may increase with menstruation, anal sex, concurrent STDs that involve scratching, sores or blisters, and increasing viraemia (often observed in early, acute stages of HCV infection). Uninfected partners should also avoid oro-facial abrasions of infected sexual partners (e.g., from toothbrushing or razor cuts). People with hepatitis C who are contemplating having children would be advised to seek medical advice regarding their HCV-RNA PCR status, hepatic enzyme function, and clinical symptoms as markers of viral activity. The low frequency of unexplained transmission in this study (< 1%) was almost entirely attributable to the high rate of reporting of injecting drug use. Other studies have found much lower rates of injecting drug use in HCV-positive subjects, but have been unable to explain transmission in a much higher proportion (27%-45%),1,3-5 possibly because of reluctance to admit illicit drug use. In our study, the privacy afforded by the self-administered questionnaire may have encouraged more truthful reporting than may occur in an interview or clinic situation. Many IDUs were former users, suggesting not only reluctance of current IDUs to participate, but also that much HCV infection is due to past drug use. Current IDUs shared injection equipment significantly less often than former IDUs, indicating increased awareness of the dangers and the effectiveness of needle and syringe exchange programs. However, sharing of injection equipment remains the commonest route of transmission of HCV, responsible for an estimated 10 000 new infections each year in Australia.25 The proportion of cases due to IDU will increase with blood product screening. This emphasises the need for transmission prevention and harm-minimisation programs, especially targeting adolescents before any experimental drug-taking. Community development and peer education of IDUs to promote safer injecting practices should be strengthened.26 The impacts of improved access to needle and syringe exchange and methadone programs, campaigns to encourage non-injecting routes of drug administration, development of non-reusable syringes,25 supply of heroin to registered users27 and provision of "safe-house" injecting venues on HCV transmission all need to be investigated. Acknowledgements Kieran Mutimer and staff at the Lismore Sexual Health and AIDS Service assisted with piloting and circulating questionnaires. References Alter MJ, Hadler SC, Judson FN, et al. Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 1990; 264: 2231-2235. Mistry SA. Hepatitis C notifications in the Australian Capital Territory, January to June 1993. Comm Dis Intell 1995; 19: 183-188. Curran M. Acute hepatitis C notifications and associated risk factors in Australia, 1995 first quarter report. Comm Dis Intell 1995; 19: 615-617. Strasser SI, Watson KJR, Lee CS, et al. Risk factors and predictors of outcome in an Australian cohort with hepatitis C virus infection. Med J Aust 1995; 162: 355-358. Weinstock HS, Bolan B, Reingold AL, Polish LB. Hepatitis C virus infection among patients attending a clinic for sexually transmitted diseases. JAMA 1993; 269: 392-394. Tor J, Llibre JM, Carbonell M, et al. Sexual transmission of hepatitis C virus and its relation with hepatitis B and HIV. BMJ 1990; 301: 1130-1133. Crofts N, Hopper JL, Bowden DS, et al. Hepatitis C virus infection among a cohort of Victorian injecting drug users. Med J Aust 1993; 159: 237-241. Meisel H, Reip A, Faltus B, et al. Transmission of hepatitis C virus to children and husbands by women infected with contaminated anti-D immunoglobulin. Lancet 1995; 345: 1209-1211. Bresters D, Mauser-Brunschoten EP, Reesink HW, et al. Sexual transmission of hepatitis C virus. Lancet 1993; 342: 210-211. Kaldor JM, Archer GT, Buring ML, et al. Risk factors for hepatitis C virus infection in blood donors: a case-control study. Med J Aust 1992; 157: 227-230. Fairley CK, Leslie DE, Nicholson S, Gust ID. Epidemiology and hepatitis C in Victoria. Med J Aust 1990; 153: 271-273. Anand CM, Fonseca K, Walle RP, et al. Antibody to hepatitis C virus in selected groups of a Canadian urban population. Int J Epidemiol 1992; 21: 142-145. van der Poel CL, Cuypers HT, Reesink HW. Hepatitis C virus six years on. Lancet 1994; 344: 1475-1479. Davis AR. Contaminated razor blades as a possible source of hepatitis C virus infection [letter]. Med J Aust 1995; 163: 275. Chant K, Kociuba K, Munro R, et al. Investigation of possible patient-to-patient transmission of hepatitis C in a hospital. NSW Public Health Bull 1994; 5: 47-51. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334: 555-560. Zanetti AR, Tanzi E, Paccagnini S, et al. Mother-to-infant transmission of hepatitis C virus. Lancet 1995; 345: 289-291. Grayson ML, Braniff KM, Bowden DS, Turnidge JD. Breastfeeding and the risk of vertical transmission of hepatitis C virus [letter]. Med J Aust 1995; 163: 107. Davis AR, Kowalik AM. Hepatitis C virus transmission to heterosexual partner: bedroom or bathroom hazard? [letter] Med J Aust 1996; 164: 126. Strasser SI. Hepatitis C: questions still to be answered [editorial]. Med J Aust 1996; 164: 132-133. Sladden TJ, Hickey AR, Beard JR. Hepatitis C on the North Coast of NSW [letter]. Med J Aust 1995; 162: 166. Longbottom H, Evans D, Myint H, Hargreaves J. Annual Report of the National Notifiable Diseases Surveillance System. Comm Dis Intell 1994; 18: 521, 533. National Health and Medical Research Council Hepatitis C Working Party. Draft report on a strategy for the detection and management of hepatitis C virus in Australia. Canberra: NHMRC, 1996. Census Applications. Socio-economic profile of the north coast of New South Wales. Lismore: North Coast Regional Co-ordination Pilot Program, NSW Premier's Department, 1996. Wodak A, Crofts N. HIV revisited: preventing the spread of blood-borne viruses among injecting drug users. Aust J Public Health 1994; 18: 239-240. Feachem RGA. Valuing the past. . .investing in the future. Evaluation of the National HIV/AIDS Strategy 1993-94 to 1995-96. Canberra: Commonwealth Department of Human Services and Health, 1995 (ISBN 0644356944). Bammer G, editor. Feasibility research into the controlled availability of opioids. Canberra: NCEPH/AIC, 1991 (ISBN 0731512359). (Received 8 Feb, accepted 20 Nov, 1996) Authors' details North Coast Public Health Unit, NSW Health Department, Lismore, NSW. Tim J Sladden, MSc, MPH, Epidemiologist; Alan R Hickey, RN, Research Assistant; Therese M Dunn, BAppSc(Comp), Research Assistant; John R Beard, MB BS, FAFPHM, Director. Reprints: Mr T J Sladden, North Coast Public Health Unit, NSW Health Department, PO Box 498, Lismore, NSW 2480. E-mail: tslad AT doh.health.nsw.gov.au - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Tim J Sladden · Alan R Hickey · Therese M Dunn · John R Beard

Reported use of asthma management plans in South Australia Justin J Beilby, Melanie A Wakefield and Richard E Ruffin MJA 1997; 166: 298 For comment see Jenkins & Bauman 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 - Asthma management plans - Good management - Discussion - References - Authors' details - - ©MJA1997 Abstract Objective: To examine the use of asthma management plans (AMPs) and specific elements of AMPs in a South Australian community. Design: Cross-sectional questionnaire survey by experienced interviewers. Participants and Setting: 307 adults with current asthma, confirmed by a doctor, who were among 3001 respondents of a representative sample of 4065 South Australian adults recruited by multistage systematic clustered area sampling for a larger study in March 1995. Main Outcome Measures: Prevalence of reported use of AMPs and of specific elements of AMPs, such as knowledge of trigger factors and having an action plan, and the proportion of adults with asthma receiving what we defined as "good management". Results: 46% reported having an AMP; 63% had discussed trigger factors with their doctors and 39.5% had action plans. 82% had been told the severity of their asthma, and 23.3% were receiving good management. Conclusion: Less than half of people with asthma use AMPs, although certain elements within the AMPs are reportedly being used more frequently. More research is required on why AMPs are not more generally used and, more importantly, on what elements within the AMP model are useful and effective for people with asthma and likely to be used by their general practitioners (GPs). MJA 1997; 166: 298-301 Introduction Asthma causes substantial morbidity1 and mortality,2 and costs -- in the range of $585-$720 million in Australia in 1991.3 Approximately 9% of Australians (over 1.4 million people) have reported asthma as "either a recent or long term condition in the last 12 months".4 There is evidence that the prevalence of the disease is increasing,5 and that it is both undertreated and underdiagnosed.6 The variability of the condition in both adults and children further complicates these concerns. In an attempt to create a unified approach to the management of asthma, a group of "accepted experts" developed the Asthma Management Plan (AMP), a set of consensus guidelines for health professionals.7 The Australian AMP comprises six steps: Assessing the severity of asthma; Achieving best lung function; Maintaining best lung function by identifying and avoiding triggers; Maintaining best lung function with optimal medication; Developing an action plan; and Educating the patient and reviewing regularly. These steps are aimed at doctors as an aid to achieving good asthma management. Hence, any reported use of elements of the AMP will, in part, be dependent on the use of these steps by doctors as well as on patient factors. In this study we examine the current use of AMPs and determine the specific elements of the plan that have been adopted by people with asthma and their doctors. Such information is important in planning ongoing asthma management campaigns. Methods In March 1995, a representative population sample of adults in South Australia was obtained for the Health Omnibus Survey,8 as follows. A multistage systematic clustered area sample of households was used to give a sample comprising 75% selected from the Adelaide metropolitan area and the rem ainder from country centres with populations of 1000 or more. At each household, one person aged 15 years or over (the person whose birthday was last) was selected for interview. Interviews were conducted in the respondent's home by trained interviewers, with up to six call-back visits if the selected respondent was not at home. For the purposes of our study, we included a number of questions in the Health Omnibus Survey. Respondents were asked whether they had asthma, and if they answered "yes" they were then asked to respond to the questions listed in Box 1. For the purposes of the interviews, we defined: Asthma management plans as "a coordinated method of management that covers aspects of your asthma -- medication, trigger factors, lung function measurement, etc."; Trigger factors as "incidents that can cause you to have an asthma attack"; and An asthma action plan as "written or verbal instructions of what to do if your asthma is out of control, i.e., having a bad attack". We initially examined questionnaire responses against sociodemographic variables, including age, sex, place of birth, educational attainment, and household income. Conventional chi-squared tests were used for comparisons at the univariate level, and unconditional logistic re gression analysis to adjust for potential confounders. In further analyses, we adjusted for confounding and/or interaction between variables such as place of residence, severity, age, sex and whether respondents had been told about their level of asthma severity. Separate logistic regression analyses were run for the subgroup who had been told about their asthma severity to determine the independent contribution of severity level on the dependent variable of interest. Similarly, the responses of those who had a regular doctor were analysed separately to determine differences between sources of care. Finally, we considered that patients who reported having an AMP, being told about trigger factors and having an action plan were receiving "good management", and examined factors related to good management. We excluded the optimisation of pharmacological intervention from our definition. SPSS was used for all statistical analyses.9 Results 3001 of a possible 4065 people responded (response rate, 73.8%). Of these 3001 respondents, 558 (18.6%) indicated that they had ever had asthma, and 521 (93.4%) of these had had their asthma confirmed by a doctor. Of these 521, 307 (58.9%) indicated that they still had asthma, representing 10.2% of the total sample and comprising 120 men and 186 women (one respondent did not indicate sex), with a mean age of 39.4 years (SD, 18.3; range, 15-84 years). Box 2 (below) shows that current medically confirmed asthma was more common among women than men, and declined in prevalence with increasing age. It was also more common among rural than metropolitan respondents, and among Australian-born respondents than those born elsewhere; this difference remained significant after adjusting for age and sex in logistic regression analyses. There was no relationship between current confirmed asthma prevalence and post-secondary education or annual gross household income, even after adjusting for age and sex. Asthma management plans Box 3 (above) summarises our findings on asthma management among respondents with currently confirmed asthma. Further analyses showed that having an AMP was not related to age, sex, area of residence, or whether people had been told their level of severity. However, those who had a regular doctor were more likely to have an AMP (P = 0.03). Those who saw both a general practitioner (GP) and specialist were significantly more likely to have an AMP (81.7%) than those who saw a GP only (47.6%), specialist only (41.1%) or no one (22.6%; P = 0.02). Among respondents who had been told their level of severity, those with moderate or severe asthma were more likely to report having an AMP than those with mild asthma (P < 0.01), after adjustment for other covariates. Women were more likely than men to have been told about their asthma severity (86.3% v. 75.0%; chi-squared = 6.1; P = 0.01), and those who had been told tended to be younger than those who had not (t = 3.1; P = 0.07). Among those who had been told, reported level of severity increased with advancing age (t = 5.3; P < 0.01). Severity did not vary by sex, but was greater among rural respondents than metropolitan respondents (chi-squared = 8.6; P = 0.01). The reported prevalence of discussing trigger factors and having an action plan increased with increasing asthma severity (see Box 4). It is notable that only 14 (25.4%) of those who had not been told their asthma severity had an action plan. Men were more likely than women to have no regular doctor for asthma care (22.7% v. 12.4%; chi-squared = 5.7; P = 0.02); there was no difference by age. Overall, those who had discussed trigger factors did not differ by sex, area of residence or whether they had been told their level of severity. After adjustment for covariates, discussion of trigger factors was more likely among younger respondents (P < 0.05) and those who had a regular doctor (P < 0.01). Among those who had been told their level of severity, logistic regression analysis showed that those with severe asthma were more likely than those with moderate or mild asthma to have discussed trigger factors (P < 0.05). Of those with a regular doctor, source of care was unrelated to discussion of trigger factors. Respondents who reported having an action plan did not vary by age, area of residence or whether they had been told their level of severity. Action plans were more common among women (P < 0.05) and those who had a regular doctor (P < 0.05), and among those who had been told they had moderate or severe asthma than mild asthma (P < 0.01). For respondents with a regular doctor, source of care was unrelated to having an action plan. Good management Seventy-one respondents with currently confirmed asthma (23.3%) were receiving "good management". Good management was unrelated to age, sex, area of residence or whether respondents had been told their level of severity, but was more likely among those who had a regular doctor (P < 0.05). Among those who had been told their level of severity, those with moderate or severe asthma were more likely to be receiving good management than those with mild asthma (P < 0.001). Of those with a regular doctor, source of care was unrelated to receiving good management. Discussion Given that the AMP model was initiated in 1989, our finding of a prevalence of reported use of AMPs of 46%, with much higher prevalences for certain elements of AMPs, is reassuring. It is noteworthy that we found AMPs to be more common among people who had been told their asthma was severe and those with a regular doctor. Our finding that 39.5% of respondents had an action plan is a somewhat higher result than those of previous reports,10,11 possibly indicating an increase in their use. As we found that reported use of action plans did not vary by age, the different age profile of our study compared with that of Comino and colleagues10 (mean, 39.4 years; range, 15-84 years v. mean, 37.4 years; range, 18-50 years) is unlikely to have contributed to the apparent doubling in prevalence of action plan use that we observed. However, unlike the other study, we included verbal as well as written action plans, and this may have been responsible for the difference. Our study was based on self-report, and responses were not validated. However, our method of assessing self-reported asthma has been used in a previous validated epidemiological study.12 There may have been under-reporting in the responses to the questions, even though we used trained interviewers. However, despite these methodological problems, the key measure of the acceptability of the AMP and its elements is their reported use in the community. We are aware that the term "asthma management plan" may have introduced some problems in that our def inition of the AMP encompassed as - sessment of severity, trigger-factor discussions and the development of an action plan. Hence, it is possible that people who reported using an AMP may have been including the other three elements. However, as a main objective was to compare the uptake of the "complete" AMP with that of its individual elements, we believed it was important to include all these questions in the survey. We found that certain elements of the AMP are being adopted more frequently than others, which may indicate that patients find these steps more appropriate to their specific needs, or that doctors (GPs and specialists) find certain elements of the AMP easier to use or implement. GPs are the principal providers of asthma care in the community and it is probable that they have a considerable effect on the uptake of the AMP model. Developing a "complete" management plan may be too onerous a task for a busy GP. Conversely, GPs may find the AMP model does not satisfy their individual needs and, as a consequence, choose specific elements from the AMP model for their everyday practice.13 Over 80% of our respondents, most of whom had mild to moderate asthma, saw a GP for all or part of their asthma care. As there is evidence that GPs' management of asthma is very variable,14,15 it is important to concentrate on providing useful and focused education for GPs. Urgent clarification is needed of the key steps within the AMP model that will reduce mortality and morbidity in people with asthma and improve their quality of life. Interestingly, we found that only 41% of the respondents attending a specialist only had an AMP. As specialists spend more time with their patients and deal with people with more severe asthma, this finding requires further investigation. It has been suggested that some steps of the AMP may be inappropriate for general application. For example, peak flow meters are supposed to be used in both steps 2 and 3, but Ruffin and Pierce have proposed that aiming to have all asthmatic patients record peak expiratory flow over the long term may not be worthwhile,16 and that focusing on, for example, those at risk of dying, those in uncertain clinical situations (e.g., those with exercise-induced asthma) and those who are "particularly interested" in monitoring their asthma would be more cost effective. They emphasised the need for a more rigorous scientific approach to examining "the basis for and benefit of" peak expiratory flow.16 In a more recent paper Gibson et al. state that "action plans have received little controlled evaluation".17 Among 35 adult asthma patients, they found that the current increase in medication recommended in the AMP action plan had a high failure rate. On the other hand, there is evidence that regular review (step 6 of the AMP) can reduce days lost from work or school18 and home visits by GPs,19 and that patient education (step 5) improves symptom control20 and reduces visits to accident and emergency departments.21 The guidelines in the AMP model have come to be accepted as the "gold standard" of asthma management in most countries.22,23 However, what is needed now is a careful re-evaluation 24 to ensure that "unsound practice" does not become formalised.25 A new perspective may be required that embraces the variability in management and clinical encounters.26 Not surprisingly, we found that having a regular doctor is the main determinant of "good management" -- regular review is likely to allow time for the introduction of more steps in the AMP. The challenge in continuing to evaluate an introduced management program in clinical practice is substantial. If over half the population of asthmatic patients have already been exposed to the asthma management plan in part or in full, how can this be done? Small intensive clinical trials with objective outcomes such as peak flow measurements, or case-control studies comparing asthmatic patients with and without good quality of life, could be performed, but would have the disadvantage of not being generalisable to the population at large. Large population studies with specific outcome measures would rely on the outcome measures being validated against accepted criteria of asthma control. A national project that used specific health outcomes, such as prescriptions of reliever or preventer agents, and monitored hospital admissions for asthma could be used to evaluate interventions introduced on a State or regional basis. To coordinate and cooperate in such a project would present a challenge to organisations involved in asthma management. There is current interest in coordinated care programs for chronic diseases and the time is right to introduce an evaluation strategy for different interventions in asthma. References Campbell D, Ruffin R, McEvoy RD, Crockett AJ. South Australian asthma symptoms prevalence survey [abstract]. Paper presented at the Annual Scientific Meeting of The Thoracic Society of Australia and New Zealand. 1991 7-11 Apr; Lorne, Vic. Aust N Z J Med 1991; 21: 658. Jenkins WA, Hurley SF, et al. Trends in Australian mortality of asthma 1979-1985. Med J Aust 1988; 149: 620-624. National Asthma Campaign. Report on the cost of asthma in Australia 1994. Melbourne: National Asthma Campaign, 1994. National Health Survey 1989/90. Canberra: Australian Bureau of Statistics, 1991. Robertson CF, Heycock E, Bishop J, et al. Prevalence of asthma in Melbourne school children: change over 26 years. BMJ 1991; 302: 1116-1118. Bauman A, Young L, Peat J, et al. Asthma under-recognition and under-treatment in an Australian Community. Aust N Z J Med 1992; 22: 36-40. Woolcock A, Rubinfield A, Seale P, et al. Asthma management plan, 1989. Med J Aust 1989; 151: 650-652. Wilson D, Wakefield M, Taylor A. The South Australian Health Omnibus Survey. Health Promotion J Aust 1992; 2: 47-49. Nornsis MJ. SPSS for Windows. Advanced statistics release 6.0. Chicago: SPSS Inc, 1993. Comino E, Mitchell C, Bauman A, et al. Asthma management in eastern Australia, 1990 and 1993. Med J Aust 1996; 164: 403-406. Tse M, Bridges-Webb C, Bauman A. The impact of a mass communication campaign on the reported management of asthma by general practitioners. Fam Pract 1993; 10: 263-267. Abramson M, Kutin J, Bowes G. The prevalence of asthma in Victorian adults. Aust N Z J Med 1992; 22: 358-363. Armstrong D, Fry J, Armstrong P. General practitioners' views of clinical guidelines for the management of asthma. Int J Qual Health Care 1994; 6: 199-202. Bauman A, McKenzie D, Young L, Yoon R. Asthma education: the perception of family physicians. J Asthma 1990; 27: 385-392. Coates J, Steven I, Beilby J, et al. Knowledge and reported asthma management among South Australian General Practitioners. Br J Gen Pract 1994; 44: 123-126. Ruffin R, Pierce R. Peak flow monitoring -- which asthmatics, when and how? Aust N Z J Med 1994; 24: 519-520. Gibson P, Wlodarczyk J, Hensley M, et al. Using quality-control analysis of peak expiratory flow recordings to guide therapy for asthma. Ann Intern Med 1995; 123: 488-492. Charlton I, Charlton G, Broomfield J, Rullee M. Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in general practice. Br J Gen Pract 1991; 41: 227-231. Charlton I, Charlton G, Broomfield J, Campbell M. An evaluation of a nurse-run asthma-clinic in general practice using an attitudes and morbidity questionnaire. Fam Pract 1992; 9: 154-160. Wilson S, German D, Sulochina L, et al. A controlled trial of two forms of self-management education for adults with asthma. Am J Med 1993; 94: 564-576. Bolton M, Tilley B, Kuder J, et al. The cost and effectiveness of an education program for adults who have asthma. J Gen Intern Med 1991; 6: 401-407. Guidelines for the diagnosis and management of asthma. Bethesda, Md.: United States Department of Health and Human Services, August 1991. (Publication No. 91-3042.) International consensus report on diagnosis and managment of Asthma. Bethesda, Md.: United States Department of Health and Human Services. June 1992. (Publication No. 92-3091.) Thompson P, Lavender M, Madhok R. How to ensure that guidelines are effective. BMJ 1995; 311: 237-242. Delamothe T. Wanted: guidelines that doctors will follow. Implementation is the problem. BMJ 1993; 307: 218. Parmley W. Clinical practice guidelines. Does the cookbook have enough recipes? JAMA 1994; 272: 1374-1375. (Received 17 Apr, accepted 11 Nov, 1996) Authors' details Research & Health Promotion Unit, Royal Australian College of General Practitioners, Adelaide, SA. Justin J Beilby, MPH, FRACGP, Director. Behavioural Epidemiology Unit, South Australian Health Commission, Adelaide, SA. Melanie A Wakefield, MA, PhD, Senior Behavioural Scientist. Department of Thoracic Medicine, The Queen Elizabeth Hospital, Adelaide, SA. Richard E Ruffin, MD, FRACP, Director. No reprints will be available. Correspondence: Dr J J Beilby, Department of General Practice, University of Adelaide, Adelaide, SA 5005. - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Justin J Beilby · Melanie A Wakefield · Richard E Ruffin