Tuberculosis, focussed tools and the right schools: estimated impact and cost of a targeted student screening programme for tuberculosis infection.

BACKGROUND: The World Health Organization (WHO) recommends targeted screening for latent tuberculosis infection (LTBI) among high-risk populations. Recent studies that evaluate targeted school-based programmes in low burden settings are scarce. AIMS: To evaluate a school screening programme for recently arrived migrant students from moderate and high tuberculosis (TB) burden countries and estimate (1) the number of cases of active TB that were prevented and (2) the cost per case of active TB prevented. METHODS: Students were screened with tuberculin skin tests (TST) at schools with a high migrant population intake. Those with positive results were referred for specialist evaluation. Outcomes were retrospectively assessed using 5 years of prospectively collected data. Cost data were collected. Main outcomes measured were the number of children were diagnosed with LTBI who completed treatment, and programme costs. RESULTS: Of 4728 student screened, 295 (6.2%) were diagnosed with LTBI. Of these, 273 (92.5%) were offered preventive therapy, 242 (82.0%) commenced and 204 (69.2%) completed therapy. The number needed to screen (NNS) was 23 per completed course of preventive treatment for LTBI. Assuming a 10% lifetime risk of reactivation, the NNS was 386 per case of TB disease notification avoided. The cost of screening was A$23 932 per case of TB disease avoided. CONCLUSIONS: This TB strategy is supported by the high rate of TB infection in the student group, the treatment uptake and completion rates. Cost-benefit is linked with lifetime risk of TB reactivation. Targeted school screening programmes represent an important opportunity for TB control in low-burden settings.

Tuberculosis mortality: quantifying agreement in clinical cause of death assessments.

OBJECTIVES: Mortality is a key statistic for public health globally, and mortality reduction is a key target of 'End TB' strategy. However, cause of death in relation to tuberculosis (TB) may be controversial, and we aimed to evaluate classification in Australia. METHODS: We surveyed Australian clinicians and public health officers, presenting a variety of scenarios. Respondents were asked to classify each scenario with regards to whether TB was considered causative, contributory or not related to death. RESULTS: Fifty-nine individuals completed the survey. Respondents were experienced TB clinicians and public health officers (median 14 years of TB care experience), with a majority having recently been involved in death certification/classification. In most scenarios, there was substantial variation, particularly where death was related to TB medications, or if an alternative contributing process was recognised, such as cardiovascular complications. Variation in classification was not evidently associated with classification experience. CONCLUSION: We found significant variation in cause of death classification among experienced TB clinicians and public health officers, using representative TB death scenarios. IMPLICATIONS FOR PUBLIC HEALTH: Consensus and transparency with regards to classification would assist in more uniform cause of death classification across jurisdictions and allow for better tracking of this critical performance measure.

Use of Infliximab to Treat Paradoxical Tuberculous Meningitis Reactions.

We documented dramatic responses to infliximab in 4 tuberculous meningitis cases with severe paradoxical reactions after effective antibacterial treatment, despite high-dose steroids. In every instance, infliximab was used as a last resort after all other options were exhausted, resulting in delayed initiation that may have adversely affected patient outcomes.

Tuberculosis notifications in Australia, 2014.

In 2014, the National Notifiable Diseases Surveillance System received 1,339 tuberculosis (TB) notifications, representing a rate of 5.7 per 100,000 population. Australia has achieved and maintained good tuberculosis (TB) control since the mid-1980s, sustaining a low annual TB incidence rate of approximately 5 to 6 cases per 100,000 population. The number of multi-drug resistant TB (MDR-TB) cases diagnosed in Australia is low by international standards, with approximately 1-2% of notifications per year being classified as MDR-TB. Australia's overseas-born population continued to represent the majority (86%) of TB notifications and Australia's Aboriginal and Torres Strait Islander population continue to record TB rates around 6 times higher than the Australian born non Indigenous population. Whilst Australia has achieved excellent and sustained control of TB in Australia, sustained effort is still required to reduce rates further and contribute to the achievement of the World Health Organization's goal to end the global TB epidemic by 2035.

Tuberculosis notifications in Australia, 2012 and 2013.

The National Notifiable Diseases Surveillance System received 1,317 tuberculosis (TB) notifications in 2012 and 1,263 notifications in 2013. This represents a rate of 5.8 per 100,000 population in 2012 and 5.5 per 100,000 population in 2013 and a reversal of the upward trend in TB incidence reported since 2007. In 2012 and 2013, Australia's overseas-born population continued to represent the majority of TB notifications with an incidence rate of 19.5 per 100,000 and 18.4 per 100,000 respectively. The incidence of TB in the Australian-born Indigenous population has fluctuated over the last decade; however, it remained reasonably steady in 2012 and 2013 with an incidence rate of 4.5 per 100,000 and 4.6 per 100,000 respectively. The incidence of TB in the Australian-born non-Indigenous population has continued to remain low at 0.7 per 100,000 in 2012 and 0.8 per 100,000 in 2013. Australia continued to record only a small number of multi-drug resistant TB cases nationally (2012: n=20; 2013: n=22) of which nearly all were identified in the overseas-born population. This report demonstrates excellent and sustained control of TB in Australia and reflects Australia's commitment to reducing the global burden of TB.

Tuberculosis notifications in Australia, 2010.

The National Notifiable Diseases Surveillance System received 1,353 tuberculosis (TB) notifications in 2010, representing a rate of 6.1 cases per 100,000 population. While rates of 5 to 6 cases per 100,000 population for TB have been maintained in Australia, since first achieved in the mid-1980s, there has been a steady increase in incidence over the past decade. The incidence in the Australian-born Indigenous population was 7.5 per 100,000 population, which is 11 times the incidence reported in the Australian-born non-Indigenous population of 0.7 per 100,000 population. Overseas-born people accounted for 90% of all cases notified in 2010 and represented a rate of 24 per 100,000 population. International students have been recognised as an increasingly important group, representing 25% of all overseas-born cases notified in 2010, and are a focus of this report. Household or other close contact with TB or past residence in a high risk country were the most commonly reported risk factors for TB infection. Outcome data for the 2009 TB cohort indicate that treatment success was attained in more than 95% of cases. As Australia continues to contribute to global TB control it is important to maintain good centralised national reporting of TB to identify populations at risk and monitor trends in TB.

Tuberculosis notifications in Australia, 2011.

The National Notifiable Diseases Surveillance System received 1,385 tuberculosis (TB) notifications in 2011, representing a rate of 6.2 cases per 100,000 population. While Australia has maintained a rate of 5 to 6 cases per 100,000 for TB since the mid-1980s, there has been a steady increase in incidence over the past decade. In 2011, Australia's overseas-born population continued to represent the majority of TB notifications (88%) with a notification rate of 20.2 per 100,000. The incidence of TB in the Australian-born Indigenous population has fluctuated over the last decade and showed no clear trend; however, in 2011 the notification rate was 4.9 per 100,000, which is a notable decrease from the 7.5 per 100,000 recorded in 2010. The incidence of TB in the Australian-born non-Indigenous population has continued to remain low at 0.9 per 100,000. Australia continued to record only a small number of multi-drug-resistant TB (MDR-TB) cases nationally (n=25), all of which were identified in the overseas-born population. To ensure that Australia can retain its low TB rate and work toward reducing rates further, it is essential that Australia maintains good centralised national TB reporting to monitor trends and identify at-risk populations, and continues to contribute to global TB control initiatives.

Tuberculosis notifications in Australia, 2008 and 2009.

The National Notifiable Diseases Surveillance System received 1,194 tuberculosis (TB) notifications in 2008 and 1,322 notifications in 2009. The incidence of TB in Australia was 5.6 cases per 100,000 population in 2008 and 6.0 per 100,000 in 2009, similar to rates since 1986. In both 2008 and 2009, more than 85% of cases occurred in the overseas-born population. The incidence in the Australian-born Indigenous population was 6.2 per 100,000 population in 2008 and 4.8 per 100,000 in 2009. By contrast, the incidence of TB in the Australian-born non-Indigenous population was 0.9 per 100,000 in both 2008 and 2009. Household or other close contact with TB or past residence in a high risk country were the most commonly reported risk factors for TB infection. In 2008, 83 cases of TB were reported in health care workers; this decreased to 75 in 2009. There were no reports of TB transmission in Australian health care settings. Outcome data of the 2007 and 2008 TB cohort indicate that treatment success was attained in more than 95% of cases. As Australia continues to contribute to global TB control it is important to maintain good centralised reporting of TB to identify populations at risk and for early detection of reversal in trends in TB.

Investigation of spa pools associated with lung disorders caused by Mycobacterium avium complex in immunocompetent adults.

Three cases of Mycobacterium avium complex-related lung disorders were associated with two poorly maintained spa pools by genotypic investigations. Inadequate disinfection of the two spas had reduced the load of environmental bacteria to less than 1 CFU/ml but allowed levels of M. avium complex of 4.3 x 10(4) and 4.5 x 10(3) CFU/ml. Persistence of the disease-associated genotype was demonstrated in one spa pool for over 5 months until repeated treatments with greater than 10 mg of chlorine per liter for 1-h intervals eliminated M. avium complex from the spa pool. A fourth case of Mycobacterium avium complex-related lung disease was associated epidemiologically but not genotypically with another spa pool that had had no maintenance undertaken. This spa pool contained low numbers of mycobacteria by smear and was culture positive for M. avium complex, and the nonmycobacterial organism count was 5.2 x 10(6) CFU/ml. Public awareness about the proper maintenance of private (residential) spa pools must be promoted by health departments in partnership with spa pool retailers.