Evaluation of the 2016-2020 regional tuberculosis response framework, WHO Western Pacific Region.

OBJECTIVE: To assess the implementation of the Regional framework for action on implementation of the End TB Strategy in the Western Pacific, 2016-2020 in countries and areas in the World Health Organization Western Pacific Region. METHODS: We used a mixed methods approach to assess the framework's measurable and perceived impact. We conducted an analysis of national tuberculosis strategic plans, a cross-sectional survey of senior staff of tuberculosis programmes, key informant interviews and some country case studies. FINDINGS: Of the 37 countries and areas of the Western Pacific Region, 14 had a national tuberculosis strategic plan, including all countries and areas with a high incidence of tuberculosis. Most senior tuberculosis programme staff who responded to the survey (16/23) found the regional framework useful when developing their national targets and grant applications. Programmatic challenges identified included financing, human resources, public-private mix, active case finding, and paediatric and drug-resistant tuberculosis. Most of the 17 key informants thought that the regional framework's categorization of actions (for all settings, for specific settings and for pre-elimination settings) was useful, but that the added value of the regional framework over other relevant documents was not obvious because of overlap in content. CONCLUSION: The regional framework influenced national level tuberculosis control planning and implementation in a positive way. A future regional framework should provide a longer-term strategic horizon and specifically address emerging trends and persistent problems faced by countries or areas of the region.

Epidemiology of tuberculosis in the Western Pacific Region: Progress towards the 2020 milestones of the End TB Strategy.

Since 2015, the End TB Strategy and the Regional Framework for Action on Implementation of the End TB Strategy in the Western Pacific 2016-2020 have guided national tuberculosis (TB) responses in countries and areas of the Region. This paper provides an overview of the TB epidemiological situation in the Western Pacific Region and of progress towards the 2020 milestones of the Strategy. A descriptive analysis was conducted of TB surveillance and programme data reported to WHO and estimates of the TB burden generated by WHO for the period 2000-2018. An estimated 1.8 million people developed TB and 90 000 people died from it in the Region in 2018. Since 2015, the estimated TB incidence rate and the estimated number of TB deaths in the Region decreased by 3% and 10%, with annual reduction rates of 1.0% and 3.4%, respectively. With current efforts, the Region is unlikely to achieve the 2020 milestones and other targets of the Strategy. Major challenges include: (1) wide variation in the geographical distribution and rate of TB incidence among countries; (2) a substantial proportion (23%) of TB cases that remain unreached, undiagnosed or unreported; (3) insufficient coverage of drug susceptibility testing (51%) for bacteriologically confirmed cases and limited use of WHO-recommended rapid diagnostics (11 countries reported < 60% coverage); (4) suboptimal treatment outcomes of TB (60% of countries reported < 85% success), of TB/HIV co-infection (79%) and of multidrug- or rifampicin-resistant TB (59%); (5) limited coverage of TB preventive treatment among people living with HIV (39%) and child contacts (12%); and (6) substantial proportions (35-70%) of TB-affected families facing catastrophic costs. For the Region to stay on track to achieve the End TB Strategy targets, an accelerated multisectoral response to TB is required in every country.

Post-migration follow-up programme for migrants at increased risk of developing tuberculosis: a cohort study.

Following pre-migration screening for tuberculosis (TB), migrants who are deemed to be at a high risk of developing TB must attend post-entry follow-up in Australia. We aimed to evaluate the effectiveness of post-migration TB follow-up in the state of New South Wales to diagnose TB in these high-risk migrants. In this retrospective cohort study, we assessed the risk of TB in migrants who arrived in New South Wales between 2000 and 2015 and were referred for post-migration follow-up. Clinical notes were examined for a nested cohort to determine whether TB was diagnosed via the follow-up programme or via passive case finding. Of the 32 550 migrants referred for follow-up, 428 (1.3%) developed TB. The incidence of TB was 436 per 100 000 person-years (95% CI 384-491 per 100 000 person-years) in the first 2 years after arrival and 128 per 100 000 person-years (95% CI 116-140 per 100 000 person-years) over the mean study observation period of 10.3 years. An estimated 63% of cases were diagnosed via follow-up. TB notifications occurred 0.55 years earlier since time of arrival in Australia in migrants who attended follow-up than in those who did not. Post-migration follow-up detected 63% of TB cases in high-risk migrants and potentially prevented delay of TB diagnosis.

EpiReview: tuberculosis in NSW, 2009-2011.

AIM: To describe the epidemiology of tuberculosis in NSW between 2009 and 2011 and compare with previous years. METHODS: Data from all cases of tuberculosis notified in NSW during this period were extracted from the Notifiable Conditions Information Management System. Descriptive analyses of notification data were undertaken. Incidence rates were calculated per 100000 population. RESULTS: Between 2009 and 2011, there were 1548 cases of tuberculosis notified in NSW, translating to an average annual notification rate of 7.2 per 100000 population for this period. A total of 89% (n=1371) of notified cases were overseas-born, and 1.6% (n=24) of cases were recorded as Aboriginal persons. The most common site of infection was the lung (60% of cases). Of notified cases, 68% were reported as having been tested for HIV, of which 3%(n=28) of cases had HIV/tuberculosis co-infection. There were 20 cases of multidrug-resistant tuberculosis, including one case of extensively drug-resistant tuberculosis. CONCLUSION: The notification rate of tuberculosis in NSW has remained relatively stable over the past two decades, though small incremental increases since 2003 are evident. Endemic transmission of tuberculosis within sub-groups of the NSW population, as well as the ongoing high endemnicity for tuberculosis in neighbouring countries, highlight the importance of tuberculosis control as a continued strategic priority for disease control in NSW.

Spectrum of Disease in Children Treated for Tuberculosis at a Tertiary Children's Hospital in Australia.

BACKGROUND: Tuberculosis (TB) notification rates in Australia have plateaued at a low level, but the pediatric disease burden remains poorly described. Child cases provide a marker of recent transmission and present unique diagnostic challenges. METHODS: We performed an audit of all children (<18 years of age) treated for TB at the Children's Hospital at Westmead, Sydney, Australia from January 2008 to December 2011. Demographics, clinical presentation, diagnostics, disease profile, treatment, and outcome were reviewed. RESULTS: A total of 25 children were treated for TB: 15 had microbiologically confirmed TB; 7 were diagnosed on clinical grounds; and in 3, an alternate diagnosis was established (2 bacille Calmette-Guérin disease and 1 atypical mycobacterial infection). Of the 22 TB cases, 21 had a history of immigration or travel to a TB-endemic country and 4 reported recent contact with a TB source case within Australia. Isolated intrathoracic TB was documented in 16 (72%) cases. Symptoms on presentation included the following: lethargy, weakness, or malaise (75%); fever (73%); and cough (64%). Among the 15 children with microbiologically confirmed TB, 11 (73%) were positive by culture and 11 of 13 (85%) by polymerase chain reaction test. Tuberculin skin test was positive (≥10 mm) in 80% (16 of 20) of cases, and interferon-gamma release assay was positive in 87% (13 of 15) of cases. All children received directly observed therapy and recovered. CONCLUSIONS: This series demonstrates the broad spectrum of disease with which pediatric TB cases present and the need for ongoing vigilance. A more comprehensive review of pediatric TB cases throughout Australia would be informative.

EpiReview: notifications of Q fever in NSW, 2001-2010.

UNLABELLED: Q fever is the most frequently notified zoonotic infection in NSW residents. The past decade has seen the introduction of a targeted national Q fever vaccination program. METHODS: We undertook a descriptive analysis of Q fever notifications in NSW, for the period 2001-2010. RESULTS: A total of 1912 cases of Q fever were notified in NSW between 2001 and 2010 (average 2.8 per 100 000 persons per annum). The majority of Q fever cases were reported in men, aged 40-59 years, living in rural NSW and working in agricultural related occupations. CONCLUSION: The results suggest changes in the epidemiology of Q fever in response to the targeted vaccination program.

Who gives pertussis to infants? Source of infection for laboratory confirmed cases less than 12 months of age during an epidemic, Sydney, 2009.

An important approach to protecting infants against pertussis is to provide a booster vaccination to close contacts, however this strategy requires a good understanding of infection sources to be effective. The objective of this study was to identify the most important sources of transmission of pertussis infection to infants, regardless of hospitalisation status. Standardised interviews were conducted during routine follow-up calls with the parent or guardian of laboratory confirmed pertussis cases less than 12 months of age notified to 3 Sydney metropolitan public health units during a pertussis outbreak from January to May 2009. All contacts with a coughing illness or laboratory confirmed pertussis during the 3 weeks prior to onset of illness in the index case, were recorded. A source of infection could not be identified for 29 infants (31%) and a total of 86 known or suspected sources were identified for the other 66 infants. The most frequently identified sources were siblings (36%) and parents (24%), followed by other family members (21%), friends (13%), and settings outside the home such as medical centres (6%). Of 20 siblings aged 3 or 4 years, 16 (80%) were sources of infection, compared with 14 of the 44 (32%) other siblings less than 18 years of age. During this epidemic siblings were more important sources of infant infection than parents. Siblings aged 3 and 4 years of age were particularly important transmitters of pertussis infection to infants. Minimising pertussis infection in 3 and 4 year olds may be an important measure to prevent infant infection.

Why do I need it? I am not at risk! Public perceptions towards the pandemic (H1N1) 2009 vaccine.

BACKGROUND: On the 30th September 2009, the pandemic (H1N1) 2009 influenza vaccine was made available to adults and children aged 10 years and over, in Australia. Acceptance of a novel vaccine is influenced by perceptions of risk including risk of infection, risk of death or severe illness and risk of serious vaccine side-effects. We surveyed a sample of residents from Sydney, Australia to ascertain their risk perception, attitudes towards the pandemic and willingness to accept the pandemic (H1N1) 2009 influenza vaccine. METHODS: We sampled residents using a cross-sectional intercept design during the WHO Phase 6. Members of the public were approached in shopping and pedestrian malls to undertake the survey during September and October 2009. The survey measured perceived risk, seriousness of disease, recent behavioural changes, likely acceptance of the pandemic (H1N1) 2009 vaccine and issues relating to uptake and perceived safety. RESULTS: Of the 627 respondents, the majority felt that they had a "very low to low" (332/627, 52.9%) risk of acquiring H1N1. 24.5% (154/627) of respondents believed that the disease would "very seriously or extremely" affect their health. Nearly half (305/627, 48.6%) reported that in response to the "swine flu" outbreak they had undertaken one or more of the investigated behavioural changes. Overall, the self-reported likelihood of accepting vaccination against novel H1N1 was 54.7% (343/627). CONCLUSIONS: While, most participants did not believe they were at high risk of acquiring pandemic H1N1 2009, over half of the sample indicated that they would accept the vaccine. Participants who were vaccinated against the seasonal influenza were more likely to receive the H1N1 vaccine. Concerns about safety, the possibility of side effects and the vaccine development process need to be addressed.

Pandemic (H1N1) 2009 influenza vaccine roll-out in NSW.

The roll-out of the pandemic (H1N1) 2009 influenza vaccine in NSW was significantly different to that envisaged for a pandemic vaccination program. Pre-pandemic planning had focused on the urgent roll-out of a vaccine through mass vaccination clinics in a time of high demand due to a virulent influenza virus. Instead the situation was less urgent, with the vaccine available only after the peak of incidence of infections in NSW. Consequently mass vaccination clinics were considered to be a less appropriate method of delivering the vaccine than a primary care focused delivery model. This paper describes the program, some of the controversies considered during its roll-out and factors to be considered in planning for future pandemics.

The community's attitude towards swine flu and pandemic influenza.

OBJECTIVE: To ascertain the beliefs, perceived risks and initial attitudes of the Australian community towards the influenza pandemic declared by the World Health Organization in response to the emergence of an A(H1N1) influenza subtype. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional survey of Sydney residents during WHO Phase 5 of pandemic (H1N1) 2009. Members of the public were approached in shopping and pedestrian malls in seven areas of Sydney between 2 May and 29 May 2009 to undertake the survey. The survey was also made available by email. MAIN OUTCOME MEASURES: Perceived personal risk and seriousness of the disease, opinion on the government and health authorities' response, feelings about quarantine and infection control methods, and potential compliance with antiviral prophylaxis. RESULTS: Of 620 respondents, 596 (96%) were aware of pandemic (H1N1) 2009, but 44% (273/620) felt they did not have enough information about the situation. More than a third (38%; 235/620) ranked their risk of catching influenza during a pandemic as low. When asked how they felt pandemic influenza would affect their health if they were infected, only a third (33%; 206/620) said "very seriously". Just over half of the respondents (58%; 360/620) believed the pandemic would be over within a year. Respondents rated quarantine and vaccination with a pandemic vaccine as more effective than hand hygiene for the prevention of pandemic influenza. CONCLUSIONS: Emphasising the efficacy of recommended actions (such as hand hygiene), risks from the disease and the possible duration of the outbreak may help to promote compliance with official advice.