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• Immigration

Australia Health Requirements Guide: Everything You Need To Know

Key Takeaways:

• Visa applicants must meet health standards to protect public health, control costs, and preserve access to services.
• Health examinations may be required based on the type of visa, planned stay, activities, and country of origin.
• Use ImmiAccount to check and arrange health exams with a HAP ID, or await contact for paper applications.

Imagine preparing for an exciting new chapter in Australia, a land of vibrant cities, stunning landscapes, and top-notch health standards. But before you pack your bags, there’s an important step you must take: ensuring you meet Australia’s health requirements. Whether you’re moving for work, study, or family, understanding and fulfilling these health prerequisites is crucial for your visa application process . This guide will walk you through everything you need to know about meeting Australia’s health standards, ensuring you and your loved ones are ready for your big adventure Down Under.

Australia’s rigorous health requirements are designed to protect its community’s well-being and sustain its excellent healthcare system. By following these guidelines, you help maintain public health safety and ensure equitable access to healthcare and community services for all residents. From understanding why these requirements exist to the specifics of health examinations, this guide will equip you with all the information you’ll need. So, let’s dive into the essentials of Australia’s health requirements and how to navigate them successfully.

What are Australia’s Health Requirements for Visa Applicants?

Australia is known for its high health standards. To maintain these, most visa applicants must meet certain health criteria. This is known as ‘meeting the health requirement,’ and it often involves a health assessment as part of the visa application process.

Why Do You Need to Meet Australia’s Health Requirement?

Visa applicants must meet these health standards to:

• Protect the Australian community from public health risks, especially diseases like active tuberculosis.
• Control expenditure on services such as social security, benefits, allowances, and pensions.
• Ensure Australian citizens and permanent residents can access health and community services, which may be limited.

Most visa applicants, along with their family members, even if they are not migrating, may need to meet these requirements based on the type of visa applied for.

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To meet the health requirement, you must be free from any disease or condition that:

• Incurs significant healthcare and community service costs to the Australian community.
• Limits access to healthcare and community services by placing a demand on those services, termed as ‘prejudicing access.’

What Happens During a Health Examination?

To prove you meet the health requirements, you might need to undergo health examinations. A Medical Officer of the Commonwealth (MOC) will assess your examination results. If you have a significant medical condition, the MOC will determine whether the condition is likely to:

• Threaten public health.
• Resulting in significant healthcare and community service costs.
• Place a demand on healthcare or community services that are in short supply.

How Does the MOC Assess Your Condition?

The MOC evaluates what services a hypothetical person with a similar condition would need. Their assessment is based solely on your medical situation.

Important Note : “When the MOC gives us advice, they can only consider your medical situation, not your other personal circumstances. For instance, the MOC cannot consider whether having private health insurance or sufficient funds for treatment will impact your use of available public services.”

Could You Be Asked to Sign a Health Undertaking?

In some cases, the MOC might recommend that you sign a health undertaking. This is a formal agreement to meet specific health-monitoring requirements after your arrival in Australia.

For more detailed information, you can visit the official Australian Department of Home Affairs .

By understanding these requirements and ensuring that you meet them, you can successfully proceed with your visa application to Australia.

Who Needs Health Examinations for Australian Visas?

Do You Need Health Examinations for Your Visa Application?

If you and your family members are applying for a visa to Australia, you may need to undergo health examinations to meet health requirements. Additional health checks might be necessary if you come from a country with public health concerns such as polio or Ebola Virus Disease (EVD). For further details, you can refer to information about public health threats on Australia’s immigration website .

What Do Permanent and Provisional Visa Applicants Need to Know?

Permanent and provisional visa applicants must have health examinations. This applies to:

• You and any family members applying with you.
• In some cases, family members not accompanying you to Australia might also need these examinations.

What About Temporary Visa Applicants?

Temporary visa applicants may also need health examinations. The need and type of examinations depend on several factors:

• The visa you’re applying for.
• The duration of your stay in Australia.
• Activities planned during your stay.
• The country of application.
• Special circumstances are relevant to your case.
• Any significant medical conditions you might have.

How to Check If Health Examinations Are Required?

For Online Visa Applications:

• Log in to your ImmiAccount.
• Open your application.
• Click the ‘View health assessment’ link in the Application Status section.
• If examinations are needed, you’ll see an ‘Organise health examinations’ link. If not, there’ll be no link.
• Click this link to complete your medical history and receive a referral letter containing a HAP ID. You’ll need this ID to arrange health examinations.

For Paper Visa Applications: Your visa processing officer will inform you if health examinations are necessary. You’ll receive a referral letter with a HAP ID, essential for arranging the examinations.

Have You Had Health Examinations in the Last 12 Months?

You might not need to retake all the health examinations if you had any within the last 12 months. The referral letter will specify which tests you need to complete.

By understanding these criteria and processes, you can better navigate the health examination requirements for your Australian visa application. For more detailed guidelines on arranging health examinations, visit the official Australian immigration website .

What Health Examinations Are Required for Visa Applicants?

Permanent and provisional visa applicants.

For those applying for a permanent or provisional visa, specific health examinations are necessary:

• Under 2 years:
• Medical examination
• 2 to under 11 years:
• TB screening test (TST or IGRA) if from a higher-risk country for tuberculosis or applying for a refugee/humanitarian visa
• 11 to under 15 years:
• Chest x-ray
• 15 years and older:
• Serum creatinine/eGFR

Additional Tests: You may need further tests if you fit any of the following situations:

• 15 years or older and planning to be a healthcare professional (doctor, dentist, nurse, paramedic):
• Hepatitis B and C tests
• 15 years or older and planning to work in healthcare, aged care, or disability care from a higher-risk country:
• Latent TB Infection Screening test
• 15 years or older and applying for an onshore protection visa:
• Syphilis test
• 15 years or older and applying for a refugee visa:
• Tests targeting specific health risks
• Pregnant and planning to deliver in Australia:
• Hepatitis B test
• Children for adoption:

Further tests might be needed if a health condition is identified during the initial examination or visa application process.

Temporary Visa Applicants

Health examination requirements for temporary visa applicants depend on various factors:

• Duration of stay
• Tuberculosis risk in your country
• Your health significance related to planned activities in Australia
• Any special circumstances
• Significant medical conditions found during examinations

Generally Required Examinations:

• Low-risk countries:
• Stay less than 6 months: No health examinations unless special circumstances apply.
• Stay 6 months or more: No health examinations unless special circumstances apply.
• High-risk countries:
• Chest x-ray (if 11 years or older)
• Serum creatinine/eGFR (if 15 years or older)

Additional Tests: Additional tests might be needed under specific conditions:

• From a high-risk TB country and likely to be in a healthcare or hospital environment:
• Chest x-ray (if 11 or older)
• Serum creatinine/eGFR (if 15 or older)
• Pregnant and planning to have the baby in Australia:
• 15 years or older and aiming to work in healthcare, aged care, or disability care from a higher-risk country:
• Planning to work (or train) at an Australian childcare center:
• Aged 75 years or older and applying for a Visitor visa (subclass 600):

Note: If you have been in Australia for the last 28 days, this time is considered when calculating the length of stay for health requirements.

Countries with Low Risk of Tuberculosis

Countries considered low-risk for tuberculosis, based on World Health Organization data, include:

Here is the alphabetical list of countries with their flag emojis:

• 🇦🇸 American Samoa
• 🇦🇮 Anguilla
• 🇦🇬 Antigua and Barbuda
• 🇦🇷 Argentina
• 🇦🇺 Australia
• 🇧🇧 Barbados
• 🇧🇦 Bosnia and Herzegovina
• 🇧🇻 Bouvet Island
• 🇻🇬 British Virgin Islands
• 🇧🇬 Bulgaria
• 🇨🇻 Cabo Verde
• 🇰🇾 Cayman Islands
• 🇨🇽 Christmas Island
• 🇨🇨 Cocos (Keeling) Islands
• 🇨🇰 Cook Islands
• 🇨🇷 Costa Rica
• 🇨🇿 Czech Republic
• 🇩🇲 Dominica
• 🇫🇰 Falkland Islands
• 🇫🇴 Faroe Islands
• 🇵🇫 French Polynesia
• 🇬🇮 Gibraltar
• 🇬🇵 Guadeloupe
• 🇬🇹 Guatemala
• 🇭🇲 Heard and McDonald Islands
• 🇭🇳 Honduras
• 🇱🇮 Liechtenstein
• 🇱🇹 Lithuania
• 🇱🇺 Luxembourg
• 🇲🇻 Maldives
• 🇲🇺 Mauritius
• 🇲🇪 Montenegro
• 🇲🇸 Montserrat
• 🇳🇱 Netherlands
• 🇦🇳 Netherlands Antilles
• 🇳🇨 New Caledonia
• 🇳🇿 New Zealand
• 🇳🇫 Norfolk Island
• 🇲🇰 North Macedonia
• 🇵🇸 Occupied Palestinian Territory
• 🇵🇳 Pitcairn Islands
• 🇵🇹 Portugal
• 🇵🇷 Puerto Rico
• 🇷🇪 Reunion Island
• 🇸🇽 Saint Eustatius & Saba
• 🇸🇭 Saint Helena (Ascension and Tristan da Cunha)
• 🇰🇳 Saint Kitts and Nevis
• 🇱🇨 Saint Lucia
• 🇸🇽 Saint Martin (Dutch)
• 🇻🇨 Saint Vincent and the Grenadines
• 🇸🇲 San Marino
• 🇸🇦 Saudi Arabia
• 🇸🇨 Seychelles
• 🇸🇰 Slovakia
• 🇸🇮 Slovenia
• 🇬🇸 South Georgia and the South Sandwich Islands
• 🇸🇷 Suriname
• 🇸🇯 Svalbard & Jan Mayen
• 🇨🇭 Switzerland
• 🇸🇾 Syrian Arab Republic
• 🇹🇹 Trinidad and Tobago
• 🇹🇨 Turks and Caicos Islands
• 🇦🇪 United Arab Emirates
• 🇬🇧 United Kingdom
• 🇺🇸 United States
• 🇻🇦 Vatican City
• 🇻🇬 Virgin Islands (British)
• 🇻🇮 Virgin Islands (US)
• 🇼🇫 Wallis and Futuna Islands

For further details about required health examinations based on your specific visa and circumstances, please refer to the official Australian Government Department of Home Affairs website . This source provides authoritative information that can help streamline your visa process.

When Should You Complete Health Examinations for Your Visa?

Should you use my health declarations (mhd) before applying for a visa.

The My Health Declarations (MHD) service allows you to complete your health examinations before you submit a visa application. However, do not use MHD if:

• The visa you plan to apply for is not listed in the MHD service.
• You have already lodged a visa application.

Health examination results are typically valid for 12 months. If there’s a delay in processing your application, you might need to redo your health examinations. To avoid unnecessary repetition, refer to the Visa processing times page before deciding to use MHD. Note that you must pay for any health examinations.

To learn how to use the MHD service, refer to the Completing the My Health Declarations form .

If you experience technical issues after following the guidelines in the form, contact us via the ImmiAccount Technical Support Form .

If your circumstances change after submitting your MHD form and before completing your health examinations, inform the panel clinic during your appointment.

Find more information on arranging your health exams .

Can You Include Family Members in the My Health Declarations?

Yes, you can include family members on your My Health Declarations form. Do not include family members who are not migrating with you. After your visa application, the processing officer will inform you if any non-migrating family members need health examinations.

What If You Apply for a Visa After Completing Health Examinations?

If the visa subclass you intend to apply for is not an option in the My Health Declarations form, wait until after applying for the visa to complete your health examinations. You will be notified if health examinations are required.

Do You Need Further Health Examinations for Permanent Visas?

Even if you had permanent health examinations for the provisional visa, you might need additional health examinations for the permanent visa. The visa processing officer will inform you if this is necessary during the second stage of your application.

• If you had a Contributory Parent (Subclass 173 or 884) visa:
• You are now applying for Contributory Parent (Subclass 143 or 864).
• If you had a Skilled – Regional (Subclass 475, 487, or 489) visa:
• You are now applying for Skilled – Regional (Subclass 887).
• If you had a Skilled Work Regional (Subclass 491) or Skilled Employer Sponsored Regional (Subclass 494) visa:
• You are now applying for Skilled Regional (Subclass 191) (Regional Provisional stream).
• If you had a Business Innovation and Investment (Subclass 160, 161, 162, 163, 164, 165, or 188) visa:
• You are now applying for Business Innovation and Investment (Subclass 888).

For in-depth official information on health examinations and other immigration inquiries, visit the Department of Home Affairs website.

How to Arrange Your Health Examinations for Your Visa

What do you need for health examinations.

When applying for a visa, you may be required to complete health examinations. If this is necessary, you will receive:

• A list of mandatory examinations.
• An identifier is known as a HAP ID .

You will need your HAP ID to schedule an appointment for these health examinations.

What If You Can’t Complete Your Health Examination on Time?

If you’re unable to complete your health examination within the timeframe specified in your Request for Health Examination letter, notify the Department. You can do this by attaching the details through your ImmiAccount.

Can You Undertake Health Examinations Before Submitting a Visa Application?

If you haven’t yet lodged a visa application but want to complete your health examinations upfront, you might use the My Health Declarations service to get a HAP ID. Refer to the relevant section about “When to have health examinations.”

How to Book Health Examinations in Australia?

In Australia, arrange your health examinations through Bupa Medical Visa Services. You can book your examinations online via their service.

Booking and Modifying Appointments

If you need to cancel or change your appointment:

• Use Bupa’s online booking system.
• Select Modify/Cancel Booking.
• Call Bupa’s Contact Centre at 1300 794 919.

To make changes to a booking, you’ll need the HAP ID used to schedule the original appointment.

When to Call Bupa Directly

Call 1300 794 919 to arrange health examinations if:

• You do not have internet access.
• You need a Carer visa assessment.
• You need a fitness to depart or travel assessment.

How to Arrange Health Examinations Outside Australia?

Outside Australia, you must be examined by one of the Department’s approved panel physicians or clinics.

A panel physician is a doctor or radiologist appointed by the department to conduct health examinations at an approved clinic.

For more detailed information, visit the official government page on arranging health examinations .

What to Bring to Your Health Examinations Appointment

When you go to your health examination appointment for your Australian visa, make sure to bring the following:

• A valid original passport (no digital copies or photocopies are accepted).
• Your HAP ID and the ‘Health Examination List’ letter or the Referral Letter provided by the Department.

If you lodged an online visa application, your HAP ID is in the Referral Letter you download from your ImmiAccount when you apply. For those who lodged a paper visa application or cannot generate a Referral Letter through their ImmiAccount, find your HAP ID in your Health Examination List letter or the equivalent document provided.

Without your HAP ID, the clinic will not be able to locate your case in the health processing system.

Also, bring:

• Prescription glasses or contact lenses if you use them.
• Any existing specialist or other medical reports for known medical conditions.
• Previous chest x-rays , if applicable.

How is Your Health Information Processed?

Health information for Australian immigration is processed through the electronic visa health processing system, eMedical. This system stores data about applicants’ health examinations for Australian visa applications.

eMedical allows panel physicians and clinic staff to save:

• Your medical history
• Digital photos and X-rays
• Examination results

This electronic process eliminates the need for paper-based reports and ensures that health information reaches the Department instantly.

Look for the eMedical logo next to the clinic’s name when searching for clinics that use this system.

What if eMedical is Not Available?

If eMedical is not available at your clinic, download and print these forms to bring to your appointment:

• Form 26 Medical examination for an Australian visa
• Form 160 Radiological report on chest x-ray of an applicant for an Australian visa

What are the Costs Involved?

You’re responsible for all costs related to your health examinations, including:

• Fees for examining physicians or radiologists
• Costs for special tests, investigations, or treatment
• Fees for any specialists you need to see
• Courier fees

Costs can vary by country and are comparable to what you’d pay locally for a comprehensive health examination. Contact the clinic beforehand to ask about specific costs.

Learn more about visa health examination costs in Australia from Bupa Medical Visa Services .

Do Some Applicants Get Exemptions from Fees?

If you’re an accepted Refugee or Special Humanitarian Program applicant (subclass 200, 201, 202, 203, or 204), you don’t have to pay for your health examinations. For applications lodged under the Community Proposal Pilot, the Approved Proposing Organisation covers the costs.

What if You Do Not Have a Valid Passport?

If you don’t have a valid passport, consult your visa processing officer for advice. The following documents may be accepted instead of a valid passport:

For examinations in Australia:

• The passport expired within two years of the health examination date
• Current valid emergency or temporary travel document
• Australian State/Territory driver’s license or photo identification card

For examinations outside Australia:

• United Nations High Commissioner for Refugees Identification document

Acceptable Document Combinations

You may also use the following combinations as alternatives:

• National Identity Card and a certified photocopy of your passport photo page
• Referral letter listing your examinations and a certified copy of your passport photo page
• Referral letter listing your examinations with an attached photograph stamped/sealed by the Department
• National Identity Card and a referral letter listing your examinations

We accept National Identity Cards from listed countries, including but not limited to Albania, Argentina, Austria, Bahrain, Belgium, Brazil, Canada, China, France, Germany, Italy, Japan, Malaysia, Singapore, Spain, Thailand, and others.

If you cannot provide acceptable alternative documents, contact your visa processing officer for advice before making your appointment.

What Should Family Members Provide?

Permanent visa applicants with non-migrating family members must provide at least two forms of identification, including:

• Birth certificate
• School registration documents
• Student card

For detailed and updated information on identity documents and more, visit the official Australian Government Department of Home Affairs .

What Happens After Your Health Examinations?

Steps After Your Health Check-Up

Once your health examinations are complete, the panel physician will:

• Record the results
• Make a recommendation regarding your health status to the immigration department

It’s important to note that the panel physician will not inform you if you meet the health requirements. The results and recommendations are submitted directly for further assessment.

Understanding Your Health Requirement Status

• Meet the health requirements, or
• Have your case sent to a Medical Officer of the Commonwealth (MOC) for further review

If referred to an MOC, you might be asked to:

• Provide additional information
• Undergo further health examinations

How to Check Your Health Exam Results

Using My Health Declarations

If you used My Health Declarations, be aware that you will not be informed of the outcome until you apply for a visa.

Checking Online Applications

For online applications, you can monitor your health assessment status through your ImmiAccount. Simply select ‘View health assessment’ under the ‘View application status’ section.

Inquiries About Your Health Examination Results

We can’t disclose your examination results until the panel clinic submits them to the Department. To confirm submission, you can contact the panel clinic directly.

If you have further questions about your results after submission, reach out to your visa processing officer.

What If My Health Case Requires Further Review?

Possible Health Case Outcomes

Your health case may be cleared without a referral to an MOC if:

• Your results show no significant health conditions

However, if your case is referred to an MOC, they will determine if you:

• Meet the health requirement
• Will meet the health requirement contingent on signing a health undertaking
• Do not meet the health requirement

Should you not meet the health requirement, your visa will not be granted unless a health waiver is available and approved.

How Long Are Your Health Assessment Results Valid?

• Health assessment results are valid for 12 months from the date of your examination.
• If you are required to sign a health undertaking, it remains valid for 6 months.

Will I Need Additional Health Examinations?

Depending on your health assessment results, further examinations may be necessary. Your visa processing officer will inform you if this is the case.

For comprehensive details about health examinations and visa health requirements, visit the official immigration website .

Stay informed and check your ImmiAccount regularly to ensure a smooth process. If needed, don’t hesitate to reach out to the involved medical and immigration professionals for guidance.

What is a Health Undertaking?

A health undertaking is an agreement with the Australian Government to meet health requirements. This helps in managing significant health conditions with an onshore health provider if needed.

Who Needs to Sign a Health Undertaking?

You may need to sign a health undertaking if you have significant health conditions and you:

• Completed your health examinations outside of Australia
• Are applying for a protection visa

Additionally, you might be required to sign a health undertaking if you are at risk of developing active tuberculosis. For instance:

• You have previously been treated for tuberculosis
• Your health examination chest x-ray is abnormal

Other significant health conditions that may require a health undertaking include:

• Inactive tuberculosis
• Hepatitis B or C

“If you do not sign a health undertaking when requested, we will not grant you a visa.”

How to Sign a Health Undertaking

Your visa processing officer will inform you if you need to sign a health undertaking. To do this:

• Complete and sign the health undertaking form.

This form is available in multiple languages, such as:

Here is the updated table with the country flag emojis next to the language names:

What Should You Do After Signing a Health Undertaking?

Once you sign a health undertaking, you must:

• Contact Bupa Medical Visa Services (BUPA) within 28 days of arriving in Australia. You can do this by calling 1300 794 919 (Monday to Friday, 8 am to 6 pm AEST) or through the BUPA website .
• By signing the undertaking, you agree to:
• Attend an appointment with a state or territory health clinic in Australia if required. Bupa will provide the necessary information.
• Complete any further investigation or treatment required.

Keep a copy of your signed health undertaking form for reference.

For protection visa applicants, contact BUPA within 28 days of receiving a Request for Information letter. If requested, attend an appointment with a health clinic in Australia.

Special Health Undertakings for Pregnant Protection Visa Applicants

If you are applying for a protection visa and choose not to complete a chest x-ray while pregnant, you must sign a pregnancy health undertaking. This agreement requires you to undergo a chest x-ray after giving birth. Arrange to have your chest x-ray within 28 days of receiving the Request for Information letter by contacting BUPA.

For more detailed information, refer to the official Australian Government Department of Home Affairs website.

What is a Health Waiver for Australian Visas?

A health waiver is available for some visa subclasses in Australia. If a Medical Officer of the Commonwealth (MOC) determines that you do not meet the health requirements, there might be an option to consider a health waiver.

To be eligible for a health waiver, you need to meet all other visa criteria first. Additionally, we must be convinced that granting you the visa will not:

• Result in significant healthcare or community service costs to the Australian community
• Prevent Australian citizens or permanent residents from accessing healthcare or community services that are currently in short supply

You can find more details about significant costs and services in short supply on the official government page .

When is a Health Waiver Not Granted?

There are specific health conditions that disqualify you from receiving a health waiver, including:

• Active tuberculosis
• Any health condition that poses a danger to the Australian community or is a public health threat

How Can You Obtain a Health Waiver?

You do not need to apply for a health waiver on your own. If you fail to meet the health requirements and a health waiver is available for your visa subclass, a visa processing officer will get in touch with you. They will guide you through the next steps.

Here’s what you will need to do if contacted:

• Provide more information on why a health waiver should be granted
• Complete a formal submission template detailing the reasons for exercising the health waiver

Factors Considered for Health Waivers

Each health waiver request is evaluated on a case-by-case basis. The following factors are taken into account:

• Whether you or any of your family members can reduce the potential cost of your health condition and your dependence on healthcare and community services
• Any compassionate and compelling circumstances that support your case for a health waiver

What Happens After a Health Waiver Decision?

If a health waiver is exercised, we will proceed with processing your visa application. However, if we do not grant a health waiver, your visa application will be refused. The visa processing officer will inform you of the decision.

What Factors Determine If You Meet the Health Requirement for a Visa?

A Medical Officer of the Commonwealth (MOC) evaluates if your health condition imposes a significant cost on the Australian community’s health care and community services. The assessment varies based on your visa type:

• Temporary visa applicants: Costs are evaluated over your period of stay.
• Permanent visa applicants: Costs are generally assessed over 5 years, or 3 years if you are aged 75 or older.

For those with permanent or ongoing conditions, the MOC estimates the costs over your remaining life expectancy, up to a maximum of 10 years.

Key Points:

• Having a health condition doesn’t always mean you will fail to meet the health requirement. It depends on the type and severity of your condition.
• If your condition is expected to cost AUD 51,000 or more, it is considered significant.

“We will not grant you a visa if you do not meet the health requirement because your condition is likely to be a significant cost unless a health waiver is available and exercised.”

What Happens If Your Condition Affects Access to Health Services?

The MOC also checks if your condition will prevent Australian citizens or permanent residents from accessing scarce health care or community services. This is referred to as “prejudicing access.”

Based on guidance from the Australian Department of Health, services considered in short supply include:

• Organ transplants

Can a Health Waiver Help You Get a Visa?

In certain cases, a health waiver might be available. The Department can consider this waiver if they believe granting the visa will not:

• Result in significant cost to the Australian community, or
• Prejudice the access of Australian citizens or permanent residents to health care or community services in short supply.

For more detailed information, check the official Australian Government immigration website .

What Are the Health Requirements for Australian Immigration?

To ensure you don’t pose a risk to public health or endanger the Australian community, meeting the health requirements is essential for visa applicants. Here’s an overview of specific health conditions and their related requirements:

Do I Need a Measles Vaccination to Travel to Australia?

The Australian Government does not require evidence of measles vaccination for visa applications. However, it’s strongly recommended.

• Recommendation: “Measles vaccination is strongly encouraged to protect yourself and others during travel.”
• Advice: Speak to your GP, or travel doctor, or visit the Department of Health and Aged Care website .

What Are the Tuberculosis (TB) Testing Requirements?

The World Health Organization (WHO) has declared tuberculosis an epidemic and a global emergency.

• Permanent Visa Applicants: Must undergo TB testing as part of the application process.
• Temporary Visa Applicants: May need TB testing if deemed at risk. Check the health examinations required.

Tuberculosis Testing Details:

• Active Tuberculosis: Highly infectious; testing is essential as part of the immigration process.
• For Applicants Aged 11 and Over: A chest x-ray is mandatory.
• For Applicants Aged 2 to 11: Alternative testing arrangements from high TB risk countries.

Job-related TB Testing:

• Applicants Aged 15 and Over planning to work or study in healthcare fields must undergo latent TB infection screening if from high-risk countries.

Procedure if Evidence of TB is Found:

• Further health examinations will be required if initial tests suggest TB.
• If active TB is diagnosed, visa grants are withheld until treatment is completed and a Medical Officer of the Commonwealth (MOC) confirms you are free from TB.
• Inactive TB might still meet health requirements, but signing a health undertaking could be necessary.

Should International Students Be Concerned About TB?

International students from certain regions carry a higher risk for TB compared to Australian-born individuals.

Recommendations:

• Students are advised to follow TB screening and treatment guidelines outlined by the Department of Health.
• Proper treatment ensures that visa conditions remain unaffected.

Do I Need to Get Tested for HIV and Hepatitis?

Who Needs an HIV Test?

• Anyone 15 years or older applying for a permanent visa.
• Those aiming to work or study as doctors, nurses, dentists, or paramedics.

Who Needs a Hepatitis Test?

• Pregnant applicants.
• Individuals applying for an adoption visa.
• Applicants for temporary humanitarian, resolution of status, or protection visas.
• Unaccompanied refugee minors.
• Those intending to work or study in healthcare fields.

Note: “HIV and hepatitis are usually not considered public health threats.” However, if applying for certain temporary visas in healthcare fields, your condition might be evaluated for public health impact.

Do I Need a Yellow Fever Certificate?

Applicants are encouraged to obtain an international vaccination certificate for yellow fever if:

• They are aged one or older.
• They stayed in a yellow fever-declared country for six days before arriving in Australia.

For more details, visit the Department of Health and Aged Care .

Is a Polio Vaccination Certificate Required?

Polio is a highly infectious virus affecting the nervous system.

• WHO Declaration: On 5 May 2014, WHO declared polio transmission a Public Health Emergency of International Concern.
• Vaccination Status: Due to high coverage in Australia, the risk is low, but measures are in place to prevent spread.
• Requirement: You may need to provide a valid polio vaccination certificate if traveling from high-risk countries. A visa officer will advise if this is necessary.

Countries of Risk Include:

• Afghanistan
• Central African Republic
• Cote d’Ivoire
• Democratic Republic of Congo
• South Sudan

Learn more about polio from the Department of Health and Aged Care .

Are There Special Requirements for Ebola Virus Disease (EVD)?

The WHO announced in December 2015 that countries previously affected by EVD are Ebola-free. Consequently, Australia has relaxed border screening.

• Current Status: No special requirements for entering Australia from previously affected countries.
• Ongoing Measures: Collaboration with the Department of Health and Aged Care continues to monitor the situation.

These health requirements ensure the safety of both the Australian community and incoming travelers. For specific details, always refer to the official guidelines provided by Australian Government’s Department of Home Affairs .

What Health Insurance Is Needed For Visa Holders in Australia?

Why Should You Have Health Insurance in Australia?

In Australia, if you incur health care debts, you are responsible for paying them. These debts can affect your future visa applications if left unpaid.

Most visitors to Australia are not eligible for Medicare, meaning they must cover all hospital, medical, and para-medical costs, whether these services are in public or private hospitals.

Who Is Eligible for Medicare?

Medicare eligibility is determined by the Health Insurance Act 1973 . It generally covers:

• Australian citizens
• Permanent visa holders
• New Zealand citizens
• Certain applicants for permanent residence visas

Do Visitors Need Private Health Insurance in Australia?

Visitors without Medicare eligibility are strongly advised to arrange private health insurance to cover unexpected medical and hospital care. If healthcare is needed and a person isn’t insured, they will have to pay all costs upfront as a private patient, whether in a public or private hospital.

What should you consider with Overseas Visitor Health Cover (OVHC)?

OVHC products often provide suitable health insurance coverage. However, it’s important to check what each product covers, as some may not provide comprehensive coverage for all healthcare needs.

What Are the Costs Associated with Treatment?

Even with guidelines suggesting the minimum health coverage needed, your costs may not be completely covered. You might still have to pay part of the healthcare expenses. It’s advised to seek “Informed Financial Consent” before starting treatment to understand all potential costs and ensure they are covered under your policy.

What Are Reciprocal Health Care Agreements (RHCAs)?

If you’re from a country with an RHCA with Australia, you might be eligible for Medicare during your stay. More details about RHCAs are available on the Services Australia website .

What Evidence of Health Insurance Is Required?

Certain visas require proof of adequate health insurance arrangements. You may need to show a current private health insurance policy from an Australian registered insurer for yourself and any co-applicants.

Where Can You Learn More About Private Health Insurance?

For detailed information on private health insurance, including a list of insurers operating in Australia, visit the Australian Government website .

What Benefit Levels Should Your Private Health Insurance Cover?

It’s recommended to purchase insurance that offers at least the following benefits:

• Public Hospital: Coverage equal to state and territory health authority rates for ineligible patients, including all costs for overnight, day-only accommodation, emergency department fees leading to admission, admitted patient care, and postoperative services.
• Surgically Implanted Prostheses: 100% of the minimum benefit listed in the Private Health Insurance (Prostheses) Rules 2007.
• Pharmacy: Benefits equal to the PBS-listed price in excess of the patient contribution for PBS-listed drugs, both during and post-hospital care.
• Medical Services: 100% of the Medical Benefits Schedule (MBS) fee for admitted medical services.
• Ambulance Services: 100% coverage for ambulance transport when medically necessary for hospital admission, emergency treatment onsite, or inter-hospital transfers.

What Are the Waiting Periods and Exclusions?

Australian registered private health insurers may impose waiting periods:

• 12 months for pregnancy and birth-related treatments
• 12 months for pre-existing conditions
• 2 months for psychiatric treatments, rehabilitation, or palliative care for pre-existing conditions
• 2 months for all other circumstances

Insurers are not required to cover assisted reproductive treatments, elective cosmetic treatments, stem cells, bone marrow, organ transplants, treatments outside Australia, pre-arranged treatments before arrival, or treatments covered by compensation or damages.

What Happens if You Have an Excess, Co-Payment, or Contribution?

Insurers may apply an excess, co-payment, or patient contribution. Note these costs, which can be charged annually or per-treatment basis.

What Is the Importance of Portability?

Portability ensures that when transferring between Australian insurers, your membership length affects waiting periods. For existing members of over 12 months, no further waiting periods apply. For under 12 months, any remaining waiting times must be completed with the new insurer. Insurers must recognize the continuity of cover within 30 days of leaving the previous insurer and provide a clearance certificate within 14 days of policy termination.

What Is an Arrear and How Is It Handled?

Insurers allow a 60-day period from the last financial membership date to pay premiums without terminating the membership. Treatments during periods of arrears won’t be covered unless the arrears are settled.

For more information about health insurance requirements for visa holders, visit the Australian Government’s official website .

Sure, here is a structured list of authoritative and relevant external resources that can help visa applicants understand and meet Australia’s health requirements:

Australian Department of Home Affairs

• Website: Australian Department of Home Affairs
• Description: This is the main portal for information about various visa types and their specific health requirements. It includes detailed guidelines on who needs to undergo health examinations and why these requirements are in place.

ImmiAccount

• Website: ImmiAccount
• Description: ImmiAccount is the online platform where visa applicants can manage their visa applications, including checking and organizing health examinations using a HAP ID.

Bupa Medical Visa Services

• Website: Bupa Medical Visa Services
• Description: This service allows visa applicants to book health examinations in Australia. The site includes information on how to arrange and modify appointments, the costs involved, and necessary documentation.

World Health Organization (WHO) Country Health Profiles

• Website: WHO Tuberculosis Country Profiles
• Description: This resource provides detailed information about TB risks by country, which is particularly useful for visa applicants to understand health check requirements based on their country of origin.

Australian Government Department of Health and Aged Care

• Website: Department of Health and Aged Care
• Description: Provides comprehensive information on public health issues, including vaccinations and health screening recommendations for travelers. It covers diseases such as measles, tuberculosis, polio, and more that may affect visa applications.

These resources are authoritative and directly related to understanding and meeting the health requirements for Australian visas.

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Explainer: what is TB and am I at risk of getting it in Australia?

Associate Professor, Melbourne Health

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Justin Denholm is the Medical Director of the Victorian Tuberculosis Program.

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Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis . It most commonly causes pneumonia - a lung infection. Sick people will experience cough, fever, sweats and weight loss, usually over weeks to months.

TB can also cause disease in other parts of the body. The most severe types affect the brain (TB meningitis) or spread through the bloodstream (disseminated TB).

Like other bacterial infections, tuberculosis is curable with antibiotics. It is a slow-growing bacteria, so long courses of several antibiotics are needed for effective treatment. Usually, this means a six month course of two to four antibiotics each day.

There are many strains of TB, and some drug resistant TB take much longer to finish treatment. Worldwide, there are growing problems with multi-drug resistant (MDR) TB . This is defined as being resistant to the two main antibiotics (isoniazid and rifampicin) and cases are not common in Australia (about 2% of all cases).

Tuberculosis is still a common disease in many parts of the world. There were more than ten million cases and 1.4 million deaths from the disease in 2015. The risk of contracting the disease varies a great deal globally, with countries including India, South Africa and Indonesia being most affected.

Am I at risk?

In Australia, there are around 1200 to 1300 cases of tuberculosis each year, which means we are among the lowest-risk countries in the world. Because of Australia’s low rate of TB and high health-care standards, we have been identified by the World Health Organisation as one of the countries best placed to eliminate TB entirely.

People who were born and grew up in Australia are very unlikely to get TB, unless they have close contact with a sick person.

The people most at risk of TB in Australia are those who have spent their early years of life in countries with high rates of the disease, and have contracted it without knowing. Even many years after leaving , people can still be at risk of getting sick with TB.

People who are sick with TB pneumonia can infect others through coughing. But TB is much less contagious than influenza or other viral infections. People who spent long periods of close contact, especially young children living in a household with the sick person, are most at risk of contracting TB.

People with serious immune problems, such as HIV infection or cancer chemotherapy, are also at higher risk of becoming sick if they are exposed.

If a person does have close contact with someone with TB, they can breathe in TB and become infected. Most people with a normal immune system will not become sick themselves, but instead keep TB bacteria in a “sleeping” state called latent TB infection.

People with a latent infection may never become sick, but will have a chance of developing active TB at some point in their lives. People with latent TB will not feel sick, and cannot infect others, but can be identified with blood or skin tests. Antibiotic treatment is available for people with latent TB which can greatly reduce the risk of becoming sick in future.

When cases of TB happen in Australia, state and territory public health programs make sure those who are sick receive appropriate treatment, including antibiotics and hospital care. Tuberculosis treatment is provided free of charge in Australia for anyone who needs it.

TB programs will also investigate those who may have been in contact with the contagious person. These programs will arrange testing for community members who might be at risk, and suggest treatment to prevent those found to have been infected from becoming sick.

Isn’t there a TB vaccine?

The Bacille Calmette-Guerin vaccine (BCG) for TB has been available for about 100 years, and is still one of the most widely used vaccines in the world. It is especially effective in preventing severe TB in young children , although much less effective in adults.

In Australia, the BCG vaccine was given routinely until the early 1980s, when it was removed from the vaccine schedule because falling TB rates made it unnecessary. Australian guidelines still recommend some groups of people get the vaccine.

This includes children younger than five who will be travelling overseas to countries with high rates of TB, and Aboriginal and Torres Strait Islander children living in TB-risk areas.

Australians who travel frequently, including to countries such as Vietnam, Indonesia and Papua New Guinea where TB is much more common, are fortunately at very low risk of catching TB overseas , and no pre-travel vaccines are needed.

People at very high risk of TB exposure , like those going to work in healthcare in countries with high TB rates or those on immune suppressing medication, may need special advice and should talk about risk with their doctors prior to travel.

• Infectious diseases
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• Tuberculosis (TB)

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Travelling to or from Australia with medicines and medical devices

You can enter Australia with medicines for you or an immediate family member travelling with you under the traveller’s exemption. When leaving Australia, you must follow the advice of the country you are entering.

Travelling to Australia with medicines and medical devices

The traveller's exemption allows people entering Australia to bring with them for their own personal use or the use by an immediate family member who is travelling with them:

• carry 3 months’ worth of medicine
• any medical devices.

Australian residents require a valid prescription from an Australian doctor for the medication they are travelling with. International visitors should have a valid prescription from their doctor.

Prescription medicines such as morphine, oxycodone, methadone, methylphenidate, Adderall®, and benzodiazepines are all covered by the traveller exemption.

Steps to take before travelling

• Obtain a prescription to confirm that the medicines you are carrying have been prescribed to you OR provide a letter from your doctor that states you are under their treatment and that the medication(s) you are carrying have been prescribed for your personal use. Your doctor's letter must specify the name of the medicine and dosage.
• Ensure the medication remains in its original packaging with the dispensing label intact. This will assist with identifying each substance at the border.
• Be ready to declare all medication to the Australian Border Force upon arrival.

If you need more medication

If you have run out of medication or you will run out of medication during your stay in Australia, you may visit an Australian registered prescriber (for example, a General Practitioner, Nurse Practitioner, Dentist) to obtain a valid Australian prescription. The prescription can be used to purchase medication from Australian pharmacies. Alternatively, if the item is not restricted in Australia a maximum of 3 months’ supply can be imported from overseas.

Special notice concerning codeine medications

All medications containing codeine require a prescription from your medical doctor.

For any medication containing codeine, of any strength, that you bring into Australia for your own personal use, you must have a prescription or letter from your doctor. You must comply with all other traveller’s exemption requirements.

Prohibited items

Travellers may not bring the following substances into Australia:

• Abortifacients (for example, mifepristone – RU486)
• Yohimbe (Yohimbine)
• Aminophenazone, amidopyrine, aminopyrine, dipyrone, metamizole
• Amygdalin/laetrile.

Travelling from Australia with medicines and medical devices

We recommend that all Australians who are planning to travel overseas with medication follow the same travel advice given for travellers entering Australia under the traveller's exemption.

It is important to note that some countries have very strict rules regarding certain types of medications (especially narcotics and medicinal cannabis products), being brought into their country. The Office of Drug Control is not able to provide advice on the exact rules and regulations of each country.

If you have concerns about the medication you are travelling with, check the 'Health' section of the country in question on  SmartTraveller .

The Office of Drug Control is not able to authorise documents to confirm legal authority of the traveller to possess a medication. If a person is travelling to a country that requires official documentation endorsed by the government, we recommend that you follow the advice made available at SmartTraveller .

Pharmaceutical Benefits Scheme (PBS) and travel

Medicines supplied under the PBS are subsidised by the Australian Government for personal use only. Any medicines that are suspected to be taken overseas for somebody else may be seized by border officials.

Carrying PBS medicines overseas for someone other than you or an immediate family member travelling with you on the same aircraft or ship is illegal. It carries penalties of up to $5,000 and 2 years imprisonment.

Read more about how to manage your PBS medicine overseas .

Country-specific advice for travel with medicines

Find out more information about staying healthy and travelling with medicines to specific countries at the  SmartTraveller website .

Travel enquiries

For more information, please visit Travelling with medicines and medical devices on the Therapeutic Goods Administration (TGA) website.

For any travel enquiries, please contact the TGA:

• phone  1800 080 653
• email [email protected]
• or by webform here .
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• Narcotic and psychotropic drugs

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• Signs and Symptoms
• Causes and Spread
• Testing for Tuberculosis
• Risk Factors
• Clinical Overview
• Clinical Signs and Symptoms
• Clinical Testing and Diagnosis
• Mantoux Tuberculin Skin Test Toolkit
• Health Care Provider Communication and Education Resources
• ICD-10-CM Codes for TB
• Tuberculosis Case Reporting
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• False-Positive Investigation Toolkit
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TB Risk and People Born in or Who Travel to Places Where TB is Common

• Tuberculosis (TB) occurs throughout the world, but is more common in some countries than in the United States.
• If you were born in or frequently travel to places where TB disease is common, you are at a greater risk of being exposed to TB germs.
• If you are at risk for TB infection, talk to your health care provider about getting tested.

TB is common throughout the world

If you were born in or frequently travel to countries where TB is common , including some countries in Asia, Africa, or Latin America, you have a higher chance of being infected with TB germs. You may be at risk even if you have lived in the United States for a long time.

TB germs can live in the body without making you sick. This is called inactive TB , or latent TB infection . People with inactive TB are infected with TB germs, but they do not have active TB disease. They do not feel sick, do not have any symptoms, and cannot spread TB to others.

Without treatment, people with inactive TB can develop active TB disease at any time and become sick.

TB germs become active if the immune system can't stop them from growing. When TB germs are active (multiplying in your body), this is called active TB disease . People with active TB disease feel sick. They may also be able to spread the germs to people they spend time with every day. Without treatment, active TB disease can be fatal.

Some people think that because they were screened during their immigration process to the United States, they are not at risk for TB. However, immigration exams mainly screen for active TB disease.

If you received the TB vaccine

Bacille Calmette-Guérin (BCG) is a vaccine for TB disease. The vaccine is not generally used in the United States. It is given to infants and small children in countries where TB is common. It protects children from getting severe forms of active TB disease, such as TB meningitis.

Tell your health care provider if you have received the TB vaccine, especially if you are getting tested for TB infection because it can cause a false positive TB skin test reaction. TB blood tests are the preferred tests for people who have received the BCG TB vaccine.

Places with increased risk

You have a higher risk of being exposed to TB germs if you were born in or frequently travel to countries where TB is common , such as some countries in Asia, Africa, and Latin America.

While traveling, avoid spending time with someone who has active TB disease . You should also avoid crowded places where TB is known to spread , including:

• Homeless shelters, and
• Nursing homes.

A traveler's chances of exposure to TB germs on a plane are very low.

People who were born in or who frequently travel to countries where TB is common

If you were born in or frequently travel to countries where TB is common , talk to your health care provider about getting tested .

If you have inactive TB, treating it is the best way to protect you from getting sick with active TB disease.

If you have active TB disease, you can be treated with medicine. You will need to take and finish all of your TB medicine as directed by your health care provider. This is to help you feel better and prevent other people from getting sick.

Travelers planning to work in health care settings

If you are traveling to work in a clinic, hospital, or other health care setting where patients with active TB disease are likely to be, talk with infection control or occupational health experts.

• Ask about administrative and environmental procedures to prevent exposure to TB germs.
• Consider using personal respiratory protective devices .

If you think you may be around people with TB disease for long periods of time while traveling, get a TB blood test or a TB skin test before leaving the United States.

• If the test reaction is negative, repeat the test eight to ten weeks after returning to the United States.
• Repeated or prolonged exposure or
• An extended stay over a period of years.
• People with HIV are more likely to have an impaired response to TB tests.

Questions and Answers About Tuberculosis Booklet

Think. Test. Treat TB

Data and Statistics

Travelers' Health

Tuberculosis

Intercountry (International) Adoption: Tuberculosis

Tuberculosis (TB)

Tuberculosis is caused by bacteria called Mycobacterium tuberculosis . The bacteria usually attack the lungs but can attack any part of the body.

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Latent tuberculosis in the general practice context

Latent tuberculosis infection (LTBI) is an asymptomatic condition that may progress to active tuberculosis (TB), sometimes decades after exposure. Most people with active TB in Australia have not had recent contact and have been unaware of their risk. Tests for LTBI are available, allowing for diagnosis and preventive therapy to avoid active disease.

The aim of this article is to review current approaches to the diagnosis and management of LTBI, with particular focus on the Australian general practice setting. Groups at elevated risk of having LTBI and progressing to active disease are outlined. Recent research into the prevalence and distribution of LTBI in Australia is reviewed, and Australian guidelines for testing and treatment are summarised.

LTBI occurs in an estimated 5% of all Australian residents. However, this is a particular issue for those born in TB-endemic countries. Approximately 17% of all overseas-born Australian residents, but only 0.4% of Australian-born residents, have LTBI. Appropriate diagnosis and management is an important long-term health promotion activity, and many people with LTBI can be managed safely and effectively in Australian general practice settings.

Latent tuberculosis infection (LTBI) occurs after a person has contact with active tuberculosis (TB), when inhaled droplets containing Mycobacterium tuberculosis enter the lungs. 1 While a proportion of people exposed to TB (especially those with immature or compromised immunity) progress to become unwell soon after exposure, the majority of people spontaneously control the initial infection and enter a state of latency. 2 LTBI is asymptomatic and may persist lifelong, and people with LTBI remain at increased risk of ‘reactivation’ and development of active TB in the future.

LTBI is frequently under-recognised within both general and healthcare communities. Community focus groups and healthcare worker surveys conducted by the Victorian Tuberculosis Program have consistently found that general practitioners (GPs) were the preferred source of trusted health information about LTBI, but also that many GPs identified a need for more training and support in providing information confidently. The purpose of this article is to review LTBI, with a particular focus on management in Australian general practice settings.

LTBI prevalence and distribution in Australia

Although exposure to active TB, and acquisition of LTBI, is uncommon in Australia, approximately one-quarter of the world’s population is affected. 3 Recent work into the prevalence and distribution of LTBI in Australia, based on census data and international studies of TB risk, has highlighted important trends. LTBI affects approximately 5% of all Australian residents; however, it more commonly affects those born in TB-endemic countries. 4 Approximately 17% of all overseas-born Australian residents, but only 0.4% of Australian-born residents, have LTBI. 4 Residents in urban areas are also more likely to have LTBI. 4 Following migration to Australia, people with LTBI have the highest risk of developing active disease in the first five years (approximately 400/100,000/year), but risk persists lifelong at higher rates than for the Australian-born population and may increase with ageing. 5,6

Although the risk of active disease persists long term, most individuals with LTBI (up to 90% overall) will never reactivate. 5 Factors known to increase the risk of active disease include immunosuppressive medications or conditions, such as human immunodeficiency virus; use of tumour necrosis factor–α inhibitors or corticosteroids; diabetes; chemotherapeutic agents and haemodialysis. However, most people who develop active TB in Australia have no specific risk factors for reactivation, and the mechanisms for triggering active disease remain unclear in many cases.

Diagnosis of LTBI

Making a diagnosis of LTBI is valuable, because it allows appropriate management to reduce the risk of developing active disease. Two diagnostic tests for LTBI are available in Australia: the tuberculin skin test (TST; also known as the Mantoux test) and the interferon-gamma release assay (IGRA). These tests have a number of similarities and some key differences (Table 1). Both tests assess the cellular immunological response of individuals with a history of possible TB exposure and tend to remain positive indefinitely after infection or disease. In practice, local test accessibility and a history of Bacillus Calmette–Guérin (BCG) vaccination are typically key factors in determining which test should be used, as both are recommended by Australian guidelines. 7 Importantly, neither test distinguishes between LTBI and active TB disease, so clinical features and other investigations are required to exclude active TB prior to establishing a diagnosis of LTBI. This assessment should include at least a clinical review for any symptoms of active TB (including fever, cough, weight loss or lymphadenopathy, particularly when present for >3 weeks) and a chest X-ray.

Australian national guidelines recommend that either a TST or an IGRA may be appropriate for the diagnosis of LTBI. 7 TSTs are generally preferred for children under the age of five to avoid venepuncture, while IGRAs are typically preferred for those with a history of BCG vaccination. Some patients will be eligible for a Medicare Benefits Schedule (MBS) rebate on IGRAs, including individuals at higher risk of TB exposure (eg those with a history of TB contact) and those at higher risk of developing active TB in the future (eg those with immunosuppressive conditions or treatment, silicosis or undergoing haemodialysis). For individuals not eligible for an MBS rebate, IGRAs typically cost $60–80 but may vary between providers.

Some patients may present requesting a test for LTBI, particularly as part of pre-employment or education placement testing. However, as LTBI is an asymptomatic condition, most affected individuals will not spontaneously identify the need for testing. It is therefore important that GPs are alert to patients at risk of past infection, especially those born in countries with high rates of TB, and consider opportunistic testing for people presenting for other reasons. Testing is most valuable soon after migration but may still provide a useful opportunity for TB prevention years after arrival. Of note, the current Australasian Society of Infectious Diseases guidelines recommend screening of all people from a refugee background, preferably within one month of arrival. 8

Treatment of LTBI

Several medication regimens are used internationally for the treatment of LTBI, including those based on rifampicin or rifapentine. 9 In Australia, currently only isoniazid is listed on the Pharmaceutical Benefits Scheme for LTBI treatment, and it is normally prescribed as a once-daily therapy (10 mg/kg, up to 300mg) for a duration of 6–9 months. 7 Isoniazid is generally well tolerated, with Australian treatment series showing high levels of completion and low rates of serious adverse effects. 10,11 The most common side effects include gastrointestinal upset and acne; hepatotoxicity may also occur during treatment. The risk of hepatotoxicity is higher in older people (particularly those aged >50 years) and those with abnormal liver function tests prior to therapy. Peripheral neuropathy has also been described, particularly in those with underlying nutritional deficiencies, and co-prescription of vitamin B6 (pyridoxine) is generally offered. Patients aged <35 years with normal liver function tests can be prioritised for treatment in general practice settings, while others at higher risk for adverse effects during treatment can be referred for assessment and management by appropriate local infectious diseases physicians or chest clinics.

Managing LTBI in the general practice setting

Historically, most management of LTBI has been provided in tertiary care settings, particularly chest clinics and infectious diseases outpatient services. However, such settings may be difficult to access or result in delays in initiating therapy. Reflecting an increasing recognition of the extent of LTBI in the Australian community, a range of approaches to support GPs in safe and effective management exist. The Victorian Tuberculosis Program has produced a series of video tutorials focusing on different aspects of LTBI diagnosis and management in the Australian general practice context. These are available online (refer to Resources). A flowchart highlighting key steps in community-based LTBI management is presented in Figure 1.

Figure 1. Flowchart for general practice management of suspected latent tuberculosis infection

After initiating therapy, strong adherence is important for successful outcomes. Ongoing clinical review is needed to help support patients to successfully complete treatment and monitor for any adverse effects of medication. 12 Support for patients may include provision of educational materials; review from practice nurses and GPs to discuss adherence to treatment, side effects or interruptions; and encouragement of continuation and successful treatment. An important patient consideration is the level of health literacy and proficiency in English, while an important practice consideration is the ability to allocate sufficient appointment time. Assuming these criteria can be met, applying MBS billing item numbers such as a Chronic Disease Management Plan and/or a Team Care Arrangement can facilitate the required staff resources.

Discussion with, or referral to, a local TB service may be required for some patients at various stages on the LTBI management pathway. In particular, patients with signs or symptoms of active disease, those who are pregnant or those with significant adverse effects from LTBI treatment should be referred for specialist involvement. A good working relationship with an appropriately experienced specialist or clinic is helpful for facilitating timely review, and remote support via telephone or video consultation may supplement safe and convenient care. 13

Cases 1 and 2 illustrate common scenarios that may be encountered in general practice settings. Although both individuals migrated from countries with a high incidence of TB and have a positive test for LTBI, differences in their comorbidities and ages affect the risk of reactivation and adverse effects with treatment. Consideration of these factors helps to determine whether non-GP specialist review is appropriate prior to initiation of LTBI therapy.

Practice tips

Patients are often uncertain about the significance of an LTBI diagnosis and may ask whether there is a risk of transmission to others around them. It is important to reassure patients that LTBI is not contagious, and there is no risk of transmission to others unless reactivation occurs. Patient education should include recognition of the signs and symptoms of reactivation to active TB to facilitate early treatment in the unlikely event this occurs.

To cater for people who are culturally and linguistically diverse, special attention should be given to medication safety, cultural competence and the ability to work with trained interpreters. The use of interpreters is important to ensure appropriate communication and understanding, and free telephone interpreting services are available through the Translating and Interpreting Service (TIS National). A variety of free online resources are available and may be helpful (refer to Resources).

Each state and territory in Australia has a dedicated TB program, with particular responsibility for management of the clinical and public health issues related to TB. A diagnosis of active TB requires notification to the appropriate jurisdictional service, which will then also arrange for any LTBI testing needed for community members with possible contact.

Patients who present and report being exposed to recent local cases of TB should be discussed directly with relevant jurisdictional TB programs, which are responsible for testing and follow-up in cases of confirmed disease.

S, aged 22 years, is a male asylum seeker who arrived from Myanmar three months ago. He completes the recommended refugee screening tests, which include an IGRA that is subsequently found to be positive. He is well, with no symptoms suggesting active TB. He remembers that his aunt had TB when he was a child, but he says that he has never been tested for LTBI before. His GP orders a chest X-ray and liver function tests, which are both unremarkable. The GP therefore discusses with S the diagnosis of LTBI and suggests that he consider treatment with daily isoniazid for six months to prevent becoming unwell in future. S agrees and completes a successful course of therapy while continuing his nursing studies.

W, aged 65 years, is a woman from India who has recently been diagnosed with rheumatoid arthritis. As part of an assessment during consideration of immunosuppressive therapy, she is found to have a positive IGRA. She has a normal chest X-ray and no symptoms of active TB, but is noted to have a history of fatty liver disease; her most recent alanine transaminase result is 73 U/L. Her GP discusses the diagnosis of LTBI and the possibility of treatment with W, but recognises her higher risk of adverse effects. The GP therefore arranges for her to be reviewed by a local infectious diseases outpatient clinic, which ultimately monitors her through a course of rifampicin.

LTBI is a common condition in Australia but is often unrecognised. As trusted care providers, GPs can play an important part in the diagnosis and management of LTBI in community-based settings. Appropriate and timely management of LTBI is a valuable part of long-term health promotion. This management provides a key contribution to lowering individual risk of TB and reducing Australian TB incidence towards elimination.

Many online resources can assist the general practice management of latent tuberculosis. Some examples the authors have found helpful include:

• Video tutorials produced by the Victorian Tuberculosis Program, www.youtube.com/watch?v=3ru7Aw3byRk
• NSW Refugee Health Service – Appointment reminder translation tool, www.swslhd.health.nsw.gov.au/refugee/appointment/
• Easidose – Pictorial prescribing, http://easidose.com
• Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) – Cultural competence in working with people from refugee backgrounds, www.startts.org.au/media/Participant-Booklet_STARTTS-Cultural-Competence-Workshop_Feb2019.pdf
• Tips on working with interpreters, www.tisnational.gov.au/en/

Acknowledgements

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• Getahun H, Matteelli A, Chaisson RE, Raviglione M. Latent Mycobacterium tuberculosis infection. N Eng J Med 2015;372(22):2127–35. doi: 10.1056/NEJMra1405427. Search PubMed
• Trauer JM, Moyo N, Tay EL, et al. Risk of active tuberculosis in the five years following infection … 15%? Chest 2016;149(2):516–25. doi: 10.1016/j.chest.2015.11.017. Search PubMed
• Houben RM, Dodd PJ. The global burden of latent tuberculosis infection: A re-estimation using mathematical modelling. PLoS Med 2016;13(10):e1002152. doi: 10.1371/journal.pmed.1002152. Search PubMed
• Dale KD, Trauer JM, Dodd PJ, Houben RMGJ, Denholm JT. Estimating the prevalence of latent tuberculosis in a low-incidence setting: Australia. Eur Respir J 2018;52(6):pii.1801218. doi: 10.1183/13993003.01218-2018. Search PubMed
• McBryde ES, Denholm JT. Risk of active tuberculosis in immigrants: Effects of age, region of origin and time since arrival in a low-exposure setting. Med J Aust 2012;197(8):458–61. doi: 10.5694/mja12.10035 Search PubMed
• Dale KD, Trauer JM, Dodd PJ, Houben RMGJ, Denholm JT. Estimating long-term tuberculosis reactivation rates in Australian migrants. Clin Infect Dis 2019:pii:ciz569. doi: 10.1093/cid/ciz569. Search PubMed
• Stock D. National position statement for the management of latent tuberculosis infection. Commun Dis Intell Q Rep 2017;41(3):E204–E8. Search PubMed
• Chaves NJ, Paxton G, Biggs BA, et al. Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds. Surry Hills, NSW: Australasian Society for Infectious Diseases, 2016. Search PubMed
• Fox GJ, Dobler CC, Marais BJ, Denholm JT. Preventive therapy for latent tuberculosis infection – The promise and the challenges. Int J Infect Dis 2017;56:68–76. doi: 10.1016/j.ijid.2016.11.006. Search PubMed
• Denholm JT, McBryde ES, Eisen D, et al. SIRCLE: A randomised controlled cost comparison of self-administered short-course isoniazid and rifapentine for cost-effective latent tuberculosis eradication. Intern Med J 2017;47(12):1433–36. doi: 10.1111/imj.13601. Search PubMed
• Denholm JT, McBryde ES, Eisen DP, Penington JS, Chen C, Street AC. Adverse effects of isoniazid preventative therapy for latent tuberculosis infection: A prospective cohort study. Drug Healthc Patient Saf 2014;6:145–49. doi: 10.2147/DHPS.S68837. Search PubMed
• Rubinowicz A, Bartlett G, MacGibbon B, et al. Evaluating the role of primary care physicians in the treatment of latent tuberculosis: A population study. Int J Tuberc Lung Dis 2014;18(12):1449–54. doi: 10.5588/ijtld.14.0166. Search PubMed
• Schulz TR, Richards M, Gasko H, Lohrey J, Hibbert ME, Biggs BA. Telehealth: Experience of the first 120 consultations delivered from a new refugee telehealth clinic. Int Med J Search PubMed

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Tuberculosis (TB)

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• Tuberculosis (TB) is an infectious disease that can affect any part of your body, most commonly your lungs.
• TB can be latent (where you don’t have any symptoms and are not infectious), or active (where you are unwell).
• The tuberculin skin test or a blood test can check if you have been infected with TB.
• TB can be treated with a combination of antibiotics that you will need to take for at least 6 months.
• The BCG vaccine prevents you becoming very unwell with TB, but it is only recommended in Australia for people at high risk of exposure to TB.

What is tuberculosis?

Tuberculosis (TB) is an infectious disease that most often damages your lungs, but can affect any part of your body. It can cause serious illness and death if it’s not treated. TB is caused by the bacterium m ycobacterium tuberculosis .

It’s very uncommon to catch TB in Australia. However, TB is common in some other countries. Many Australians born overseas have TB.

There are 2 types of TB:

• Latent TB infection — this is when someone is infected with TB but does not get sick, because their immune system is able to control the infection.
• Active TB disease — this is when the TB bacteria multiply and the immune system is not able to control them. Active TB causes symptoms.

Most people with latent TB never become unwell from it, but about 1 in 10 will develop active TB. This could happen shortly after becoming infected, or many years later. Young children, older people, and people with a weakened immune system are more likely to become unwell.

What are the symptoms of tuberculosis?

People with TB may:

• lose weight without trying to
• have a fever
• sweat in bed at night
• lose their appetite

If you have pulmonary (lung) TB, you might have:

• a cough that lasts at least 3 weeks
• sputum (phlegm) containing blood

TB in other parts of your body can cause pain or swelling in that area. Lymph node TB can cause swollen glands.

CHECK YOUR SYMPTOMS — Use the Symptom Checker and find out if you need to seek medical help.

How is tuberculosis spread?

TB is spread through the air when a person with active TB in their lungs or throat coughs , sneezes, speaks, laughs or sings. If other people nearby breathe in the bacteria, they can catch TB.

People with active TB in other parts of their body are not infectious. Latent TB is also not infectious.

You are most at risk of catching TB if you:

• have had close contact with someone with active TB — the longer, more often or more closely you were in contact, the higher your risk
• live in a country where TB is common
• have a weakened immune system

When should I see my doctor?

See your doctor if you have symptoms of TB, or if you have been exposed to someone infectious. Your doctor can refer you for testing.

If you are a refugee, see a doctor and have a TB test soon after you arrive in Australia.

You may also need a TB test if you:

• have moved to Australia from a country where TB is common
• are starting a medicine that weakens your immune system
• live in crowded surroundings
• work with people who may have TB
• are starting a new job
• use injected drugs

FIND A HEALTH SERVICE — The Service Finder can help you find doctors, pharmacies, hospitals and other health services.

ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist.

How is tuberculosis diagnosed?

Your doctor may order a tuberculin skin test, also called a Mantoux test. A small amount of liquid is injected just under the skin of your forearm. A healthcare worker will check the site 48 – 72 hours later. If there is a red lump, it means you have been infected with TB.

Sometimes a blood test is used to detect TB.

These tests can’t tell you if you have active or latent TB. If the test is positive, you may have a chest x-ray, a physical examination or a sputum culture to see if you have active TB. If TB outside the lungs is suspected, you may need a different test, such as a biopsy .

Active TB is a notifiable disease .

How is tuberculosis treated?

For latent TB, your doctor can prescribe antibiotics to reduce the risk of you developing active TB. You will need to take them for at least 6 months. Not everyone with latent TB needs to be treated — some people are monitored over time.

For active TB, you will be prescribed a combination of antibiotics, which you must take for at least 6 months. You will need to stay home from school or work until you are no longer infectious. Your close contacts should be tested.

You may need treatment through a hospital clinic, but some people are treated by their general practitioner (GP) . If you complete the full treatment, you have an excellent chance of being cured of TB disease.

It’s important to take all your medicines according to your doctor’s instructions. Don’t stop taking your medicines early. If you don’t complete treatment, you could develop drug-resistant TB, where the infection does not respond to the usual antibiotics. This is harder to treat and requires different medicines for up to 2 years.

Can tuberculosis be prevented?

The vaccine for tuberculosis ­is called the bacille Calmette–Guérin (BCG) vaccine. It does not prevent you from becoming infected with TB, but it helps prevent severe or life-threatening TB disease, especially in young children.

Most Australian children do not need the BCG vaccine, as TB is very uncommon in Australia. The vaccine is not part of the National Immunisation Program schedule .

The vaccine is recommended for:

• Aboriginal and/or Torres Strait Islander children living in some parts of Australia
• children who are travelling to areas where TB is common
• babies whose parents or carers have TB
• young children who are exposed to leprosy at home
• some babies born to parents from countries where TB is common
• some healthcare workers

The BCG vaccine, which is registered for use in Australia, is not always readily available. Ask your doctor, or contact your state or territory immunisation health service , to find out how to get the BCG vaccine. Other BCG vaccines may be available through special prescribing arrangements.

Everyone who may have been exposed to TB in the past should have a skin test before they are vaccinated.

Tuberculosis vaccine

Vaccination is your best protection against the severe effects of TB. This table explains how the vaccine is given, who should get it, and whether it is on the National Immunisation Program Schedule. Some diseases can be prevented with different vaccines, so talk to your doctor about which one is appropriate for you.

Complications of tuberculosis

TB can cause damage to your lungs or other organs.

It can also cause very serious illnesses, such as:

• miliary TB — affecting the whole body

Resources and support

Find out more if you are a parent considering TB vaccination for your child .

If you prefer a language other than English, you can find information about TB in many other languages from the New South Wales Multicultural Health Communication Service .

If you have lung disease, visit Lung Foundation Australia for information and support services.

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Last reviewed: December 2022

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Risk factors for TB in Australia and their association with delayed treatment completion

N. j. coorey.

1 Australian National University Medical School, Canberra ACT, Australia

2 Research School of Population Health, Australian National University College of Health and Medicine, Australian National University, Canberra ACT, Australia

5 South Australia Health, Adelaide, SA, Australia

6 Northern Territory Health, Darwin, NT, Australia

7 Victorian Tuberculosis Program, Melbourne Health, VIC, Australia

8 Department of Infectious Diseases, Doherty Institute, The University of Melbourne, VIC, Australia

9 Sydney Medical School-Central, The University of Sydney, Sydney, NSW, Australia

C. Lowbridge

10 Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia

13 Western Australia Health, Perth, WA, Australia

14 Western Australia Tuberculosis Control Program, Perth, WA, Australia

11 Centre for Research Excellence in Tuberculosis (TB-CRE), The University of Sydney, Sydney, NSW, Australia

12 Marie Bashir Institute for Infectious Diseases and Biosecurity (MBI), The University of Sydney, Sydney, NSW, Australia

3 School of Public Health, The University of Sydney, Sydney, NSW, Australia

4 Department of Global Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

BACKGROUND :

Australia has a low incidence of TB and has committed to eliminating the disease. Identification of risk factors associated with TB is critical to achieving this goal.

We undertook a prospective cohort study involving persons receiving TB treatment in four Australian jurisdictions. Risk factors and their association with delayed treatment completion (treatment delayed by at least 1 month) were analysed using univariate analyses and multivariate logistic regression.

Baseline surveys were completed for 402 persons with TB. Most (86.1%) were born overseas. Exposure to a person with TB was reported by 19.4%. Diabetes mellitus (10.2%), homelessness (9.2%), cigarette smoking (8.7%), excess alcohol consumption (6.0%) and mental illness (6.2%) were other common risk factors. At follow-up, 24.8% of patients had delayed treatment completion, which was associated with adverse events (34.1%, aOR 6.67, 95% CI 3.36–13.27), excess alcohol consumption (6.0%, aOR 21.94, 95% CI 6.03–79.85) and HIV co-infection (2.7%, aOR 8.10, 95% CI 1.16–56.60).

CONCLUSIONS :

We identified risk factors for TB and their association with delayed treatment completion, not all of which are routinely collected for surveillance purposes. Recognition of these risk factors should facilitate patient-centred care and assist Australia in reaching TB elimination.

L’incidence de la TB en Australie est faible et le pays s’est engagé à éliminer la maladie. Afin d’atteindre cet objectif, il est essentiel d’identifier les facteurs de risque associés à la TB.

MÉTHODES :

Nous avons réalisé une étude de cohorte prospective auprès de personnes sous traitement antituberculeux dans quatre juridictions du pays. Les facteurs de risque et leur association avec un retard d’achèvement du traitement (d’au moins 1 mois) ont été analysés par analyses univariées et régression logistique multivariée.

RÉSULTATS :

Au total, 402 personnes ont répondu aux enquêtes initiales. La plupart (86,1%) étaient nées à l’étranger. Un contact avec un cas de TB a été rapporté par 19,4% d’entre elles. Diabète sucré (10,2%), absence de domicile fixe (9,2%), tabagisme (8,7%), consommation excessive d’alcool (6,0%) et troubles mentaux (6,2%) étaient d’autres facteurs de risque courants. Pendant la période de suivi, 24,8% des patients ont connu un retard d’achèvement du traitement, associé à des évènements indésirables (34,1%, OR ajusté [ORa] 6,67 ; IC 95% 3,36–13,27), une consommation excessive d’alcool (6,0% ; aOR 21,94 ; IC 95% 6,03–79,85) et à une co-infection par le VIH (2,7% ; aOR 8,10 ; IC 95% 1,16–56,60).

Nous avons identifié les facteurs de risque de TB et leur association avec un retard d’achèvement du traitement, tous n’étant pas recueillis en routine à des fins de surveillance. L’identification de ces facteurs de risque devrait faciliter les soins centrés sur le patient et aider l’Australie à éliminer la TB.

TB continues to pose a major global public health challenge. Although the vast majority of this disease burden occurs in low- and middle-income countries, 1 , 2 high-income countries also grapple with optimal case management of TB, especially in high-risk populations. TB is associated with multiple social determinants. 3 , 4 Careful consideration of these determinants may provide insights that can assist in optimisation of public health strategies and patient-centred approaches. 5 , 6

Australia reports one of the lowest incidence rates of TB globally (5.8 cases per 100,000 population in 2018). 7 Rates have been static since the mid-1980s. Annually, approximately 1,400 TB cases are notified, with nearly 90% of cases identified in persons born overseas. 8 Australia’s migration intake includes people from high TB incidence countries (defined as >40 cases/100,000). 1 , 2 While most people are screened for active TB before arriving in Australia, some have undiagnosed TB infection on arrival. Also, many frequently return to their country of origin, which provides an ongoing source of exposure and infection. 9 Australia has published its strategic plan to control TB, 8 which aims to achieve TB elimination (defined as <1 case/million) by the year 2050. 1 , 2 , 8

TB is a notifiable disease in Australia. 10 Jurisdictions (states and territories) report these data according to a pre-defined protocol to the National Notifiable Diseases Surveillance System (NNDSS). 11 Approximately 15 variables are collected for TB in the NNDSS, including HIV status, household TB contact, health industry employment within the past 5 years, and past residence (≥3 months) in a high TB incidence country. 12 Some other important variables are not recorded in the NNDSS, but may be accessible through medical case notes or other information systems which, if analysed, may assist policy makers and those working in TB programmes to refine efforts to provide patient-centred care and eliminate TB.

In this study, we collected information on risk factors associated with TB disease and treatment outcomes in a sample of patients treated for TB in Australia. This included risk factors not routinely captured in the NNDSS. Our purpose was to inform the delivery of patient-centred care in Australia and other low TB incidence settings.

Study design

We undertook a prospective cohort study of all persons with TB who received treatment for TB on 1 November 2018 in Victoria (VIC), South Australia (SA) and the Northern Territory (NT), and on 1 August 2019 in Western Australia (WA). This study included a baseline questionnaire with a follow-up survey after 12 months.

Study population

All persons with confirmed TB from four Australian jurisdictions (VIC, SA, NT and WA) were included. Jurisdictional TB programme managers compiled a list of persons with TB who were receiving treatment, or who were due to receive treatment on a specified day which provided a cross-sectional sample of all persons undergoing TB treatment.

In Australia, all patients notified to a jurisdictional TB surveillance system fulfil national TB case definition criteria as specified by the Australian Commonwealth Department of Health. 13 These case definition criteria require a diagnosis accepted by the Director of Tuberculosis Control (or equivalent) in the relevant jurisdiction, based on either 1) definitive laboratory evidence, or 2) clinical evidence. Definitive laboratory evidence is defined as 1) isolation of Mycobacterium tuberculosis complex ( M. tuberculosis, M. bovis or M. africanum , excluding M. bovis var bacille Calmette-Guérin) using culture, or 2) detection of M. tuberculosis complex using nucleic acid testing, except where this is likely to be due to previously treated or inactive disease. 13 Clinical evidence is defined as a clinical diagnosis of TB, including clinical follow-up assessment to ensure a consistent clinical course, by a clinician experienced in TB management.

Data collection

Two paper-based questionnaires (Supplementary Data 1.1, 1.2) were developed to collect information on risk factors associated with TB at baseline, as well as treatment outcomes 12 months later. The risk factor variables were based on a review of current risk factor variables used for TB surveillance in Australia, as well as a comprehensive literature search identifying additional risk factors not routinely captured in the NNDSS.

Variables in the baseline questionnaire included risk factors such as homelessness, history of incarceration, cigarette smoking, diabetes mellitus, HIV status, illicit drug use and excessive alcohol use, as well as routinely collected data such as age, sex and country of birth. 14 The follow-up questionnaire collected information on TB treatment outcomes, including cure, completion, failure and death, for which NNDSS definitions were applied (i.e., dataset field specifications v6.2.1; personal communication, Data Manager, NNDSS, January 2020). Both questionnaires were piloted by TB case managers in VIC using information from a small group of persons with TB who had completed treatment.

Baseline and follow-up data (12 months from baseline) were collected in VIC, SA and NT. Collection of data in other Australian jurisdictions and follow-up data in WA were not completed due to the time required for ethics approvals; the different dates for the baseline questionnaires reflect the timing of ethics approvals. Questionnaires were completed by trained data collectors, including TB nurses or physicians responsible for patient management. Questionnaires were completed based on information in medical records and within jurisdictional TB surveillance systems. Following completion of the questionnaires, data were checked by senior TB programme staff and were sent via a secure route to study investigators. Data were entered into a restricted MS Access database (MicroSoft, Redmond, WA, USA) on a password protected server, with in-built data quality checks. A unique identifier was allocated to each patient. Any missing, unclear or inconsistent data were checked with jurisdictional TB programme staff and were corrected.

Data analysis

We conducted descriptive analyses using numbers and proportions. Statistical comparison between the study sample and the 2018 Australian population with TB was conducted using Pearson’s χ 2 test and Fisher’s exact test, in case of small numbers. We conducted univariate analyses, calculating odds ratios (ORs) and 95% confidence intervals (95% CIs) for the association between risk factors and delayed treatment completion. This was defined as treatment that was not completed within 1 month of the planned treatment completion date for a given regimen (e.g., drug-susceptible or drug-resistant TB). Drug resistance categories in our analyses were classified according to WHO guidelines. 15

Selected variables ( P < 0.4) were included in a multivariate regression model and controlled for the effects of age and sex, with backwards elimination at a 0.05 significance level. This model was used to calculate adjusted ORs (aORs). All data were analysed using Stata Statistical Software: Release 15.1 (StataCorp, College Station, TX, USA; 2017).

Ethical issues

A summary of all ethical and site-specific approvals obtained is provided in Supplementary Data 1.3. A waiver of consent was sought and approved as the research involved analysis of data gathered under Public Health Acts within local jurisdictions for the purpose of legislated activities under these Acts, rather than for research purposes.

Demographic characteristics

Baseline data were available for 402 persons with TB from VIC ( n = 277, 68.9%), WA ( n = 66, 16.4%), SA = 42, 10.4%) and the NT ( n = 17, 4.2%). Follow-up data at 12 months were available for 331 persons with TB (82.3%), excluding patients from WA (see Methods).

Demographic and clinical characteristics of the 402 persons with TB are given in Tables 1 and ​ and2. 2 . The demographic characteristics of the sample were not significantly different from the overall Australian population with TB for 2018 ( Table 1 ). Our study sample included 201 females (50.0%), with a median age of 35 years. Most ( n = 346, 86.1%) were born overseas and 6 (1.5%) were of Aboriginal and/or Torres Strait Islander (Indigenous) origin. One quarter ( n = 101, 25.1%) were not eligible for the Medicare Benefits Scheme (MBS), whereby the Australian Government pays a rebate to subsidise the cost of medical services ( Table 2 ). Those not eligible for the MBS were primarily overseas students (54.5%), visitors (18.8%) and those with other types of VISAs (13.9%). Thirty-one (7.7%) patients had drug-resistant TB, including five with multidrug-resistant TB (MDR-TB; defined as TB resistant to at least rifampicin and isoniazid) and five with extensively drug-resistant TB (XDR-TB; defined as MDR-TB with additional resistance to a fluoroquinolone and at least one of the second-line injectable agents [amikacin, kanamycin, or capreomycin]). Additional information describing immigration status and travel history is provided in Supplementary Data 1.4.

Sociodemographic characteristics of all patients with TB in Australia (2018) compared to 402 patients from Victoria, Western Australia, South Australia and the Northern Territory (2018–2019)

* All patients reported to the National Notifiable Diseases Surveillance System.

† Statistically significant.

‡ Persons of Aboriginal and Torres Strait Islander descent ( n = 399; 3 with missing data).

Social and clinical characteristics of surveyed Australian TB patients

* This variable was collected as a proxy for the language used most frequently by the patient.

† Multiple diagnostic methods could be used in one patient.

‡ N = 294 as drug resistance status was not available for 108 patients.

§ Drug susceptibility defined as susceptibility to first-line TB medicines; determination attempted in all culture-confirmed cases.

¶ Defined as resistance to one of the first-line TB medicines (i.e., rifampicin, isoniazid, pyrazinamide or ethambutol). All 21 patients with mono-resistance were resistant to isoniazid. There were no cases of rifampicin mono-resistance.

# Four patients received full treatment in Australia, four received partial treatment overseas and one received full or partial treatment overseas. MDR = multidrug-resistant; RR-TB = rifampicin-resistant TB; XDR-TB = extensively drug-resistant TB.

Risk factors

Data on risk factors are presented in Table 3 . Known contact with a person with TB was the most common risk factor ( n = 78, 19.4%), followed by employment in the health or aged care sector ( n =37, 9.2% overall and 20.7% of the employed sample of 177 persons). Of the 402 people with TB, 37 (9.2%) reported homelessness (currently or in the previous 2 years); 24 (6.0%) were reported to drink alcohol excessively; 35 (8.7%) were current smokers and 58 (14.4%) reported having smoked previously; 25 (6.2%) reported having a mental illness; 19 (4.7%) reported illicit drug use (three of these reported intravenous drug use) and 5 (1.2%) had a history of previous incarceration.

Reported risk factors of surveyed Australian TB patients

* Includes three patients reporting intravenous drug use and 16 patients reporting non-intravenous drug use.

The HIV status of most (84.5%) patients was known, but unknown for 15.5%; 11 patients were HIV-positive (2.7%). Overall, 8 had hepatitis C (2.0%), 5 had hepatitis B (1.2%) and 3 had both hepatitis B and C virus infection (0.7%). Four patients had both HIV and concomitant hepatitis B or C infection. In addition, 41 (10.2%) had diabetes mellitus, 26 (6.5%) reported use of an immunosuppressant medication and 8 had chronic kidney disease (2.0%). Five women (2.5% of all women) were pregnant at the time of TB diagnosis. Additional information on TB treatment and care, including health service utilisation, is provided in Supplementary Data 1.4.

Treatment outcomes

Follow-up data on treatment outcomes were collected for 331 patients from VIC, SA and the NT ( Table 4 ). Most patients completed treatment ( n =294, 88.8%), with 214 (64.7%) of patients completing treatment within 1 month of the planned completion date. One patient died from heart failure 7 months after TB treatment started. Forty-one patients (12.4%) reported economic or social consequences related to TB. Feeling socially isolated (3.9%) and perceived stigma (2.7%) were noted, but were uncommon.

Treatment outcomes of surveyed Australian TB patients

* At the time of the follow-up survey, these patients were still receiving TB treatment.

† Treatment outcome data from Western Australia were not collected for this study.

‡ Other treatment outcomes are possible (i.e., treatment failed, not followed up, outcome unknown). However, there were no patients with these outcomes reported.

§ Patient passed away from heart failure 7 months after commencing treatment for TB.

¶ Defined as treatment delayed by at least 1 month past the planned treatment completion date. The planned treatment completion date may vary according to the TB resistance status and pattern.

# Multiple social and economic consequences may occur in a single patient.

Delayed tuberculosis treatment completion

There were 82 patients (24.8%) for whom treatment completion was delayed by at least 1 month. Table 5 shows the association between selected characteristics and risk factors with delayed treatment completion. Delayed treatment completion was reported for patients with excessive alcohol intake (79.0%), illicit drug users (73.3%), persons living with HIV (70.0%), Indigenous patients (60.0%), patients who had experienced homelessness in the past 2 years (56.7%) and those with mental illness (58.8%). Furthermore, treatment completion was delayed in over 50% of patients with drug-resistant TB, including those with mono-resistant (52.9%), as well as MDR- or XDR-TB (66.7%). In our multivariable regression, adverse events during treatment (aOR 6.67, 95% CI 3.36–13.27; P < 0.001), excessive alcohol consumption (aOR 21.94, 95% CI 6.03–79.85; P < 0.001) and HIV co-infection (aOR 8.10, 95% CI 1.16–56.60; P = 0.05) were associated with delayed TB treatment completion.

Association between patient and social characteristics and delayed TB treatment * outcome of surveyed Australian TB patients †

* Delayed treatment completion was defined as treatment delayed by at least 1 month past the planned treatment completion date. The planned treatment completion date may vary according to the TB resistance status and pattern.

† N = 296 as patients with ongoing treatment or who transferred overseas were not identified as having an outcome relating to time of treatment completion. Eight patients were transferred overseas and 27 patients had ongoing treatment at the time of survey.

‡ Note that some risk factors included in Table 3 were omitted from this table due to low count numbers.

§ Proportion of patients with the risk factor who had delayed treatment completion, i.e., there were 10 HIV patients identified from the follow-up survey, and seven (70%) of these had delayed treatment completion. The number of persons with TB with delayed treatment completion overall was 82.

¶ Odds were adjusted for age group, sex, adverse events during treatment, high alcohol consumption and HIV status.

# Statistically significant.

** The adherence support measures included video directly observed treatment, SMS adherence support and other methods of adherence support. OR = odds ratio; CI = confidence interval; aOR = adjusted OR; MDR/XDR-TB = multidrug/extensively drug-resistant TB.

TB is one of a small number of notifiable diseases in Australia for which enhanced surveillance is conducted. The NNDSS captures a specified number of data variables and risk factors for each person with TB, as recommended and endorsed by the National Tuberculosis Advisory Committee. This study identified multiple risk factors among persons with TB in Australia, not all of which are routinely collected in the NNDSS. TB treatment completion overall was high (89%), but a quarter of persons had delayed treatment completion. This delay was significantly associated with excessive alcohol use, HIV co-infection and adverse events during TB treatment. Some form of treatment support was provided to approximately three quarters (74.6%) of patients (Supplementary Data 3).

Excessive alcohol consumption may be a risk factor of under-appreciated significance. In our study, the majority (78.9%) of persons with TB with excessive alcohol consumption had delayed treatment completion (OR 12.43, 95% CI 3.97–38.96). Other studies have shown that alcohol misuse contributes to approximately 10% of TB deaths globally. 16 , 17 Alcohol is a dose-dependent risk factor, with consumption of more than 40 g of alcohol per day (or a diagnosis of alcohol use disorder) resulting in a nearly three-fold increase in TB risk. 16 , 17 Alcohol can negatively affect treatment adherence and may increase the risk of adverse events, particularly hepatotoxicity. 18

In our study, persons with TB had a higher prevalence of HIV infection (2.7%) than the general Australian population (~0.1%). 19 HIV testing and care remains important in low TB incidence settings, despite the fact that HIV-associated TB is substantially lower than the global population (8.2%). HIV is an important risk factor for developing TB, even in countries with low TB incidence. 1 , 20 – 22 Most people with TB and HIV co-infection (70%) had delayed treatment completion (OR 6.84, 95% CI 1.72–27.31). Reasons for the delay remain unclear and warrant further investigation, but may have been influenced by a low threshold to extend treatment in immunocompromised persons. The current WHO recommendation is that a standard 6-month regimen is effective in treating people with HIV and drug-susceptible pulmonary TB, provided they are taking antiretroviral treatment. 23 – 28 Only one patient with TB and HIV co-infection in our cohort had drug-resistant TB, which was mono-resistant to isoniazid. Other possible explanations for the delay include drug–drug interactions, problems adhering to treatment, unnecessary prolongation of treatment and difficulties accessing healthcare. 29 , 30

Documented adverse events were also associated with delayed treatment completion. Such events are not uncommon during TB treatment, particularly when treating drug-resistant strains, as patients may be required to stop certain medications or adjust the treatment regimen. 28 This potentially complicates and extends treatment.

A study that included all of Australia’s states and territories would have provided a more comprehensive analysis of TB risk factors in the Australian TB patient population. Although we collected data from a subset of jurisdictions, our study sample was similar to the most recent published data (2018) on the Australian TB population. We only found a minor difference in the age composition, with more people aged 0–14 years and fewer people aged ≥65 years in our sample. We were unable to perform sub-analysis by jurisdiction due to small sample sizes. Another limitation was that we did not stratify by place of birth, i.e., whether Australianborn (Indigenous or non-Indigenous) or overseas-born. Indigenous populations are disproportionately affected by TB globally, even in low TB incidence countries such as Australia, where the rate of TB in the Indigenous Australian-born population is four-fold higher than in non-Indigenous Australian-born people (but lower than in overseas-born persons). 31 , 32 Owing to our relatively small sample size of Indigenous Australians ( n = 6), we did not undertake a separate analysis for this group. A larger sample size would permit stratification.

This study has potential implications for TB management in Australia and other low TB incidence countries. Although Australia is a high-income country, 12.4% of patients reported economic or social consequences of treatment, which merits further attention. In addition, based on our study findings, we recommend the inclusion of the most important risk factors as part of routine TB data surveillance or the collection of these data during periodic surveys. 11 This should include variables such as the presence/absence of diabetes mellitus, excessive alcohol use, cigarette smoking and substance use. Future studies could aim to investigate which risk factors coexist most commonly and their relationship to treatment outcomes. Furthermore, smoking cessation and support for people with excessive use of alcohol or illicit drug use should be considered during TB treatment, 33 , 34 as well as psychological support. 28 , 35 Collecting data about factors related to TB risk and patient-centred care should further improve patient outcomes (such as timely treatment completion and health-related quality of life), refine efforts to prevent TB among high-risk groups and focus TB elimination efforts in low incidence settings, such as Australia.

Acknowledgements

The authors would like to thank the TB programme staff who managed and collected data and the staff from the Victorian TB Program who pilot tested the questionnaire; A Story (University College London Hospital NHS Trust, London, UK), who provided very useful insights as this project was being developed; O Forbes, K Deering and A Parry, who worked on the study as Research Assistants at the Research School of Population Health, Australian National University, Canberra ACT, Australia; and E Donnan, B O’Connor and Professor C Coulter for their very helpful advice on implementing the study in New South Wales and Queensland.

Funding for this study came from the TB Centre of Research Excellence, University of Sydney, Sydney, NSW, Australia, and this study was one of the seminal studies of the Australasian Clinical Tuberculosis Network (Actnet: https://www.actnet.org.au/ ). KV was supported by a Sidney Sax Early Career Fellowship Grant from the National Health and Medical Research Council (GNT1121611). The Principal Supervisor from the Australian National University (MS) is supported by a Westpac Research Fellowship.

Conflicts of interest: none declared.

Australia - Regulations on Entry, Stay and Residence for PLHIV

Restriction category relative to australia.

• Countries with restrictions for long term stays (>90 days)

HIV-specific entry and residence regulations for Australia

REGULATIONS UPDATE UNAIDS reports that Australia has made reforms to its migration health assessment requirements and procedures, including an annual increase to the “significant cost threshold”, the elimination of the cost assessment related to health services for humanitarian visa applicants and improvement to increase the transparency of the health assessment process. Also, it has been confirmed that a HIV pilot programme for African student visa applicants was officially discontinued in 2011. HIV testing for permanent visa applicants remains in force. People living with HIV are treated similarly to other people with chronic health conditions and disabilities during the country’s immigration health assessment process. Applications for visas from people living with HIV will be assessed against criteria applying to anyone with a chronic health condition. (Source: 3) Editor’s note: Due to the HIV test requirement for permanent visa applicants, we continue to list Australia as a country applying residency restrictions. We will update this page as soon as further information becomes available.

Entry and residence regulations Applicants for visas to visit or migrate to Australia are required to meet certain health requirements. These help ensure that:

• Risks to public health in the Australian community are minimized
• Public expenditure on health and community services is contained
• Australian residents have access to health and other community services in short supply.

Temporary visas Applicants for a temporary visa do not generally need to complete an HIV test. The exceptions apply to temporary visa applicants intending to work or study to become a doctor, dentist, nurse or paramedic. Students (and their dependents) from sub-Saharan Africa who intend to study in Australia for 12 months or more are also tested for HIV. Permanent visas All applicants for a permanent visa must complete an HIV test if they are 15 years or older. Individuals under 15 who may be required to undergo testing are listed here: https://immi.homeaffairs.gov.au/help-support/meeting-our-requirements/health/who-needs-health-examinations If a person is found to be HIV positive, a decision on whether they meet the health requirement for a visa is considered on the same grounds as any other pre-existing medical condition. That is, the disease or condition is not likely to:

• Require healthcare or community services while in Australia
• Result in significant costs to the Australian community
• Prejudice the access of an Australian citizen or permanent resident to healthcare or community services.

A person who initially fails the health requirement, may have it subsequently waived if they are applying for a certain limited number of visa types. The circumstances under which they may have it waived are listed here:  https://immi.homeaffairs.gov.au/help-support/meeting-our-requirements/health/who-needs-health-examinations

Up-to-date information, including information on Australia’s temporary and permanent visas, and the health requirements for each, is available at www.immi.gov.au . (Source 1,2) Some HIV/AIDS entry restrictions exist for visitors and foreigners seeking permanent residence in Australia. Depending on the type of visa you apply for, the length of your stay and your intended activities in Australia, you may be required to undergo a medical examination before the Australian Department of Immigration and Border Protection will issue you a visa. If during the course of the application process, you are found to be HIV positive, a decision on the application will be considered on the same grounds as any other pre-existing medical condition (such as tuberculosis or cancer), with the main focus being placed on the cost of the condition to Australia’s healthcare and community services. (Source: 4)

HIV treatment information for Australia

• Albion Street Centre   150 Albion St. Surry Hills 2010 NSW 2010 Australia Phone: 9332 1090 Fax: 9332 4219 E-mail: [email protected] Web: www.sesahs.nsw.gov.au/albionstcentre/   
• Sydney Sexual Health Service Nightingale Wing 3rd. Floor Sydney Hospital Maquarie St. Sydney 2000 Phone: 9382 7440 Fax: 9382 7475  
• AIDS Council of NSW (Acon Sydney) 9 Commonwealth St. Surry Hills P0 Box 350, Darlinghurst 1300 E-mail: [email protected] Phone: 9206 2000

HIV information / HIV NGOs in Australia

Global criminalisation of hiv transmission scan.

• Matthew McMahon, Assistant Director, Health Policy Section, Migration and Visa Policy, Department of Immigration and Citizenship, Belconnen ACT 2617 www.immi.gov.au , January 8, 2010; sent via Asia and Oceania Department, Ministry of Foreign Affairs, The Netherlands
• Michael Frommer, Australian Federation of AIDS Organisations, PO Box 51 Newtown NSW 2042 / level 1, 222 King Street, Newtown 2042, Australia, www.afao.org.au , by e-mail, August 28, 2014
• UNAIDS; Geneva, press release, July 10, 2014
• US State Department Of State; Bureau of Consular Affairs; https://travel.state.gov / December 17, 2019; consulted June 3, 2021

updated: 6/3/2021 Corrections and additions welcome. Please use the contact us form.

Comments on HIV-restrictions in Australia

• About the Handbook

Tuberculosis

Information about tuberculosis (TB) disease, vaccines and recommendations for vaccination from the Australian Immunisation Handbook.

Recently added

This page was added on  05 June 2018 .

Updates made

This page was updated on 05 August 2022 .  View history of updates

Vaccination for certain groups of people is funded by states and territories .

Tuberculosis is caused by the bacterium Mycobacterium tuberculosis . Most people who become infected with M. tuberculosis have latent tuberculosis infection , which means they are not ill and not infectious. People with tuberculosis disease, in contrast, are ill and usually infectious.

BCG (bacille Calmette–Guérin) vaccine is recommended for:

• Aboriginal and Torres Strait Islander children aged <5 years in some parts of Australia
• Healthcare workers with a high risk of exposure to tuberculosis
• Young children who will be travelling to settings with high tuberculosis incidence
• Some children born to parents from countries with high tuberculosis incidence
• Young children who are a household contact of a person with leprosy

BCG vaccine is given as a single dose by intradermal injection .

A tuberculin skin test pre-vaccination is recommended for some people prior to BCG vaccination, based on a risk assessment of the likely exposure to tuberculosis in the past.

The World Health Organization considers tuberculosis a global emergency. BCG vaccine is recommended for those at highest risk of severe outcomes of tuberculosis.

Recommendations

Aboriginal and torres strait islander people.

Aboriginal and Torres Strait Islander people in some states and territories experience a significant burden of tuberculosis (see Tuberculosis in Australia ). BCG vaccine is recommended for young children living in these regions. 1 Consult state and territory guidelines for more details on BCG vaccination programs for Aboriginal and Torres Strait Islander children.

Tuberculin skin test screening before vaccination is only required in some circumstances. See Tuberculin skin testing before vaccination for details.

See also Vaccination for Aboriginal and Torres Strait Islander people .

Occupational groups

The efficacy of BCG vaccination in adults is more limited compared with in children. See Vaccine Information.

In the workplace, tuberculosis prevention and control should focus on:

• infection control measures
• employment-based screening
• therapy for latent tuberculosis infection

Healthcare workers working overseas in high tuberculosis incidence settings, particularly those with limited infection prevention and control measures, have an increased risk of acquiring tuberculosis. Assess the need for BCG vaccination in these workers.

Consider BCG vaccination for TST negative health care workers in any setting who are at high risk of exposure to drug resistant tuberculosis. This is because drug resistant infections are difficult to treat.

Some other occupational groups have a risk of tuberculosis exposure but are not recommended to receive BCG vaccine because the evidence of benefit of BCG vaccination is limited and infection prevention can be undertaken. This includes healthcare workers at tuberculosis clinics or refugee health clinics, embalmers and people involved in autopsies.

Children aged <5 years travelling to countries with high tuberculosis incidence (>40 cases per 100,000 population per year) are at increased risk of acquiring tuberculosis and developing severe disease. 2 BCG vaccine is most effective at preventing severe tuberculosis (miliary tuberculosis and tuberculous meningitis) in children. See Epidemiology and Vaccine information .

Children should ideally receive the vaccine at least 3 months before departure to a high risk destination. Consider discussing future travel plans with parents and carers of young infants at the earliest possible age.

The risk assessment should take account of the following:

• the child’s age
• how long they are in the high-risk area — the longer the exposure the higher the risk of infection
• the proximity of contact to others — staying with friends or family members in the community increases the risk of infection, particularly if they have a history of recent tuberculosis
• the tuberculosis incidence at the destination

See the World Health Organization’s country-specific incidence data . 3

If additional information is needed to support the risk assessment, seek expert input. Discuss with state or territory tuberculosis services, a paediatric infectious diseases specialist or travel vaccine centres.

BCG vaccine is not as effective in older children and adults. It is not recommended for people in these age groups who are travelling to a country with high tuberculosis incidence, except in some healthcare workers.

Other groups

Children aged <5 years born to parents from countries with high tuberculosis incidence who are now living in Australia are not recommended to receive BCG vaccine, because of the low incidence of tuberculosis in Australia and the uncertainty of the benefit of vaccination compared with the risk of vaccine adverse events.

Tuberculosis is uncommon in children born in Australia. However, children born in Australia to parents from countries with a high tuberculosis incidence (>40 cases per 100,000 population per year) may have a higher risk of tuberculosis exposure from parents and travelling family, in their early life. 4 BCG vaccination may be recommended in some cases, based on an individual risk assessment.

Children born outside of Australia may also be at high risk of disease, but have often previously received a BCG vaccine shortly after birth in their country of birth. See Epidemiology .

Tuberculin skin test (TST) screening before vaccination is only required in some circumstances. See Tuberculin skin testing before vaccination for details.

BCG vaccine provides some protection against infection with Mycobacterium leprae , the organism that causes leprosy. 5 Children aged <5 years with family or household contacts who have leprosy may be recommended to receive BCG vaccine, based on an individual risk assessment.

Tuberculin skin testing before vaccination

The need for TST should be determined by an individual risk assessment that considers whether the person:

• was born in a tuberculosis-endemic country (>40 cases per 100,000 population per year)
• has lived or travelled to a tuberculosis-endemic country or region (>40 cases per 100,000 population per year)
• had exposure to a close contact with tuberculosis or who is under investigation for tuberculosis

If an immunocompetent person who was required to have a TST is confirmed to be negative (induration of <5mm), they can receive BCG vaccine. A person with a TST of 5mm or greater or who has an accelerated BCG reaction (see below), should be considered for further investigation of latent or active tuberculosis.

The TST uses tuberculin, a purified protein derivative. This causes a hypersensitivity reaction in people who have previously been infected with Mycobacterium tuberculosis . ‘False positive’ hypersensitivity reactions can also occur in:

• people infected with other (non-tuberculous) mycobacteria

• people who have previously received BCG vaccine. Vaccination interferes with the interpretation of tuberculin skin test (TST) results

Interferon-gamma release assays (IGRAs) are a type of blood test that can detect M. tuberculosis infection (similar to the TST), but the TST is still the preferred method of screening for past tuberculosis exposure before BCG vaccination. Although TST and IGRA essentially provide the same information, there is uncertainty about whether hypersensitivity detected by IGRA is also associated with an accelerated local BCG reaction (as is the case with a positive TST). 6

Both measles virus and measles-containing live attenuated vaccines  7,8 inhibit the response to tuberculin. TST-positive people may become TST-negative for 4–6 weeks after measles infection or vaccination. This should be taken into account when considering the timing of a TST in people who have had a measles-containing vaccine.

You can give a tuberculin skin test on the same day or visit with a COVID-19 vaccine. There is no specific time interval restriction between a tuberculin skin test and receiving a COVID-19 vaccine. Inhibition of response to a tuberculin skin test is not expected following administration of COVID-19 vaccines.

People with cellular immune compromise may also have a false negative TST, and BCG vaccination is generally contraindicated in this group since it is an attenuated live vaccine. See Contraindications and precautions .

Health professionals must correctly administer and interpret the TST. Consult state or territory tuberculosis guidelines for advice.

Vaccines, dosage and administration

Tuberculosis vaccines available in australia.

The Therapeutic Goods Administration website provides product information for each vaccine .

See also Vaccine information  for more details.

Note: The only BCG vaccine registered for use in Australia ( BCG vaccine (Sanofi-Aventis Australia)) has not been available for some time.

Other BCG vaccines are available in Australia under a special prescribing arrangement (e.g. BCG Vaccine SSI [Statens Serum Institut, Denmark]). These vaccines can be used in the same manner as the registered unavailable vaccine. Contact state and territory public health authorities for more information on obtaining BCG vaccines. See also Public health management .

Please note that different vaccines may use different strains of M. tuberculosis which may differ slightly in antigenic properties. See Vaccine information .

Dose and route

BCG vaccine is a single dose given by intradermal injection . The standard dose is:

• In newborns and infants <12 months of age, the dose is 0.05 mL.
• In children ≥12 months of age and adults, the dose is 0.1 mL.

If BCG is inadvertently given subcutaneously, there is no need to repeat vaccination as the vaccine will still have a protective effect. The person should be informed that they may be more likely to experience an injection site reaction, or regional lymph node involvement, but overall BCG is a very safe vaccine.

Only healthcare workers who are trained in intradermal vaccination procedures should administer BCG vaccine. See Administration of vaccines .

BCG revaccination is generally not recommended, because of a lack of evidence for increased efficacy . 9

BCG vaccine may be available from state and territory tuberculosis services , and may be available through some travel medicine clinics.

BCG vaccination procedures

BCG vaccination steps are:

1. Wear protective eyewear

The following people should wear protective eyewear:

• the person giving the vaccine
• the person receiving the vaccine
• the parent or carer holding a small child who is receiving the vaccine

Eye splashes can ulcerate. If eyes are splashed, wash the eyes with saline or water immediately. Any irritation to the eye as a result of a should be followed up in the subsequent weeks, with an assessment by a medial practitioner and/or a specialist ophthalmologist.

2. Identify the correct injection site

Inject BCG vaccine into the skin over the region where the deltoid muscle inserts into the humerus. This is just above the midpoint of the upper arm. This site is recommended to minimise the risk of keloid formation.

By convention, use the left upper arm, if possible. This can assist people who may later look for evidence of BCG vaccination.

3. Inject the vaccine intradermally

See Administration of vaccines for information on the intradermal vaccination technique.

Response to BCG vaccination

After BCG vaccination, a small, red papule forms and ulcerates within 2–3 weeks of vaccination. The ulcer heals with minimal scarring over several weeks. Local lymph nodes may be swollen and tender.

More serious injection site reactions are less common. See Adverse events .

People who have latent or previous tuberculosis infection and receive BCG vaccine are likely to have an accelerated response. An accelerated cutaneous reaction to BCG is not more severe than typical BCG reactions and have no long-term detrimental effect - it simply occurs more rapidly. This is characterised by:

• induration within 24–48 hours
• pustule formation within 5–7 days
• healing within 10–15 days

Clinical trials have not shown a consistent relationship between the size of tuberculin reactions after BCG vaccination and the level of protection.

Performing a TST to demonstrate immunity after BCG vaccination is not recommended. 10,11

Co-administration with other vaccines

People can receive BCG vaccine at the same time as, or at any time after, other inactivated vaccines.

People can receive BCG vaccine and another live parenteral vaccine (such as MMR [measles-mumps-rubella], varicella or yellow fever) either on the same day or at least 4 weeks apart.

For three months following a BCG vaccine, do not give any other vaccine in the same arm.

People can receive BCG vaccine at any time in relation to oral live vaccines. These include rotavirus vaccine and oral poliovirus vaccine (in infants who have received it overseas).

Contraindications and precautions

Contraindications.

BCG vaccine is contraindicated in people who have had anaphylaxis after any component of a tuberculosis vaccine.

BCG is an attenuated live vaccine that is contraindicated in the following groups:

• people with known or suspected HIV infection ,12 even if they are asymptomatic or have normal immune function. This is because of the risk of disseminated BCG infection 13,14
• people treated with high doses of corticosteroids or other immunosuppressive therapy . These therapies include monoclonal antibodies against tumour necrosis factor (TNF)-alpha, such as infliximab, etanercept and adalimumab. See Vaccination for people who are immunocompromised
• people with congenital cellular immunodeficiencies, including specific deficiencies of the interferon-gamma pathway
• people with active malignancies involving bone marrow or lymphoid systems, any person with cancer receiving immunosuppressive therapy , or people who completed chemotherapy within the previous 3 months. See People with cancer in Vaccination for people who are immunocompromised
• people with any serious underlying illness, including severe malnutrition
• pregnant women. BCG vaccine has not been shown to harm the fetus, but receiving live vaccines in pregnancy is not recommended
• people who have previously had tuberculosis or a positive (≥5 mm) TST

Precautions

Defer BCG vaccination in the following groups:

• neonates who are medically unstable, until the neonate is in good medical condition and ready for discharge from hospital
• infants born to mothers who are suspected or known to be HIV-positive, until HIV infection of the infant can be confidently excluded
• people with active skin disease such as eczema, dermatitis or psoriasis at or near the site of vaccination
• people being treated for latent tuberculosis infection , because the therapy is likely to inactivate the BCG vaccine
• people with significant febrile illness, until 1 month after recovery
• infants aged <6 months born to mothers who were treated with bDMARDs (biologic disease-modifying anti-rheumatic drugs) in the 3rd trimester of pregnancy. These medicines include TNF-alpha-blocking monoclonal antibodies. These infants often have detectable TNF-alpha-blocking antibodies for several months.15-17 See also Use of immunosuppressive therapy during pregnancy in Vaccination for women who are planning pregnancy, pregnant or breastfeeding

Vaccination before or after administration of immunoglobulin or blood products

People can receive BCG vaccine at any time before or after receiving immunoglobulin or any antibody-containing blood product. These preparations and BCG vaccines have minimal interaction. 18 See also Vaccination for people who have recently received normal human immunoglobulin and other blood products .

Adverse events

The normal reaction to BCG vaccination is described in Vaccines, dosage and administration . With the proper procedure less than 5% of vaccinated people experience adverse events; ~2.5% may develop a local injection site ‘cold abscess’ and ~1% regional lymphadenitis with/without ‘cold abscess’ formation. 19

Other adverse events include: 20

• local suppurative complications. This does not require treatment with anti-tuberculosis medicine unless there is perceived risk of disseminated BCG disease (see below), but BCG is inherently resistant to pyrazinamide and optimal treatment requires careful consideration; 21 it is best to seek specialist advice from state or territory tuberculosis services .
• keloid formation. This risk is minimised if the injection is no higher than the level of insertion of the deltoid muscle into the humerus
• disseminated BCG disease, but the risk is extremely low (1–4 cases per million vaccinated people) and it is only observed in people with immune compromise. Treatment with anti-tuberculosis medicines may be warranted, but BCG is inherently resistant to pyrazinamide and optimal treatment requires careful consideration; 21 it is best to seek specialist advice from state or territory tuberculosis services.

Nature of the disease

Tuberculosis is caused by Mycobacterium tuberculosis and other organisms of the M. tuberculosis complex (M. TB complex) 22 . M. tuberculosis is the cause of almost all tuberculosis in Australia 23

Pathogenesis

Infection usually occurs when a person inhales the tuberculosis bacteria , which reach the lungs. M. bovis can be ingested from unpasteurised milk, consumed in countries where M. bovis remains prevalent (not Australia)

If the person’s immune system can contain the bacteria , the person will be infected but not develop active disease. This is called latent tuberculosis infection .

If the bacteria overcome the immune system, which may occur after many years of immune control, the person develops active disease and may become infectious if pulmonary disease occurs. 24

Transmission

M. tuberculosis is usually transmitted by the airborne route. Factors affecting transmission include: 22

• duration of exposure
• frequency of exposure
• proximity to the infected person (high-density or communal living situations may increase the risk of transmission)

Persons with extrapulmonary TB with no lung or larygneal involvement are not infectious.

Clinical features

Tuberculosis most commonly presents as lung disease, which accounts for 60% of notified tuberculosis cases in Australia. 25 Common symptoms of pulmonary tuberculosis are:

• weight loss
• coughing up blood (mainly in adults with late-stage pulmonary disease)

Extrapulmonary tuberculosis can occur in any part of the body. Tuberculosis lymphadenitis is the most common extrapulmonary manifestation.

Disseminated disease (miliary tuberculosis) and meningeal tuberculosis are more common in very young children. 26 These are among the most serious manifestations of tuberculosis disease. 20

Most people infected with M. tuberculosis remain asymptomatic. There is a 10% lifetime risk of developing clinical illness. Clinical disease can develop many years after the original infection . The risk varies depending on age and immune status.

Groups more prone to rapidly progressive disease include: 22

• young children (infants and children <5 years of age)
• elderly people
• people who are immunocompromised as a result of medical treatment, disease or adverse socioenvironmental circumstances.

Epidemiology

Tuberculosis in australia.

In Australia, tuberculosis is an uncommon disease, with annual incidence remaining below 7 per 100,000 population since 1980s. 27

Most tuberculosis cases in Australia (more than 85%) occur in people who were born overseas, especially in countries with a high incidence of tuberculosis. 3,28 See latest WHO Global Tuberculosis Report for up-to-date information . 29

The rate of multidrug-resistant (MDR) tuberculosis in Australia remains low (approximately 2% of bacteriologically confirmed cases with drug susceptibility testing available). 30

Tuberculosis in animals ( Mycobacterium bovis ) has been eradicated in Australia by screening and culling programs. 31

Tuberculosis in Aboriginal and Torres Strait Islander people

In most states and territories, rates of tuberculosis among Aboriginal and Torres Strait Islander people overall are comparable to rates among Australian-born non-Indigenous people. However, notifications of tuberculosis among Aboriginal and Torres Strait Islander people in some states and territories are disproportionately higher than for Aboriginal and Torres Strait Islander people and non-Indigenous people in other states.

Regions with higher rates of tuberculosis include: 25

• the Northern Territory
• Far North Queensland

See Vaccination for Aboriginal and Torres Strait Islander people .

Screening for tuberculosis

Screening programs in Australia focus on:

• contacts of notified cases
• people at increased risk of tuberculosis infection , including refugees and healthcare workers

Tuberculosis in other countries

The World Health Organization declared tuberculosis a global emergency in 1993, and recent reports have reaffirmed the threat to human health. 32 In 2019, there were about 7.1 million incident cases of tuberculosis globally. 29

Vaccine information

When reconstituted, BCG vaccine is a suspension of a live attenuated strain of M. bovis . Worldwide, many BCG vaccines are available, but they are all derived from the original strain selected by Calmette and Guerin, which was first tested in humans in 1921. 33

Sanofi-Aventis Australia markets the only BCG vaccine registered for use in Australia, although this vaccine is currently unavailable. See Vaccines, dosage and administration . Contact your state or territory health authority to access a BCG vaccine.

Efficacy of BCG vaccine

In children.

BCG vaccination in young children provides: 34

• ~25% protection against tuberculosis infection
• ~70% protection against active tuberculosis
• >70% protection against severe forms of tuberculosis disease in young children, including miliary tuberculosis and tuberculosis meningitis. 35-39

The efficacy of BCG vaccine against pulmonary disease in adults is less consistent, and has ranged from no protection to 80% in controlled trials. 35   The reason for the wide variation is not clear, but it has been attributed to differences in:

• study quality
• BCG strains
• host factors, such as age at vaccination and nutritional status
• the prevalence of infection with environmental mycobacteria

Duration of protection

The duration of protection after BCG vaccination has been difficult to measure because the time between infection and disease can be decades. Benefit from infant vaccination has been found in studies with follow-up of up to 40 years, but protection is thought to decline over 10–20 years. 20 Immune memory responses may remain for 10–50 years. 41-43

Other uses of BCG vaccine

BCG vaccination offers some protection against Mycobacterium leprae , which causes leprosy. 5

BCG is also used as treatment for bladder cancer, but this is a different preparation that is instilled directly into the bladder.

Transporting, storing and handling vaccines

The currently available vaccine, BCG Vaccine SSI, is presented in a multidose vial. For more information on use of multidose vials, see Administration of vaccines .

Transport according to National Vaccine Storage Guidelines: Strive for 5. 44 Store at +2°C to +8°C. Do not freeze. Protect from light.

BCG vaccine must be reconstituted . Add the entire contents of the diluent container to the vial and shake until the powder completely dissolves. Reconstituted vaccine is very unstable. Use within 4–6 hours.

Public health management

Tuberculosis is a notifiable disease in all states and territories in Australia. The Communicable Diseases Network Australia national guidelines for the public health management of tuberculosis 40 have details on the management of tuberculosis cases and their contacts.

State and territory public health authorities can provide further advice about:

• public health management of tuberculosis
• using alternative vaccine products in special circumstances, such as during shortages of the registered vaccine
• National Tuberculosis Advisory Committee. The BCG vaccine: information and recommendations for use in Australia – National Tuberculosis Advisory Committee update October 2012. Communicable Diseases Intelligence 2013;37:E65-72.
• Toms C, Stapledon R, Coulter C, Douglas P, National Tuberculosis Advisory Committee. Tuberculosis notifications in Australia, 2014. Communicable Diseases Intelligence 2017;41:E247-63.
• World Health Organization. World health statistics - Tuberculosis profile. 2022. (Accessed 25 April 2022). https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22AF%22
• Smith BB, Hazelton BJ, Heywood AE, et al. Disseminated tuberculosis and tuberculous meningitis in Australian-born children; case reports and review of current epidemiology and management. Journal of Paediatrics and Child Health 2013;49:E246-50.
• Zodpey SP, Bansod BS, Shrikhande SN, Maldhure BR, Kulkarni SW. Protective effect of Bacillus Calmette Guerin ( BCG ) against leprosy: a population-based case-control study in Nagpur, India. Leprosy Review 1999;70:287-94.
• National Tuberculosis Advisory Committee. Position statement on interferon-γ release assays in the detection of latent tuberculosis infection . Communicable Diseases Intelligence 2012;36:125-31.
• McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). [erratum appears in MMWR Morb Mortal Wkly Rep. 2015 Mar 13;64(9):259]. MMWR. Recommendations and Reports 2013;62(RR-4):1-34.
• Starr S, Berkovich S. Effects of measles, gamma-globulin-modified measles and vaccine measles on the tuberculin test. New England Journal of Medicine 1964;270:386-91.
• World Health Organization. SAGE Evidence to recommendations framework. 2017. (Accessed 28 March 2022). https://www.who.int/immunization/sage/meetings/2017/october/2_EvidencetoRecommendationFramework_BCG.pdf
• Menzies D. What does tuberculin reactivity after bacille Calmette-Guérin vaccination tell us? Clinical Infectious Diseases 2000;31 Suppl 3:S71-4.
• Hart PD, Sutherland I, Thomas J. The immunity conferred by effective BCG and vole bacillus vaccines in relation to individual variations in induced tuberculin sensitivity and to technical variations in the vaccines. Tubercle 1967;48:201-10.
• Hesseling AC, Marais BJ, Gie RP, et al. The risk of disseminated Bacille Calmette-Guerin ( BCG ) disease in HIV-infected children. Vaccine 2007;25:14-8.
• Hesseling AC, Cotton MF, Fordham von Reyn C, et al. Consensus statement on the revised World Health Organization recommendations for BCG vaccination in HIV-infected infants. International Journal of Tuberculosis and Lung Disease 2008;12:1376-9.
• Mansoor N, Scriba TJ, de Kock M, et al. HIV-1 infection in infants severely impairs the immune response induced by Bacille Calmette-Guérin vaccine. Journal of Infectious Diseases 2009;199:982-90.
• Cheent K, Nolan J, Shariq S, et al. Case report: Fatal case of disseminated BCG infection in an infant born to a mother taking infliximab for Crohn's disease. Journal of Crohn's and Colitis 2010;4:603-5.
• Mahadevan U, Terdiman JP, Church J, et al. Infliximab levels in infants born to women with inflammatory bowel disease. Gastroenterology 2007;132 Suppl 2:A144.
• Mahadevan U, Miller JK, Wolfe DC. Adalimumab levels detected in cord blood and infants exposed in utero. Gastroenterology 2011;140 Suppl 1:S61-2.
• Connelly Smith K, Orme IM , Starke JR. Tuberculosis vaccines. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines. 6th ed. Philadelphia, PA: Elsevier Saunders; 2013.
• Turnbull FM, McIntyre PB, Achat HM, et al. National study of adverse reactions after vaccination with bacille Calmette-Guérin. Clinical Infectious Diseases 2002;34:447-53.
• World Health Organization. BCG vaccines: WHO position paper – February 2018. Weekly Epidemiological Record 2018;93:73-96.
• Hesseling AC, Rabie H, Marais BJ, et al. Bacille Calmette-Guérin vaccine-induced disease in HIV-infected and HIV-uninfected children. Clinical Infectious Diseases 2006;42:548-58.
• Fitzgerald DW, Sterling TR, Haas DW. Mycobacterium tuberculosis. In: Bennett JE , Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015.
• Lumb R, Bastian IB, Jelfs PJ, et al. Tuberculosis in Australia: bacteriologically-confirmed cases and drug resistance, 2011. A report of the Australian Mycobacterium Reference Laboratory Network. Communicable Diseases Intelligence 2014;38:E369-75.
• National Center for HIV/ AIDS , Viral Hepatitis, STD, and TB Prevention, Division of Tuberculosis Elimination. Introduction to the Core Curriculum on Tuberculosis: what the clinician should know. 6th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2013. https://www.cdc.gov/tb/education/corecurr/pdf/corecurr_all.pdf
• Barry C, Konstantinos A, National Tuberculosis Advisory Committee. Tuberculosis notifications in Australia, 2007. Communicable Diseases Intelligence 2009;33:304-15.
• Perez-Velez CM, Marais BJ. Tuberculosis in children. New England Journal of Medicine 2012;367:348-61.
• Bareja C, Waring J, Stapledon R, Toms C, Douglas P. Tuberculosis notifications in Australia, 2011. Communicable diseases intelligence quarterly report 2014;38:E356-68.
• NSW Health. List of countries with a tuberculosis incidence of 40 cases per 100,000 persons or greater. 2021. (Accessed 28 March 2022). https://www.health.nsw.gov.au/Infectious/tuberculosis/Pages/high-incidence-countries.aspx
• World Health Organization. Tuberculosis data: global tuberculosis report. 2021. (Accessed 28 March 2022). https://www.who.int/teams/global-tuberculosis-programme/data
• World Health Organization. BCG vaccines: WHO position paper – February 2018. 2018. (Accessed 28 March 2022). https://apps.who.int/iris/bitstream/handle/10665/260307/WER9308-73-96.pdf?sequence=1&isAllowed=y
• Ingram PR, Bremner P, Inglis TJ, Murray RJ, Cousins DV. Zoonotic tuberculosis: on the decline. Communicable Diseases Intelligence 2010;34:339-41.
• World Health Organization (WHO). The End TB Strategy: global strategy and targets for tuberculosis prevention, care and control after 2015. Geneva: WHO; 2014. http://www.who.int/tb/strategy/End_TB_Strategy.pdf
• Wittes RC. Immunology of bacille Calmette-Guérin and related topics. Clinical Infectious Diseases 2000;31 Suppl 3:S59-63.
• Roy A, Eisenhut M, Harris RJ, et al. Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systematic review and meta-analysis. BMJ 2014;349:g4643.
• Bourdin Trunz B, Fine PE, Dye C. Effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide: a meta-analysis and assessment of cost-effectiveness. The Lancet 2006;367:1173-80.
• Colditz GA, Berkey CS, Mosteller F, et al. The efficacy of bacillus Calmette-Guérin vaccination of newborns and infants in the prevention of tuberculosis: meta-analyses of the published literature. Pediatrics 1995;96:29-35.
• Rodrigues LC, Diwan VK, Wheeler JG. Protective effect of BCG against tuberculous meningitis and miliary tuberculosis: a meta-analysis. International Journal of Epidemiology 1993;22:1154-8.
• Colditz GA, Brewer TF, Berkey CS, et al. Efficacy of BCG vaccine in the prevention of tuberculosis: meta-analysis of the published literature. JAMA 1994;271:698-702.
• Brewer TF. Preventing tuberculosis with bacillus Calmette-Guérin vaccine: a meta-analysis of the literature. Clinical Infectious Diseases 2000;31 Suppl 3:S64-7.
• Barreto ML, Pereira SM, Ferreira AA. BCG vaccine: efficacy and indications for vaccination and revaccination. Jornal de Pediatria 2006;82(3 Suppl):S45-54.
• Aronson NE, Santosham M, Comstock GW, et al. Long-term efficacy of BCG vaccine in American Indians and Alaska Natives: a 60-year follow-up study. JAMA 2004;291:2086-91.
• Sterne JA, Rodrigues LC, Guedes IN. Does the efficacy of BCG decline with time since vaccination? International Journal of Tuberculosis and Lung Disease 1998;2:200-7.
• Weir RE, Gorak-Stolinska P, Floyd S, et al. Persistence of the immune response induced by BCG vaccination. BMC Infectious Diseases 2008;8:9.
• National vaccine storage guidelines: Strive for 5. 2nd ed. Canberra: Australian Government Department of Health and Ageing; 2013. https://beta.health.gov.au/resources/publications/national-vaccine-storage-guidelines-strive-for-5-2nd-edition
• Communicable Diseases Network Australia ( CDNA ). Tuberculosis ( TB ): CDNA national guidelines for the public health management of TB . Canberra: Australian Government Department of Health; 2015. http://www.health.gov.au/cdnasongs

Page history

Recommendations for skin testing before BCG vaccination have changed. A tuberculin skin test before BCG vaccination is now only recommended in limited circumstances, based on a risk assessment.

Updates to all sections of the Tuberculosis chapter have been made including Recommendations, Vaccines, dosage and administration, Contraindications and precautions, Adverse events, Nature of the disease, Clinical features, Epidemiology, Vaccine information, Transporting, storing and handling vaccines, Public health management and Variations from product information.

Changes to 4.20.10 Precautions

4.20.10 Precautions

Addition of text to clarify when BCG vaccination should be deferred in people with skin conditions.

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Acknowledgement

The Department of Health and Aged Care acknowledges First Nations peoples as the Traditional Owners of Country throughout Australia, and their continuing connection to land, sea and community. We pay our respects to them and their cultures, and to all Elders both past and present.

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