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Principles for the Management of Tuberculosis in NSW PD2014_050 Tuberculosis – Minimising the Risk of Tuberculosis in Patients Starting Anti TNF GL2008_007 Inhibitors Tuberculosis – Sputum Induction Guidelines GL2009_006 Tuberculosis in Children and Adolescents GL2005_060 Tuberculin Skin Testing PD2009_005 BCG (Bacille Calmette Guerin) Vaccination PD2013_032 Tuberculosis Contact Tracing PD2008_017 Rescinding PD2005_209 Tuberculosis Screening & Protection – Health Care IB2007_016 Worker Sexually Transmissible Diseases HIV/AIDS, NSW Supported Accommodation Plan 2007-2010 GL2008_004 HIV/AIDS STI & Hepatitis C Strategies: Implementation Plan for Aboriginal GL2007_002 People 2006-2009 Hepatitis B Vaccination Policy PD2005_222 Australian Childhood Immunisation Register PD2005_085 Australian Childhood Immunisation Register (ACIR) PD2005_098 Immunisation Services - Authority for Registered Nurses and Midwives PD2015_011 Pandemic Management – Governance Arrangements – Escalation of Health System GL2009_011 Response Influenza – Minimising Transmission of Influenza in Healthcare Facilities: 2010 GL2010_006 Influenza Season Statewide Standing Orders for the Supply or Administration of Medication for PD2013_035 Public Health Response Influenza Pandemic – Providing Critical Care PD2010_028 Influenza – NSW Health Influenza Pandemic Plan PD2010_052 Management of Reportable Infection Control Incidents PD2005_203 Infection Control Policy PD2007_036 Infection Control Policy: Prevention & Management of Multi-Resistant Organisms PD2007_084 (MRO) Infection Control Policy - Animals as Patients in Health Organisations PD2009_030 Community Sharps Disposal by Area Health Services PD2008_004 NSW Needle and Syringe Program Guideline 2013

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(PD2014_050) PD2014_050 rescinds PD2009_028, PD2008_019, PD2005_159 & PD2008_018.

PURPOSE This policy sets out the mandatory principles for the provision of Tuberculosis (TB) services in New South Wales (NSW).

TB Services are required to operate in accordance with this policy in conjunction with the current relevant guidelines for the prevention and control of tuberculosis in NSW, which reflect best practice for the clinical and public health management of TB.


All staff must adhere to these principles. All services related to the screening, care and management of people with active, latent, or suspected TB are available at no charge to patients within the NSW Public Health system. The treatment for people with active TB is to be administered by directly observed treatment.


Chief Executives must ensure that:

• The principles and requirements of this policy are applied, achieved and sustained.

• Relevant staff are made aware of their obligations in relation to the Policy Directive.

• Documented procedures are in place to support the Policy Directive.


• Must comply with this Policy Directive.


1.1 About this document Tuberculosis (TB) continues to be a disease of public health significance in Australia. Each year there are over 1300 cases of active TB notified in Australia and approximately 40% of these cases live in NSW.

The clinical and public health management of patients with TB requires a collaborative approach.

Treating physicians are responsible for the implementation of appropriate treatment strategies with the support of TB services.

NSW TB services are delivered through a network of metropolitan and regional local health districts, in a range of environments, including; large metropolitan chest clinics and community health centres in regional and rural areas.

Patients with suspected or confirmed TB should be referred to their local TB service. The TB service should review the case, develop a management plan with the treating physician and initiate appropriate public health actions.

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TB is a notifiable condition. Doctors, hospitals and laboratories are required to notify all cases of active TB to either their local chest clinic or public health unit, in accordance with the NSW Public Health Act 2010.

1.2 Key definitions TB is caused by bacterium from the Mycobacterium tuberculosis complex. The disease most commonly occurs in the lungs (pulmonary TB), although it can affect any region of the body (extrapulmonary TB). The pulmonary form is most infectious.


Treatment for people with active TB should be administered by directly observed therapy (DOT), which means that a health professional observes the person take their medication and records the treatment that was administered.

Supervised TB treatment is a supportive measure provided to minimise the risk of development of drug resistance or reactivation of disease attributable to non-adherence, as well as facilitating early detection and attention to side-effects of TB treatment.


Multi-drug resistant TB (MDR-TB) is defined as disease caused by Mycobacterium tuberculosis bacilli that are resistant to isoniazid and rifampicin, with or without resistance to other first-line antituberculous agents. MDR-TB represents an important public health concern for the effective control of TB.

In order to ensure best practice management of MDR-TB, an expert panel will be convened by Health Protection NSW to review all identified cases of MDR-TB in NSW. The expert panel will review and provide advice on the clinical and public health management and develop a case management plan for each case of MDR-TB.


All patients diagnosed with TB in NSW should be tested for HIV using an HIV antibody/antigen test with standard informed consent.

Obtaining informed consent includes an explanation of the testing process, as well as a discussion of the possible outcomes of the test.

The HIV test should be undertaken shortly after TB diagnosis as the immediate commencement of antiviral therapy improves survival in people with advanced HIV infection and TB.


5.1 Provision of TB services free of charge to the patient All services related to diagnosis and treatment of suspected or proven TB (active or latent) are available at no charge to patients within the NSW public health system. This includes the provision of services for TB-related investigations, care and treatment.

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This policy applies to (but is not limited to) the following:

• All Australian residents, including prison inmates and persons in juvenile detention centres.

• Migrants and refugees referred by the Commonwealth and/or State Health Departments or their nominated delegates.

• Persons who are ineligible for Medicare benefits.

• Temporary residents or overseas visitors.

• Asylum seekers.

• Persons without legal status in Australia.

This policy applies regardless of whether the person attends with or without a referral from another health care provider.

5.2 Investigation All clinical, laboratory and other investigations for cases, or suspected cases, of TB (active or latent) carried out through admitted patient and non-admitted patient services (including ambulatory care services) in NSW public hospitals and health facilities must be provided free of charge to the patient.

5.3 Treatment and medication All medications related to the treatment of active or latent TB provided through admitted patient and non-admitted patient services (including ambulatory care) in NSW public hospitals and health facilities must be provided free of charge to the patient.

Medication and other treatments required for ensuring that TB treatment can be tolerated and/or completed without side effects must be provided free of charge to the patient.

Investigations required for patient monitoring prior to and during treatment, such as blood chemistry, audiometry and visual acuity, carried out through admitted patient and non-admitted patient services (including ambulatory care services) in NSW public hospitals and health facilities must be provided free of charge to the patient.

5.4 TB prevention

The provision of TB prevention services through admitted patient and non-admitted patient services (including ambulatory care) in NSW public hospitals and health facilities must be provided free of charge to the community and patients. These services include contact tracing assessments (TSTs, CXR and clinical evaluation), and professional and community education.

5.5 Circumstances where charging for TB services is permitted Local Health Districts may apply a fee for services in the specific situations listed below (5.2.1-5.2.5).

However, issues surrounding financial remuneration should not delay investigations, care, or treatment for persons with TB.

5.5.1 Occupational screening for students and new healthcare workers Students and new health service employees who require screening for TB in accordance with the policy directive, PD2011_005 Occupational Assessment, Screening and Vaccination against Specified Infectious Diseases.

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5.5.2 Occupational screening for existing healthcare workers Employers (in both the public and private sectors) of healthcare workers are responsible for meeting the cost of occupational screening programs related to TB, including TST. The principle for charging employers for occupational screening is one of cost recovery.

5.5.3 Occupational screening (other than healthcare workers) Any worker or group of workers requiring occupational screening for TB, unless this is related to contact screening, in which case it must be provided free of charge.

5.5.4 Immigration detention Where TB Services are provided to a person held under Commonwealth immigration detention, including persons in community detention, the local health district may charge the Commonwealth Department of Immigration through its contractor at the appropriate ineligible patient rate.

5.6 BCG vaccination TB Services may elect to charge patients a service fee for BCG vaccination.

5.7 Referral to private providers Where a public health organisation initiates investigations (on behalf of a patient) with a private practitioner or service, the public health organisation is responsible for meeting the cost of the service or investigations and the patient is not responsible for meeting these costs. Local health districts should have mechanisms in place for the reimbursement of private practitioners.

5.8 Medicare benefits

Medicare benefits cannot be paid for professional services related to the care and treatment of TB provided for public patients in public health facilities funded by either the State or Commonwealth Health Department unless the Federal Minister for Health has directed that Medicare benefits are to be paid.

Services related to investigations, care, treatment, screening and BCG vaccination provided within the public health system cannot be billed to Medicare.

For a Medicare benefit to be payable for a patient in a public hospital, the patient must be classified as a private patient, at the time the service was rendered.

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This Guideline is to be read in conjunction with the following Policy Directive:

PD2009_005 Tuberculin Skin Testing Introduction Tumor necrosis factor (TNF) is a proinflammatory cytokine which has a pivotal role in the pathogenesis of several autoimmune diseases, including rheumatoid arthritis and other inflammatory joint disease, psoriasis, and inflammatory bowel disease.

Three anti-TNF α agents are now available in Australia (infliximab, etanercept, and adalimumab) to treat selected autoimmune diseases. However, TNF α is a significant component of the human immune response to infection i, and treatment with anti-TNF α agents is associated with an increased risk of infection. The development of active Tuberculosis (TB) disease has occurred in some patients who have received anti-TNF α therapy in countries with high TB prevalence ii.

The following guidelines have been developed to reduce the risk of active TB developing in patients receiving anti-TNF α therapy.

Before starting ANTI-TNF α inhibitors all patients should have:

1. A careful review of their history of exposure to TB, and an assessment to exclude active TB.

A baseline Tuberculin Skin Test for evidence of TB infection. a 2.

3. A Chest X ray to exclude active TB and assess evidence of past or current TB.

Latent Tuberculosis Patients with evidence of latent tuberculosis infection (LTBI) who have not previously received effective treatment for TB and in whom active TB is excluded should be treated with isoniazid (5mg/kg to maximum of 300 mg/day) and pyridoxine (25mg/day) for a period of 9 months iii. The first month of isoniazid treatment should be completed prior to starting an anti-TNF α inhibitor. Evidence

of LTBI may include:

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Patients with chest x-ray abnormalities, cough or other clinical features suggestive of active TB should have sputum examined for AFBs before commencing treatment with isoniazid.

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