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During a five-week period in 1996, a passenger with highly infectious tuberculosis travelled on five long-haul aircraft flights. We investigated passengers and crew on two of these flights to identify whether transmission of Mycobacterium tuberculosis had occurred.Crew and passengers were identified from airline and immigration records. Contacts were notified of their exposure and invited to attend their local public health clinic. At the clinic, a questionnaire was administered by a public health worker, and a Mantoux skin test was performed. When indicated, a second test was carried out twelve weeks later. Test positivity and conversion were defined according to the 1996 New Zealand tuberculosis control guidelines.Data were obtained on 206 (87%) of the 238 contacts. Twenty four contacts had a positive Mantoux test result, four of which were conversions. All of these contacts had at least one other major risk factor for a positive result, such as a previous BCG vaccination (n=17) or having lived in a country in which tuberculosis is endemic (n=15). To our knowledge, no contacts have subsequently developed tuberculosis disease.The investigation produced inconclusive evidence about the hypothesis that Mycobacterium tuberculosis was transmitted on one or both of these flights.

To assess the operative outcome, cardiac and neurodevelopmental sequelae in infants with transposition of the great arteries (TGA) undergoing the arterial switch operation (ASO).Cross-sectional review of the 48 consecutive patients operated on in the calendar years 1995 and 1996 was undertaken to obtain recent cardiac, growth and neurodevelopmental parameters, and the mortality results were compared to the entire cohort of infants who underwent the ASO for definitive repair of TGA and double outlet right ventricle at Greenlane hospital between 1984 and 1998.Between January 1995 and December 1996, 48 patients underwent the ASO. 96% were alive, and 88% alive and free from reoperation or significant neurological sequelae at a mean followup interval of sixteen months. Six (13%) had important residual cardiac lesions, of which supra valvular pulmonary stenosis was the most common. Growth parameters at follow-up were normal, as was the neurodevelopmental progress of all but two survivors (96%).In the current era, the ASO is a relatively safe procedure with excellent cardiac and neurodevelopmental outcome in the majority of infants.

First, to quantify the interval between the onset of symptoms and the start of anti-tuberculous treatment in a series of Auckland tuberculosis patients. Second, to examine the help-seeking behaviour of the patients and the responses of the health-care providers whom they consulted about their symptoms. Third, to identify potentially modifiable reasons for delayed presentation or diagnosis.100 patients with tuberculosis (TB) were interviewed using a questionnaire which sought symptom duration and help-seeking behaviour. The doctors whom they consulted were surveyed about their diagnostic, therapeutic and referral responses.Delayed presentation by patients ('patient delay') was found in smokers, patients who reported cough, patients who hoped their symptoms would go away on their own, and patients reporting fear of what would be found on diagnosis. 'Doctor delay' (the interval from first consultation with a doctor to start of treatment) was longer than that found in most published series and was a more important component of total delay than delayed presentation by patients. Longer doctor delay was found if patients had pre-existing lung disease or consulted multiple doctors, and if doctors did not inquire into past exposure to TB or request a chest X-ray.Awareness programmes for high-risk communities are needed to encourage early reporting of symptoms. Continuing medical education for general practitioners is needed to encourage vigilance for TB and earlier use of diagnostic tests in patients who have symptoms of TB and are in high-risk groups.

To describe a school and community outbreak of tuberculosis in South Auckland in 1997/8.Cases were diagnosed according to national guidelines at Middlemore, Green Lane and Starship Hospitals. Public health follow-up was conducted by Auckland Healthcare.Twelve cases were diagnosed during the outbreak. Nine cases were from the same South Auckland secondary school; six reported no association outside school. Three cases were in younger children who had close household contact with two of the school cases. Nine cases (including eight from the school) had identical Mycobacterium tuberculosis isolates on restriction fragment length polymorphism testing. No microbiological culture was obtained from the three remaining cases. Contact investigation detected five of the cases. Chemoprophylaxis was prescribed for twenty-six school students, two adult staff, and nine household contacts.This is the first published account of a tuberculosis outbreak in a New Zealand school setting for decades. Recognition of the outbreak was delayed. DNA fingerprinting played a valuable role in the investigation. The source case may have been a school student. The social impact of the outbreak and preventability with routine adolescent BCG vaccination are discussed.

Immigrants and visitors are a significant factor in the epidemiology of tuberculosis (TB) in New Zealand, accounting for an increasing proportion of notifications in recent years. At present screening of immigrants from countries with a high incidence of TB is inadequate. There are deficiencies in procedures, inadequate screening coverage, ineffectual coordination between the Ministry of Health and New Zealand Immigration Service, incomplete follow-up on those at risk of TB, confusion over financial responsibility, inadequate data to describe the problems and monitor interventions, and a lack of commitment to assistance with TB control in neighbouring countries from which some of our TB arises. We make recommendations in all of these areas. Timely screening of high-risk immigrants should be seen as health protection for ethnic minorities.

To describe the recent epidemiology of tuberculosis in Auckland and the outcome of contact investigations.Routine public health data were used to review the experience of tuberculosis (TB) in the Auckland region during a twelve month period in 1992-3.There were 152 cases, an age-standardised rate of 2.7 per 100,000 for Europeans, 37.8 for Maori, 70.9 for Pacific Island Polynesians and 131.3 for other ethnic groups. Fifty-two (35%) were born in New Zealand; 46 (31%) in Asia; 44 (30%) in the Pacific Islands. Forty-seven percent of foreign-born cases (28% of all cases) arrived in New Zealand in the 4 years preceding their notification. Forty-one per cent of cases appear not to have been diagnosed until 3 months or longer after the onset of their symptoms. Fifteen cases (including three sputum smear-positive cases) took 4 weeks or longer from diagnosis to be notified to the public health office. 12.5% of isolates were not notified. Two per cent of the 1079 contacts examined had tuberculosis.This review highlights the need for tuberculosis and the importance of timely comprehensive screening of immigrants from high incidence countries; reducing the interval between onset of symptoms and diagnosis; improving the notification rate of tuberculosis; and focusing contact investigation on those at highest risk.

To perform a one year audit of a referral fetal echocardiography service.In 1992, 132 fetuses were referred for two dimensional fetal echocardiography, 40% being less than 24 weeks gestation. Validation of the accuracy of the fetal diagnosis by postnatal clinical or appropriate cardiac investigation was undertaken.Indications for referral were a family history of congenital heart disease (n = 36), maternal indications, (40) suspected congenital heart disease on obstetric scan, (21) noncardiac fetal abnormality (19) and fetal arrhythmia. (16) The fetal echocardiogram was normal in 112, abnormal in 18 and not technically possible in two. The negative prediction of congenital heart disease was 96% accurate with four cases of congenital heart disease not diagnosed in utero. The positive prediction of congenital heart disease was 93% accurate with one false positive of a ventricular septal defect. The overall incidence of congenital heart disease was 17%. Four of 14 fetuses with major congenital heart disease had a chromosomal abnormality and five a coexistent noncardiac abnormality. The outcome of these 14 fetuses was poor, with three stillbirths, one termination of pregnancy, seven neonatal deaths and three only surviving beyond the neonatal period. Eleven of 21 cases referred with suspected congenital heart disease on obstetric scan were abnormal.Detailed fetal echocardiography can predict significant congenital heart disease with a high degree of accuracy. Suspected cardiac abnormality on obstetric scans warrants referral for detailed fetal echocardiography, as do those considered at increased risk of congenital heart disease.

To report the prevalence of drug-resistant Mycobacterium tuberculosis in Auckland.Review of all M tuberculosis culture positive cases from January 1988 to December 1992. Ethnicity was recorded from the national Paxus medical information data base and drug sensitivity results from the Green Lane Hospital tuberculosis reference laboratory. The clinical details of all patients with drug resistant tuberculosis were extracted from hospital case records.Of the 417 patients with positive cultures, 43 (10%) had isolates resistant to one or more antituberculous drugs. Only 4 patients had multidrug-resistant organisms (defined as resistance to at least isoniazid and rifampicin) and there is no evidence that this is an increasing problem. Resistance rates were highest in those previously treated for M tuberculosis, and those born in, or likely to have acquired their organism from, Samoa, all other Pacific Islands, or South East Asia.Drug resistant M tuberculosis is a problem in Auckland but rates and patterns are little different from 1980-1982. Multidrug-resistance is not yet a problem in Auckland, as it is in the United States of America. Ways of maintaining this situation are discussed.

To describe the initial New Zealand experience of transcatheter patent ductus arteriosus closure in adults and children.Twenty-three children beyond infancy and four adults with isolated patent ductus arteriosus were selected for transcatheter umbrella closure. Rashkind umbrellas were placed across the patent ductus arteriosus through a percutaneously inserted long venous sheath using the Mullins technique.In 25 of the 27 patients a Rashkind umbrella was placed accurately. In two patients the umbrella could not be placed accurately: in one the procedure was abandoned uneventfully and in one the umbrella embolised to the right pulmonary artery necessitating surgical removal of the device and patent ductus arteriosus closure. There were no other significant complications. A second umbrella insertion is planned in two children for a significant residual leak at 1-year follow up.Transcatheter patent ductus arteriosus closure is a low risk and usually effective alternative to surgical closure for the majority of patients beyond infancy.

Quality assurance has an important contribution to make in the judicious use of scarce resources. Auckland Hospital has established a transfusion committee because there was an escalating usage of blood and blood products which are expensive prescription medicines. A pilot audit of red cell transfusions indicated that 29% of red cell transfusions may have been unnecessary. A wide range of initiatives at Auckland Hospital has reduced blood product usage. Inappropriate use of blood carries an opportunity cost and may subject patients to unnecessary risk of reactions, including potential disease transmission. Strategies which need to be employed by transfusion committees include the introduction of clinical audit, physician education, restrictions on availability, and clinical budgeting. It is recommended that transfusion committees be set up in all major hospitals.