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Objectives: Changes in circulating Bordetella pertussis genotypes, including a novel pertussis toxin promoter ptxP3 allele and absence of pertactin (Prn) antigen, have been reported from several countries but limited data on relative severity are available. We compared markers of disease severity in children with B. pertussis infection due to strains of differing genotype.Methods: Culture confirmed cases presenting to tertiary paediatric hospitals in three Australian states between 2008 and 2012 were classified as severe if they required a hospital stay greater than seven days, were admitted to intensive care, or if death occurred. Associations between age, vaccination, genotype and severity were assessed.Results: Of 199 pertussis cases, 81 (41%) were <3 months, including 32/39 (82%) of severe cases. The proportion of isolates from these cases that were Prn deficient increased markedly between 2008 and 2012. Of B. pertussis isolates, the proportion considered severe was similar for Prn positive (27/128, 21%) and Prn deficient (12/71, 17%) cases but only 1/22 (4.5%) of non ptxP3 cases were severe versus 38/177 (21.4%) ptxP3 positive. Adjusting for ptxP type, vaccination status and age, disease severity was not significantly associated with Prn status (RRA: 0.95, [0.57-1.56]; p = 0.83).Conclusions: In children, we found no relationship between Prn status and markers of severe pertussis. An increased proportion of severe disease in isolates with the ptxP3 allele was observed. [ABSTRACT FROM AUTHOR]

Objectives: To describe the epidemiology of mumps and examine potential factors underlying the recent increase in the incidence of mumps in Australia.Design, Setting and Participants: Analytical descriptive study, for all Australian states and territories, of mumps notifications (1994-2007); hospitalisations for mumps (1994-2005); and mumps seroprevalence in a nationally representative sample of 2787 subjects (1997).Main Outcome Measures: Incidence of notifications and hospitalisations for mumps; seropositivity by birth cohort.Results: Notified mumps cases increased from 60 in 2002 to 231 in 2005 and 512 in 2007. Between 1994 and 2005, there were 605 hospitalisations for mumps. Mumps seropositivity in all states and territories in 1997 was high (range, 87.1%-94.3%). The predominant age group affected by mumps shifted to adults over time: between 2005 and 2007, 41% of cases occurred among people aged 20-29 years. Cases were concentrated among the birth cohort of 1978 to 1982, who had higher rates of notifications and hospitalisations for mumps and a lower seropositivity rate (92% [95% CI, 89%-94%]) than other birth cohorts.Conclusions: The birth cohort of 1978 to 1982 was too old to reliably receive a second dose of measles-mumps-rubella (MMR) vaccine in the 1998 Australian Measles Control Campaign and too young to have had mumps infection. Renewed efforts to maximise two-dose MMR coverage are important for prevention of mumps and measles in young adults. [ABSTRACT FROM AUTHOR]

Clin Microbiol Infect 2010; 16: 948–954 The present study describes the clinical and immunological features of children with Hib vaccine failure, who were identified through national surveillance between 1996 and 2001 in Europe, Israel and Australia. True vaccine failure was defined as invasive Hib disease occurring ≥2 weeks after one dose, given after the first birthday, or ≥1 week after ≥2 doses, given at <1 year of age. Of the 423 cases (representing 0.2 cases per 100 000 child-years at risk) reported, 330 (78%) had received three doses in the first year of life and developed disease at a median age of 28 months. Of the remaining 93, 48 had received two doses in infancy, 34 had received four doses including a booster, and 11 had received a single dose after 12 months of age. These children developed disease at a median age of 12, 33 and 71 months, respectively. In total, 47 out of 258 children (18%) with available information had an underlying medical problem (including prematurity) and 53 out of 161 (33%) had immunoglobulin deficiency. Convalescent Hib antibody concentrations were above the putative protective concentration of 1.0 mg/L in 147/194 (76%) children; low concentrations were associated with both the presence of an underlying medical problem and young age at the time of Hib disease. Almost all children who received an additional vaccine dose developed antibodies at protective concentrations. Thus, Hib vaccine failure is rare, but can occur with any immunization schedule. Children with Hib vaccine failure should have immunoglobulin and convalescent Hib antibody concentrations measured after infection and receive additional vaccination, if required. [ABSTRACT FROM AUTHOR]

Presents a study that determined the impact of the Australian Measles Control Campaign (MCC) on the transmission dynamics of measles by calculating the reproductive number before and after the MCC. Methodology; Results and discussion.

Q fever (caused by Coxiella burnetii) is thought to have an almost world-wide distribution, but few countries have conducted national serosurveys. We measured Q fever seroprevalence using residual sera from diagnostic laboratories across Australia. Individuals aged 1-79 years in 2012-2013 were sampled to be proportional to the population distribution by region, distance from metropolitan areas and gender. A 1/50 serum dilution was tested for the Phase II IgG antibody against C. burnetii by indirect immunofluorescence. We calculated crude seroprevalence estimates by age group and gender, as well as age standardised national and metropolitan/non-metropolitan seroprevalence estimates. Of 2785 sera, 99 tested positive. Age standardised seroprevalence was 5.6% (95% confidence interval (CI 4.5%-6.8%), and similar in metropolitan (5.5%; 95% CI 4.1%-6.9%) and non-metropolitan regions (6.0%; 95%CI 4.0%-8.0%). More males were seropositive (6.9%; 95% CI 5.2%-8.6%) than females (4.2%; 95% CI 2.9%-5.5%) with peak seroprevalence at 50-59 years (9.2%; 95% CI 5.2%-13.3%). Q fever seroprevalence for Australia was higher than expected (especially in metropolitan regions) and higher than estimates from the Netherlands (2.4%; pre-outbreak) and US (3.1%), but lower than for Northern Ireland (12.8%). Robust country-specific seroprevalence estimates, with detailed exposure data, are required to better understand who is at risk and the need for preventive measures.

Australia implemented conjugate meningococcal C immunization in 2003 with a single scheduled dose at age 12 months and catch-up for individuals aged 2-19 years. Several countries have recently added one or more booster doses to their programmes to maintain disease control. Australian disease surveillance and vaccine coverage data were used to assess longer term vaccine coverage and impact on invasive serogroup C disease incidence and mortality, and review vaccine failures. Coverage was 93% in 1-year-olds and 70% for catch-up cohorts. In 10 years, after adjusting for changes in diagnostic practices, population invasive serogroup C incidence declined 96% (95% confidence interval 94-98) to 0·4 and 0·6 cases/million in vaccinated and unvaccinated cohorts, respectively. Only three serogroup C deaths occurred in 2010-2012 vs. 68 in 2000-2002. Four (<1/million doses) confirmed vaccine failures were identified in 10 years with no increasing trend. Despite published evidence of waning antibody over time, an ongoing single dose of meningococcal C conjugate vaccine in the second year of life following widespread catch-up has resulted in near elimination of serogroup C disease in all age groups without evidence of vaccine failures in the first decade since introduction. Concurrently, serogroup B incidence declined independently by 55%.

In Australia, varicella vaccine was universally funded in late 2005 as a single dose at 18 months. A school-based catch-up programme for children aged 10-13 years without a history of infection or vaccination was funded until 2015, when those eligible for universal infant vaccination would have reached the age of high school entry. This study projects the impact of discontinuing catch-up vaccination on varicella and zoster incidence and morbidity using a transmission dynamic model, in comparison with alternative policy options, including two-dose strategies. At current vaccine coverage (83% at 2 years and 90% at 5 years), ceasing the adolescent catch-up programme in 2015 was projected to increase varicella-associated morbidity between 2035 and 2050 by 39%. Although two-dose infant programmes had the lowest estimated varicella morbidity, the incremental benefit from the second dose fell by 70% if first dose coverage increased from 83% to 95% by age 24 months. Overall zoster morbidity was predicted to rise after vaccination, but differences between strategies were small. Our results suggest that feasibility of one-dose coverage approaching 95% is an important consideration in estimating incremental benefit from a second dose of varicella vaccine.

Introduction: In Australia, post-marketing surveillance for intussusception following vaccination commenced with funding of RotaTeq(®) and Rotarix(®) vaccines under the National Immunization Program (NIP) in July 2007., Methods: Two active surveillance mechanisms (hospital-based case ascertainment and monthly reports from paediatricians) identified intussusception cases between 1st July 2007 and 31st December 2008 in four states. Linkage to vaccination records identified cases occurring within 1-7 and 1-21 days of rotavirus vaccination. Expected cases within the post-vaccination windows were calculated by applying rates of intussusception from national hospitalisation data over 6 years (mid-2000 to mid-2006), by age and state, to numbers vaccinated (by dose) according to the Australian Childhood Immunization Register., Results: Combining exposure windows associated with all doses of rotavirus vaccine from 1 to 9 months of age, there was no evidence of an increased risk of intussusception following vaccination for either vaccine. However, in infants 1 to <3 months of age, there was suggestive evidence of excess intussusception cases 1-7 and 1-21 days following dose 1 (1-7 days: RotaTeq(®) relative risk (RR)=5.3, 95% confidence interval [CI] 1.1,15.4; Rotarix(®) RR 3.5, 95% CI 0.7,10.1; 1-21 days: RotaTeq(®) RR 3.5, 95% CI 1.3, 7.6; Rotarix(®)RR 1.5, 95% CI 0.4, 3.9). There was no evidence that clinical outcome of intussusception occurring within 21 days of rotavirus vaccination differed from that in cases occurring later post-vaccination., Conclusion: Although we found no overall increase in intussusception following receipt of rotavirus vaccine, there was some evidence of an elevated risk following the first dose of both vaccines. Larger population-based studies using linked databases are required to provide more definitive evidence., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Unlabelled: There have been few surveys of Streptococcus pneumoniae and Neisseria meningitidis carriage in sick or frail elderly people who, with the very young, comprise the group who are at highest risk for pneumococcal disease. We studied pneumococcal carriage among participants in a pneumococcal immunisation study in the frail elderly., Methods: Subjects aged >or=60 years were recruited from a large tertiary referral hospital in Sydney, Australia. Nose and throat swabs were collected at the time of enrolment and 12 months after immunisation., Results: Before immunisation, only 1 of 315 participants was identified as a nasal carrier of S. pneumoniae; another was identified as throat carrier of N. meningitidis. None of the participants examined after immunisation was carrying either S. pneumoniae or N. meningitidis., Conclusion: The low rate of pneumococcal carriage in this population of hospitalised elderly patients was unexpected. The most likely reason is that long-term carriage is rare in this population and suggests that pneumococcal disease primarily follows recent acquisition of S. pneumoniae types not associated with carriage., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Aim: To investigate attitudes, perceptions and knowledge of elderly hospital patients in regard to vaccination in general and pneumococcal vaccination in particular., Setting: A hospital-based patient survey in Sydney, Australia., Participants: Patients aged 60 years and older who are admitted to selected wards in an 800-bed tertiary referral hospital in Sydney, Australia., Methods: A face-to-face interview administered to 200 inpatients., Results: Approximately half (49%) of the patients had a positive attitude to vaccination whereas 59% had less positive perception. There were 35% of the patients who were unvaccinated against influenza and pneumococcal disease. Positive perception (OR 2.9, 95% C.I.=1.3-6.5) and attitude (OR 4.4, 95% C.I.=2.0-9.4) significantly predicted vaccination with both vaccines. Similarly the odds of receiving pneumococcal vaccination for those who had a more positive attitude and more correct knowledge were significant (OR=2.3, 95% C.I.=1.0-5.4; OR=2.7, 95% C.I.=1.1-6.8). We explored reasons for non-vaccination. Physician recommendation was listed as an important factor by patients., Conclusions: Positive perception and attitude towards vaccination are significant factors associated with immunisation status. For the pneumococcal vaccination, having influenza vaccination is related to pneumococcal vaccination.

Neisseria meningitidis serogroup C (NMC) conjugate vaccine was introduced, in Australia, in 2003. Our aims were to determine pre-immunisation IgG NMC seroprevalence and evaluate an enzyme-linked immunosorbent assay (ELISA), previously validated against the serum bactericidal assay (SBA). 2409 sera, collected in 2002, from subjects aged 2-34 years, were tested. The geometric mean concentration (GMC) of NMC anticapsular IgG was 0.38 U/mL in subjects under 19 years and it increased to 0.67 U/mL for those aged 30-34 years. Variation in GMC correlated with reported NMC disease incidence and was higher in males than females (0.52 U/mL versus 0.41 U/mL; p=0.005). The ELISA appears suitable for serosurveillance but the IgG level that correlates with protection needs further investigation. Serosurveys will be repeated to monitor the impact of vaccination.

Hospitalisation and death from pertussis in highly immunised populations largely occurs before the first vaccination at 2 months. A Markov model was constructed to estimate the costs and health consequences of three strategies to reduce pertussis over the first 6 months of an infant's life. Earlier vaccination (at either birth or 1 month in addition to current practice) or vaccination of the parents soon after birth was compared with the current practice of vaccination at 2, 4 and 6 months. The model was populated using data on the incidence and costs from Australia. Disability-adjusted life-years (DALYs) were used as the primary outcome measure. The cost to the Australian public health system was chosen as the economic perspective, and Monte-Carlo simulations were used to accommodate uncertainties in the variables. Vaccination at birth was estimated to cost (S.D.) an additional A$33.21 (A$1.60) per infant and to reduce cases, deaths and DALYs by 45%. Vaccination at 1 month was estimated to cost an additional A$43.24 (A$8.98) per infant and to reduce morbidity by approximately 25%. Parental vaccination at birth was the most expensive alternative, costing an additional A$73.38 (A$4.98) per infant and reducing pertussis morbidity by 38%. The costs per DALY averted were A$330,175 (A$15,461) A$735,994 (A$147,679) and A$787,504 (A$48,075) for the birth, 1 month and parental vaccination strategies, respectively. Changing the estimated factor by which hospitalisations and deaths are under-reported, and the efficacy of early vaccination, had large effects on results. Parental vaccination at birth was most cost-effective where protection persisted for subsequent children. The birth vaccination strategy appears to offer the greatest potential benefit for one-child families, but the efficacy at birth (and 1 month) needs to be established.

The epidemiology of hepatitis A is changing, with an increasing proportion of the population becoming susceptible to infection. The burden of hepatitis A is comparable to that of other vaccine-preventable diseases for which new vaccines are available. Options for vaccination include selective programmes for high-risk groups, which could involve screening prior to vaccination, or universal programmes for infants and/or adolescents. Selective programmes have been shown to be highly cost-effective if well implemented, but there is evidence that they might be poorly implemented. If a universal vaccination programme were considered for Australia, an infant programme, with doses at 18 months and 2 years, possibly with an additional adolescent programme, would be the recommended option. Universal hepatitis A vaccination for infants and/or adolescents is of comparable cost-effectiveness compared with other preventive strategies, but needs to be considered in the context of competing vaccination options.

To evaluate the impact of the 1998 Australian Measles Control Campaign on immunity to measles and rubella, 4400 opportunistically-collected sera, submitted to diagnostic laboratories across Australia from subjects aged 1-49 years, and 3000 from subjects aged 1-18 years, were tested before and after the campaign, respectively. The proportion of individuals aged 1-18 years who were immune to measles rose from 85% before, to 90% after, the campaign (P < 0.001). The greatest increase was in preschool (7%, P < 0.001) and primary school (10%, P < 0.001) children, who were actively targeted by the campaign. Rubella immunity in 1-18 year-olds rose from 83% to 91% (P < 0.0001), again with significant increases in preschool (4%, P = 0.002) and primary school (16%, P < 0.001) children. 94% of individuals aged 19-49 years were immune to rubella. These serosurveys confirm other evidence of the effectiveness of the Australian Measles Control Campaign and demonstrate the value of serosurveillance using opportunistically collected sera.

Objective: To evaluate the relationships between socio-economic and demographic variables and low immunisation coverage at the national level., Methods: The Australian Childhood Immunisation Register (ACIR) contains data at the postcode level on the immunisation status of all children registered with Medicare under the age of seven years. The Australian Bureau of Statistics (ABS) produces a number of indicators of socio-economic status at the postcode level from Census data. These and other ABS demographic data were used to examine the relationship between immunisation coverage and various socio-demographic indicators., Results: Factors associated with lower immunisation uptake differed in rural and metropolitan areas. High levels of education and occupation and a high proportion of Aboriginal residents were significantly associated with lower coverage only in metropolitan postcodes. High unemployment was associated with lower immunisation coverage only in rural postcodes. A high proportion of late starters to immunisation was the strongest single predictor of coverage and was important in rural and metropolitan postcodes. A high proportion of overseas-born persons and of GP-delivered immunisations was also associated with lower coverage in all areas., Conclusions: These data suggest that in metropolitan areas, reasons for low uptake in more advantaged areas require further evaluation. In non-metropolitan areas, low coverage was associated with areas of disadvantage, for which access to services may be more important., Implications: Children who are late in starting the schedule should be targeted.

The 1998 Australian Measles Control Campaign had as its aim improved immunization coverage among children aged 1-12 years and, in the longer term, prevention of measles epidemics. The campaign included mass school-based measles-mumps-rubella vaccination of children aged 5-12 years and a catch-up programme for preschool children. More than 1.33 million children aged 5-12 years were vaccinated at school: serological monitoring showed that 94% of such children were protected after the campaign, whereas only 84% had been protected previously. Among preschool children aged 1-3.5 years the corresponding levels of protection were 89% and 82%. During the six months following the campaign there was a marked reduction in the number of measles cases among children in targeted age groups.

Childhood pneumococcal disease is associated with substantial morbidity and mortality, but total disease burden is more difficult to measure than for invasive disease caused by Haemophilus influenzae type b (Hib). A safe, effective seven-valent conjugate pneumococcal vaccine will be available in Australia by early 2001, and will certainly be indicated for high-risk groups and purchased in the private sector, as was Hib vaccine. The status of this vaccine on the Australian Standard Vaccination Schedule will require more detailed consideration of the burden and serotype distribution of pneumococcal disease in Australian children and the vaccine's likely cost-effectiveness. Postmarketing surveillance will be particularly important.

Vaccine preventable disease notifications for Australia with disease onset dates between January and March 2000 are reviewed. During this quarter, numbers of notifications for Haemophilus influenzae type b disease and measles were the lowest ever recorded, while those for rubella were the lowest recorded since before the epidemic of spring 1992. These are promising trends that are likely to represent a true reduction in disease incidence. Numbers of pertussis notifications declined compared with the last quarter of 1999, but remain high, making up 88% of notifications for the vaccine preventable diseases reported here.

Immunisation coverage reporting using data from the Australian Childhood Immunisation Register is likely to underestimate immunisation uptake. Since 1997, several initiatives have been introduced to improve both immunisation uptake and notification of immunisation encounters. These initiatives seemed likely to have changed previous coverage estimates. Re-calculation of immunisation coverage estimates for the previously reported cohorts was undertaken. This used current Australian Childhood Immunisation Register data--especially the immunisation history form and the impact of catch-up immunisations--to evaluate delayed reporting. Previous coverage estimates published in Communicable Diseases Intelligence were shown to be at least 2% to 4% below estimates based on data now held by the Australian Childhood Immunisation Register, with greater differences observed in particular jurisdictions.

The proceedings of the Pneumococcal Disease in Australia Workshop, held on 26-27 March 1999 are presented in this report. The world-wide epidemiology of the pneumococcus, with its predilection for the very young and the very old, differs between the developing and the developed world, and between indigenous and non-indigenous populations. Sources of data on pneumococcal disease in each of the Australian States, clinical aspects of invasive and non-invasive disease, and the role of the public health laboratory in surveillance of serotypes and antimicrobial sensitivity, both nationally and over time, were discussed at the Workshop. Polysaccharide pneumococcal vaccines are recommended for those over 65 years of age and for at-risk groups, but are supplied free of charge only in Victoria and for indigenous Australians over 50 years of age. Children will require conjugate vaccines, which are likely to be licensed in the United States of America early in 2000. In Australia indigenous children, especially in rural areas, will be the priority group for conjugate vaccines.

Background: Before the establishment of the Australian Childhood Immunisation Register (ACIR), measurement of childhood immunisation coverage in Australia involved a variety of methods at varying intervals by general practice (GP) divisions, state health departments and the Australian Bureau of Statistics. Such surveys may underestimate (child health records) or overestimate (parental recall) true immunisation coverage., Objective: The establishment of the ACIR in 1996 (a world first), was a huge undertaking involving 15,000 immunisation providers (60% GPs) notifying over 3 million immunisations annually. This review summarises the operation of the ACIR, how it calculates coverage, the accuracy of estimates from the ACIR and how Australia's immunisation coverage compares with that of other similar countries. Currently, the accuracy of the records on the register is questioned, especially in urban areas, but available data suggest that failure to report to the ACIR is the main source of data discrepancies., Discussion: The ACIR has the potential to measure immunisation coverage at any practice or local level with accuracy and timeliness. With full provider participation, the ACIR is capable of identifying areas of low immunisation coverage for targeted interventions and will play a key role in the current measles campaign, the General Practice Immunisation Incentives scheme and in payments to parents. Achieving the highest possible completeness and timeliness of the ACIR is in the interests of providers, consumers and health planners.

Aim: To explore the relative importance parents and general practitioners place on less reactogenic vaccines and multiple injections at each childhood immunisation encounter., Method: A random sample of western Sydney parents (n = 162) and GPs (n = 154) completed telephone questionnaires about their preference for either a single injection of pentavalent vaccine (whole-cell pertussis/diphtheria/tetanus/Hib/hepatitis B), or regimen containing the less reactogenic acellular pertussis vaccine requiring two separate injections (acellular pertussis/diphtheria/tetanus and Hib or three separate injections (acellular pertussis/diphtheria/tetanus and Hib and hepatitis B). Potential confounders were examined by univariate and multivariate analysis., Results: Regimens containing acellular pertussis vaccine (2 injections or 3 injections) were preferred by 72% and 58% of parents respectively. Those whose children were already vaccinated were less concerned about side effects and were twice (or = 2.0, 95% CI 1.0-4.0) as likely to select the pentavalent (single injection) option. 69% and 77% of GPs preferred the pentavalent rather than the two or three injection acellular option, although previous experience with a systemic adverse reaction to immunisation increased their preference for the acellular pertussis vaccine (or = 2.9, 95% CI 1.1-7.6). Only 54% of parents and 28% of GPs favoured three injections at one visit., Conclusion: Parent and GP concerns regarding reactogenicity and multiple injections differ. Parents are more concerned about vaccine reactogenicity than multiple injections. However, if the GP recommends a particular regimen, it is likely to be accepted by parents.

Objective: The description of a second case of rabies in Australia, stressing the clinical features and that long incubation periods are possible., Clinical Features: A 10-year-old Vietnamese girl presented with fever, shoulder pain, subcutaneous emphysema, swallowing difficulty and agitation. After a period of maniacal behaviour all peripheral and central nervous system function was lost., Intervention and Outcome: Despite maximal intensive care, the patient died. The diagnosis of rabies was made at autopsy., Conclusions: Rabies occurs in Australia and needs to be considered in the differential diagnosis of acute encephalitis and/or the Guillain-Barré syndrome. Incubation periods of more than six years can occur.

Objective: To determine the incidence and age distribution of invasive Haemophilus influenzae type b (Hib) disease in children (0-14 years) in the Sydney Statistical Division (SSD)., Design: Retrospective ascertainment from a defined population, 1985-1987. Eligible cases had Hib isolated from a normally sterile site or endoscopically proven epiglottitis., Setting: Sydney Statistical Division, which had a population of children aged 0-4 years of 229 165 in 1986., Patients: Cases were identified from all potential sources of relevant recorded information., Main Outcomes: There were 292 eligible cases. Among 284 previously well children, those under 18 months of age contributed 81 of 143 cases (57%) of meningitis and 22 of 71 (71%) of cellulitis/arthritis but only 8 of 91 (11%) of epiglottitis and 4 of 18 (22%) of infection in other foci. Overall, 9% of cases had occurred by 6 months of age, 42% by 18 months and 55% by 24 months. The annual incidence of invasive Hib disease was 38.5 per 100,000 children aged 0-4 years. In areas with the lowest proportion of young children (less than 5.5%), the incidence of Hib disease in the first 12 months of life was significantly lower than in the remainder of Sydney, although there were no differences in overall disease incidence in the age group 0-4 years., Conclusions: This study indicates that approximately 1 in 500 urban Australian children develop invasive Hib disease by their fifth birthday. Vaccination of children in Sydney with a conjugate Hib vaccine at 18 months of age would result in a greater potential reduction in Hib disease than in the United States, where universal vaccination at this age is current policy.

Two cases of tuberculosis have been seen over the past two years in southeast Asian women who had recently emigrated to Australia and who attended a single maternity hospital in Brisbane. One patient died of tuberculous meningitis and the other had an asymptomatic tuberculous pleural effusion. Both cases illustrate some of the difficulties in the diagnosis of extrapulmonary tuberculosis, particularly in pregnant women, and the low level of awareness of this condition. Antenatal screening for tuberculosis is not performed as a routine in Australia. Pregnant women who have emigrated recently from areas of high prevalence constitute a group at increased risk for tuberculosis who should be screened selectively with tuberculin tests and chest x-ray examinations.