Progress and challenges to TB elimination in New South Wales, Australia

In Australia, TB care and control is delivered by states and territories, with a National TB Advisory Committee to advise on national surveillance and strategy. For more than 30 years, New South Wales (NSW), Australia, has maintained TB incidence rates of <10/100,000 population, but progress toward TB elimination and 'zero local TB transmission' remains challenging. Reductions in the TB notification rate have plateaued in recent decades, mainly due to increased migration from high incidence countries. There is limited awareness of TB among the public, and a general perception of low risk, at least for Australian-born people and locally trained healthcare professionals. As in other low TB incidence settings, migrants and hard-to-reach populations are overrepresented in TB notifications. Progress in reducing TB among Australia's Aboriginal and Torres Strait Islander people has been slow, hindered by embedded disadvantage, limited healthcare access and historical mistrust. Community engagement and patient advocacy for TB is minimal. Despite excellent progress over many decades, TB elimination remains out of reach in NSW due to ongoing migration from high-incidence settings and the reality of competing health priorities. Here, we critically assess progress towards TB elimination targets and identify opportunities to further improve TB control.