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Friday, March 22, 2013

Just published: Tuberculosis surveillance and monitoring in Europe 2013

The latest report on tuberculosis surveillance and monitoring in Europe, jointly developed by the European Centre for Disease Prevention and Control and WHO Regional Office for Europe was just published.

This is fifth report launched jointly by the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe (WHO/Europe) following on from reports under the EuroTB project, established in 1996.

The WHO European Region
The 2015 Millennium Development Goal (MDG)  target of halting the prevalence and death associated with tuberculosis (TB) and reversing its incidence has been partially achieved in 2011, with TB incidence falling in the Region at a rate of about 5% per year between 2000 and 2011. Nevertheless, the prevalence of TB was estimated at 56 cases per 100 000 population (about 500 000 prevalent cases) in the Region and TB mortality was 4.9 deaths per 100 000 population (around 44 000 in total). It will therefore not be possible to reach the target of 50% reduction by 2015. 
The incidence of TB in the European Region varies among and within the countries, from a range of less than one TB case per 100 000 population to above 200 TB cases per 100 000 in others. The 53 countries of the WHO European Region account for around 4.4% of the world’s cases, representing an estimated 380 000 individuals with a new episode of TB (or relapse), or 42 cases per 100 000 population.
Since 2005, TB notifications have decreased by almost one quarter, from 41 to 33 cases per 100 000 population. In 2011, the countries of the WHO European Region detected 295 968 new TB cases and relapses. When compared to the incidence for the Region, this indicates that 78% of the estimated cases were detected, making the Region’s surveillance system one of the most sensitive in the world. Among the 380 366 cases of all types and forms of TB, 71% (271 288) were identified as new cases in 2011. Of those 55% (123 525) were confirmed by sputum smear microscopy and/ or culture. The number of laboratory  confirmations was higher in the western part of the Region than in the eastern countries (74% and 50.3% respectively).
Overall, there were twice as many male cases reported as female cases, however a large variation was observed for male predominance in the gender distribution of TB cases, ranging from almost even distribution in some western countries (1.2:1) to around three times greater in others (2.9:1).
In 2011, most of the new TB cases registered in the European Region were in the 25–44 years age group (41%). Over the last five years, region-wide trends in overall TB notification among children (age group 0–14 years) have decreased by 23%, from 8.7 to 6.7 cases per 100 000 population, accounting for 11 054 cases in 2011. However, the average percentage of patients within this age group in the Region has remained stable at around 6% over the same period. There were ten countries where under-fives accounted for more than half of the cases detected among children. In 2011, 12 751 TB cases with HIV co-infection (56.5%) were detected from the 22 500 estimated cases in the European Region. The estimated prevalence of HIV infection among TB patients was 6%.The fact that prevalence among all tested TB cases was very similar (6.2%) gives an indication of the accuracy of TB-HIV surveillance in the Region.
However, since HIV testing coverage is at 60%, the status was only known for 205 578 new and previous TB cases, 12 751 of which had an HIV co-infection. Given that so few countries report TB from correctional institutions it was difficult to calculate the extent to which prisons contribute to the regional TB burden. However, there were some countries in eastern Europe where TB cases in prisons exceeded 10% of the countrywide total of new TB cases, and in others the  notification rate was close to or exceeded 1 000 cases per 100 000 prison population. In some low-incidence countries however, there was a higher risk of TB in prisons than in the general population. This was related to the higher rate of TB transmission there due to poor control measures and/or the concentration of vulnerable population sub-groups (such as immigrants from countries with a high TB incidence).
In 2011, of an estimated 78 000 multidrug-resistant tuberculosis (MDR-TB) cases in the European Region, 29 473 (38%) were detected. The prevalence of MDR among new TB cases in the Region amounted to 14% and 47.7% among previously treated cases. Testing coverage for resistance to second line drugs almost doubled compared to last year, however it is still at a very low level (9% of MDR-TB cases). Nevertheless, this allowed detection of 381 cases of extensively drug-resistant tuberculosis (XDR-TB), representing 11% of the MDR-TB cases tested for second line drug susceptibility in the Region. New rapid methods to support TB diagnosis have recently been introduced in some countries within the Region. During the last five years, a gradual decrease in treatment success has been observed. Success rates are now down to 67.2%, 49.2% and 48.5% among new, previously treated and MDR-TB cases respectively. A decrease in the first two of the three cohorts is mostly related to an increase in the proportion of MDR-TB among them. In the third cohort it might be due to a rapid increase in the reporting coverage to nearly double that of last year (from almost 7 000 to over 12 000) and the lack of quality-assured administration of second-line drugs according to the most efficient regimens recommended by WHO.
Given the above and the fact that the vast majority of the TB burden occurs in the 18 high-priority countries of the Executive Summary. 4 Tuberculosis surveillance and monitoring in Europe 2013 SURVEILLANCE REPORT European Region1 (87% of the TB incidence, 87% of the prevalence, 92% of the mortality caused by TB, 91% of TB/HIV co-infections, and 99% of the MDR-TB), the main efforts to combat and prevent TB in the Region need to be focused there. However, in western Europe and particularly in the large cities, the TB situation still needs continuous attention.
In cooperation with national and international partners and civil society organisations, WHO Regional Office for Europe has been implementing a Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-Resistant Tuberculosis and helping Member States to adopt evidence-based interventions in order to improve TB and multidrug- and extensively drug-resistant TB (M/XDR-TB) prevention and control. All countries with a high burden of MDR-TB, except the Russian Federation, have prepared and finalised their national MDR-TB action plans in line with the regional plan. In some countries the national plans are yet to be endorsed officially by the Ministries of Health.
The WHO Regional Office for Europe has established the European Green Light Committee and the European Laboratory Initiative to help countries develop and/or adjust their national plans in response to the M/XDR-TB threat. This will help countries to reduce the proportion of MDR-TB cases among those previously treated by 20% detect 85% of estimated MDR-TB patients and successfully treat at least 75% of them.
European Union and European Economic Area countries
In 2011, 72 334 cases of TB were reported in 29 EU/EEA countries, which was 4% less than in 2010. The EU/EEA notification rate was 14.2 per 100 000 population, continuing the long-term decreasing trend.
In total, 80% of all notified TB cases were newly diagnosed and 69% of all new pulmonary TB cases were culture-confirmed. Adult age groups were equally affected by TB while the notification rate in children under the age of 15 years was 4 per 100 0000, consistent with a slightly decreasing longterm trend. Overall, ales were overrepresented by 80%. In total, 26% of all TB cases were of foreign origin, mostly residing in low-incidence countries. MDR-TB was reported for 5% of cases with drug susceptibility testing results (2% of new TB cases and 17% of previously treated cases) and continues to be most prevalent in the three Baltic countries. The overall trend is slightly decreasing. Extensively drug-resistant TB (XDR-TB) was reported for 13% of 1 017 MDR-TB cases tested for second-line drug susceptibility. In all, 5% of TB cases with known HIV status were co-infected with the virus. Seventy-four percent of TB cases notified in 2010 and 32% of MDR-TB cases notified in 2009 had successfully completed their treatment. In total, 22% of all cases were notified with exclusively extrapulmonary TB (mostly lymphatic and pleural TB); 35% of them were confirmed by culture, 1% was multidrugresistant and 82% were labelled treatment successes.
Children and cases of foreign origin were at least twice as likely to be reported with extrapulmonary TB as adults and native cases, respectively. The distribution of clinical presentations in each of these two risk groups was distinctly different from the remaining cases.
1 The 18 high-priority countries (HPC) are: Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Romania, Russia, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan.

European Centre for Disease Prevention and Control/WHO Regional
Office for Europe. Tuberculosis surveillance and monitoring in Europe
Stockholm: European Centre for Disease Prevention and Control, 2013.

For all that are interested in the full report it can be found at: