Epidemiology of tuberculosis in Europe

Marieke J. van der Werf European Centre for Disease Prevention and Control

Amsterdam, 22 September 2014

Tuberculosis surveillance in the EU

Aim: To provide a complete and reliable overview of the TB situation to identify strengths and remaining challenges in TB control and to guide actions to eventually eliminate TB

European Tuberculosis Surveillance Network

• Started in 1996

• Covers 53 countries of the WHO Europe Region

• Currently coordinated by WHO/Europe and ECDC

2

Surveillance system • Annual submission of TB surveillance data to WHO/Europe and ECDC

• Validation and analyses of data by WHO/Europe and ECDC

• Publication of report ‘Tuberculosis surveillance and monitoring in Europe’ around World TB Day (24th of March)

3

MS

Nat. institutes

Disease experts

General public

AF members

MB members

WHO

EMCDDA

EFSA

Others

…

TESSy

Data

uplo

ad a

nd a

ccess

Data

acce

ss

MSs Data users

The European Surveillance System

MS

MS

MS

MS

MS

MS

MS

MS

MS

MS

MS

MS

Surveillance information collected at EU level – Case based

• Age

• Gender

• Foreign/National

• HIV status

• Type of TB

- Pulmonary TB/extrapulmonary TB

- New/previously treated

• Laboratory diagnostic tests

- Smear microscopy

- Culture

- Nucleic acid amplification

• Drug sensitivity test results

• Treatment outcome

4

TB notifications in EU/EEA, 2012

In 2012, 68 423 TB cases were reported in the EU/EEA. The notification rate was 13.5 per 100 000 population (range 3.4–85.2).

5

Not included or not reporting

> 100 per 100 000

21 to 50 per 100 000

11 to 20 per 100 000

=< 10 per 100 000

51 to 100 per 100 000

TB notifications in WHO European Region, 2012

6

TB notification rates in EU/EEA, 2008−2012 Overall in the EU/EEA, notification rates have steadily declined.

7

0

10

20

30

40

50

60

2008 2009 2010 2011 2012

No

tifi

ca

tio

n r

ate

pe

r 1

00

,00

0

EU/EEA

TB notification rates in WHO European Region, 2008-2012 In the WHO European Region notification rates are declining.

8

0

20

40

60

80

100

120

2008 2009 2010 2011 2012

No

tifi

ca

tio

n r

ate

pe

r 1

00

,00

0

EU/EEA Non EU/EEA WHO European Region

TB in children (<15 years of age)

9

Not included or not reporting

4 to 9.9 per 100 000 child population

2 to 3.9 per 100 000 child population

≥ 10 per 100 000 child population

< 2 per 100 000 child population

In 2012, 2 845 TB cases in children were reported,

accounting for 4.2% (range 0–7.8%) of all notified TB cases

in the EU/EEA.

Notification rate

TB cases of foreign origin, EU/EEA

10

In 2012, the overall proportion of TB cases of foreign origin in the EU/EEA was 26.8% (range 0.2–85.4%).

25 to 49.9%

≥ 75%

1 to 24.9%

50 to 74.9%

< 1%

Not included or not reporting

TB cases of foreign origin, WHO European Region

11

TB/HIV co-infection

12

In 2012, the overall proportion HIV positive among TB cases with known HIV status in EU/EEA was 5.5% (range 0–16.5%).

5 to 9.9%

2 to 4.9%

≥ 10%

< 1%

Not included or not reporting

Extrapulmonary TB cases

13

In 2012, the overall proportion of extrapulmonary TB cases in the EU/EEA was 23.0% (range 2.9–48.6%).

20 to 29.9%

≥ 40%

10 to 19.9%

30 to 39.9%

< 10%

Not included or not reporting

Extrapulmonary TB risk factors, 2002-2011*

14

Pulmonary TB Extrapulmonary TB

Site unknown Total

Sex N=642,871 N=167,652 N=3,696 N=868,726

Female 32.5% 46.4% 45.3% 35.3%

Male 67.4% 53.4% 53.6% 64.5%

Unknown 0.1% 0.2% 1.1% 0.1%

Age groups N=642,871 N=167,652 N=3,696 N=868,726

0-14 3.1% 7.7% 20.4% 4.1%

15-24 10.6% 13.4% 8.5% 11.1%

25-44 35.9% 36.7% 26.3% 36.1%

45-64 32.1% 22.6% 21.4% 30.2%

>=65 18.0% 19.5% 20.6% 18.3%

Unknown 0.2% 0.2% 2.8% 0.2%

Origin N=614,199 N=156,957 N=2,744 N=773,900

Foreign 17.7% 37.9% 31.0% 21.8%

Native 79.7% 58.6% 43.7% 75.3%

Unknown 2.6% 3.4% 25.4% 2.8%

* Sandgren et al., Eurosurveillance 2013

Resistance pattern among new and previously treated TB cases*

0

5

10

15

20

25

30

35

40

2007 2008 2009 2010 2011 2012

%

0

5

10

15

20

25

30

35

40

2007 2008 2009 2010 2011 2012

%

0

5

10

15

20

25

30

35

40

2007 2008 2009 2010 2011 2012

%

Monoresistance

Polyresistancenon MDR TB

MDR TB, notXDR TB

XDR TB

Any resistance

New cases Previously treated cases 0

5

10

15

20

25

30

35

40

2007 2008 2009 2010 2011 2012

%

Monoresistance

Polyresistancenon MDR TB

MDR TB, notXDR TB

XDR TB

Any resistance

* Van der Werf et al. Eurosurveillance 2014

Characteristics of TB cases by drug resistance pattern, EU/EEA, 2012 (1)

Pan-susceptible

(%)

Monoresistant (%)

Polyresistant non-MDR TB

(%)

MDR TB not XDR TB (%)

XDR TB (%)

Total (%)

Gender

Female 32.9 32.5 33.5 25.6 21.9 32.6

Male 67.1 67.5 66.3 74.4 78.1 67.4

Unknown 0 0 0.2 0 0 0

Age groups

0 – 14 1.5 2.1 1.3 1.1 0 1.5

15 – 24 11.1 12.7 11.9 9.4 7.0 11.1

25 – 44 37.7 41.6 45.8 43.6 48.4 38.4

45 – 64 32.4 32.8 32.4 38.7 36.7 32.7

≥65 17.3 10.8 8.6 7.3 7.8 16.3

Origin

Foreign 28.1 34.6 32.4 18.7 12.5 28.1

Native 70.5 64.1 66.3 81.1 87.5 70.6

Unknown 1.4 1.3 1.3 0.2 0 1.3

Characteristics of TB cases by drug resistance pattern, EU/EEA, 2012 (2)

Pan-susceptible

(%)

Monoresistant (%)

Polyresistant non-MDR TB

(%)

MDR TB not XDR TB (%)

XDR TB (%)

Total (%)

Previous TB

No 84.1 78.2 80.1 43.7 19.5 81.6

Yes 11.9 18.0 15.3 53.1 77.3 14.4

Unknown 4 3.9 4.7 3.1 3.1 4

HIV status

HIV tested 26.6 28.5 32.2 52.7 65.6 28.1

HIV infected 4.4 8.7 8.7 10.4 13.1 5.3

Unknown 73.4 71.5 67.8 47.3 34.4 71.9

Site of disease

Pulmonary 84.5 83.0 85.8 95.3 99.2 85

Extra-pulmonary 15.3 17.0 14.0 4.7 0.8 14.8

Unknown 0.2 0 0.2 0.1 0 0.2

Multidrug-resistant TB

18

In 2012, the overall proportion of TB cases with multi-drug resistance in the EU/EEA was 4.6% (range 0–25.5%).

2 to 4.9%

≥ 10%

1 to 1.9%

5 to 9.9%

< 1%

Not included or not reporting

Multidrug-resistance among new pulmonary TB cases

19

2 to 4.9%

1 to 1.9%

≥ 5%

< 1%

Not included or not reporting

In 2012, the overall percentage of new pulmonary TB cases with multidrug resistance in the EU/EEA was 2.6% (range 0–20.5%).

MDR TB in new TB cases, WHO European Region

20

Trends in MDR TB case notification rate

In EU/EEA, mean declining trend in MDR TB In non EU/EEA, increasing trend in MDR TB

21

0

1

2

3

4

5

6

7

8

9

2008 2009 2010 2011 2012

No

tifi

ca

tio

n r

ate

pe

r 1

00

,00

0

EU/EEA non EU/EEA WHO European Region

Extensively drug-resistant TB

22

In 2012, the proportion of extensively drug-resistant TB cases among multidrug-resistant cases in EU/EEA was 13.7% (range 0–50.0%).

10 to 19.9%

1 to 9.9%

≥20%

< 1%

Not included or not reporting

Treatment success in new pulmonary TB cases

Treatment success rate for culture-confirmed new pulmonary TB cases notified in 2011 was 76.5% (range: 58.3–91.3%).

23 * Iceland and Malta reported zero new TB cases in 2011. Three EU/EEA Member States did not report treatment

outcome data

0

20

40

60

80

100

Tre

atm

ent

succ

ess

(%

)

Treatment success in previously treated pulmonary TB cases

The treatment success rate for previously treated culture-confirmed pulmonary TB cases notified in 2011 was 55.2% (range 25.0–100.0%).

24 * Iceland and Malta reported zero previously treated TB cases in 2011. Three EU/EEA Member States did not report treatment

outcome data stratified by treatment history

0

20

40

60

80

100

%

Tre

atm

ent

succ

ess

(%

)

Treatment success rate in multidrug-resistant TB*

The treatment success rate for all multidrug-resistant TB cases notified in 2010 was 33.6% (range 0–100.0%).

25 * Slovenia reported zero MDR TB cases in 2010, 9 Member States did not report treatment outcome data for MDR TB cases

0

20

40

60

80

100

Tre

atm

ent

succ

ess

(%

)

Treatment outcome in multidrug-resistant TB over time Treatment outcomes for multidrug-resistant TB cases improved slightly between the 2008 and 2010 cohort, EU/EEA.

26

0

10

20

30

40

Success Died Failed Defaulted Still on treatment Transferred orunknown

cohort 2008

cohort 2009

cohort 2010

Tre

atm

ent

succ

ess

(%

)

27

Treatment success in extensively drug-resistant TB*

The treatment success rate in extensively drug-resistant TB cases notified in 2009 was 25.0% (range 0–66.7%).

27 * Cyprus, Denmark, Iceland, Malta, Slovakia, Slovenia and Sweden reported zero XDR TB cases in 2009, 12 countries did not

report Secondline drug resistance testing results or stratified treatment outcome data

0

20

40

60

80

EU/EEA Austria Belgium Bulgaria Czech

Republic

Estonia Latvia Lithuania Norway Poland Romania United

Kingdom

Tre

atm

ent

succ

ess

(%

)

Contact the ECDC TB Programme

http://ecdc.europa.eu