© European Centre for Disease Prevention and Control, Stockholm, 2012

ECDC DIRECTOR’S PRESENTATION

* Note: In London, the meeting took place on 22 March

When you look at our cities from a tourist point-of-view, things look good.

For the past two years I've been calling this beautiful city my hometown: On the surface, everything is fine and life is good.

Vackra Sverige!

Stockholm

2

Photo: ECDC

Ladies and gentlemen, dear colleagues,

Two days ago, I spoke at the European Parliament in Brussels on the issue of multidrug resistant tuberculosis in the EU.

And today, during the week of World TB Day, meetings on urban TB are taking place in Barcelona, Milan, London* and Rotterdam.

I am of course most pleased to have been invited to my home country and to Rotterdam.

Many countries in the EU are indeed progressing towards TB elimination, and I am sure that economic growth and strengthened healthcare systems have played a role here.

So why do we need to raise awareness about urban TB in the EU and do we really need to be concerned?

Urban tuberculosis control in the European Union

World Tuberculosis Day, Rotterdam, 23 March 2012

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

2

But you don't have to go very far to find a less inspiring type of architecture and …

Vackra Sverige?

Stockholm

3

Photo: ECDC

… people that are less fortunate.

Hemlös (SE)

Stockholm

4

Photo: ECDC

It doesn't matter whether you call them "hemlös" ...

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

3

Homeless (IE, GB)

London

5

Photo: Jessica Mulley via flickr.com

... homeless.

Sans abri (BE, FR)

Brussels

6

Photo: moving_eye via flickr.com

… sans abri

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

4

Obdachlos (AT, DE)

Berlin

7

Photo: Merlijn Hoek via flickr.com

... obdachlos

Dakloos (BE, NL)

The Hague

8

Photo: Roel Wijnants via flickr.com

... or dakloos

These are people who are particularly vulnerable in bigger cities; they may also have lost their jobs, and their contacts with their families and loved ones.

This group is extremely vulnerable to all sorts of diseases.

One of them is TB.

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

5

In larger cities in Europe, TB affects a disproportionate number of people, and most of these people belong to disadvantaged population groups.

This is what the EU data tell us:

Tuberculosis in EU countries and some larger cities

In the EU, the epidemiological pattern of TB is heterogeneous

Source: ECDC surveillance report, TB surveillance in Europe 2012 (2010 data)

Figure 1: TB notification rates in a selection of countries (2010)and selected major cities (2009) in the EU/EEA

0.0

20.0

40.0

60.0

80.0

100.0

Austria

Belg

ium

Bulg

aria

Cypru

s

Cze

ch R

epublic

Denm

ark

Esto

nia

Fin

land

Fra

nce

Germ

any

Gre

ece

Hungary

Irela

nd

Italy

Latv

ia

Lith

uania

Luxem

bourg

Malta

Neth

erla

nds

Pola

nd

Portu

gal

Rom

ania

Slo

vakia

Slo

venia

Spain

Sw

eden

Unite

d k

ingdom

Icela

nd

Norw

ay

EU/EEA average:

14.6 cases per 100 000 population

16

.9Copenhagen

21

.3Rott

erd

am

44

.4London

23

.4Paris

33

.2M

ilan

23

.4Barc

elo

na

Case

s per

100000 p

opula

tion

9

And at a first glance, it looks as if our main focus should be on the high incidence countries, such as Romania, Lithuania and Latvia.

Of course we cannot neglect TB in these countries, but today I want to pay attention to the trend we see in the low-incidence countries such as Italy, the UK, Denmark and the Netherlands.

These countries with an incidence of TB well below the EU average of 14.6 cases per 100.000 population, have a disproportionate incidence of TB cases in their larger cities.

On the next page, we see another representation of "urban TB" and the two different patterns that we can observe in Europe.

If you look at the right-hand side of the graph, you can see how the TB rates in the capital cities are lower than for the whole country.

Countries on the left-hand side, however, such as the UK, Italy and the Netherlands, with an overall low level of incidence, have substantially higher notification rates in their cities.

The rates can be two to five times higher than for the rest of the country.

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

6

TB situation in big cities: major differences in the EU

Survey performed by the Metropolitan TB network (www.metropolitantb.org). Please note that ECDC does not collect city-level TB surveillance data and takes no responsibility for the accuracy of data collected for this survey.

Figure 2: TB notification rates in selected countries and major cities in the EU/EEA, in 2009

< 20 cases per 100,000 population

≥ 20 cases per 100,000 population

16.9 − 6.0Copenhagen − Denmark

21.3 − 7.0Rotterdam − Netherlands

44.4 − 14.8London − United Kingdom

23.4 − 8.2Paris − France

33.2 − 6.5Milan − Italy

24.3 − 16.6Barcelona − Spain

43.0 − 43.2Riga − Latvia

31.9 − 62.1Vilnius − Lithuania

17.8 − 21.6Warsaw − Poland

31.9 − 38.3Sofia − Bulgaria

81.0 − 108.2Bucharest − Romania

10

This imbalance is largely due to people in vulnerable groups.

These people are negatively affected by socio-economic determinants such as poverty, poor healthcare, and poor and crowded housing and are therefore more susceptible and exposed to TB.

They are also often not aware of specific health risks and may not always be paying attention to the sometimes quite diffuse symptoms of TB.

Vulnerable groups in urban settings

1

Interaction between individual risk factors and urban characteristics create specific opportunities for TB transmission.

Copenhagen

Photo: ECDC

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

7

They may be refugees, migrants, prisoners, drug users, or homeless people.

Vulnerable groups

12

Vulnerable groups include:• Refugees, asylum seekers, migrants• Homeless people• Prison inmates• Illicit drug users• Alcoholics• HIV-seropositive people• Other vulnerable groups:

− Children− Elderly

Karlsruhe

Photo: Badische Zeitung, 2011

Or simply the elderly or children.

I have also my own story to tell about childhood TB.

As I little boy in the Netherlands, I contracted TB. A child at my kindergarten was diagnosed with tuberculosis.

The health authorities immediately screened the other children at the kindergarten. They found that I had tuberculosis. My contacts were then traced, and they found that also my father was ill with TB. We both had active TB. I had to be hospitalised, while my father was looked after at home by my mother – though he did need to go into hospital for check-ups.

TB and me

13

Maastricht

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

8

Reflecting on this experience now, I can say that the public health system in the Netherlands was quite effective and that contact tracing worked. It picked up my infection, my father’s infection and, indeed several other TB cases in our community. The cases were treated and the chain of infection broken.

Without this effective detection and treatment, I can truly say that I would not be here today.

The lack of stigma attached to TB in the Netherlands at that time was an important factor here. It made people feel comfortable in coming forward for testing. And that is the signal we need to give also today in fighting urban TB.

So how can we turn the tide and efficiently combat TB in the larger cities of Europe?

We are living in challenging times for public health, with much of the focus on the financial crisis rather than on health and health protection.

But to achieve TB elimination in the big cities of Europe;

- we need to find new intervention approaches to target these hard-to-reach groups and where TB may be hard to detect.

- we need to collaborate between cities affected by a disproportionate burden of TB, and;

- share best practises to target the vulnerable groups.

What can we do to fight urban TB?

Photo: ECDC

New intervention approaches

Collaboration betweencities

Best practices to target vulnerable groups

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

9

These three actions are the main objectives for the "Metropolitan TB Control in Europe" initiative.

And I am very pleased that this European network to control urban TB has been established. And here, Rotterdam has been in the forefront, with TB mobile screening buses.

The ‘Metropolitan TB Control in Europe’ Initiative

Reaching out to vulnerable groups in urban settings

Working jointly towards the goal to eliminate TB in the EU.

Only through joint efforts such as "Metropolitan TB Control" and political commitment can we eliminate TB in European cities.

Together we need to invest in control measures and share information and lessons learned to target the vulnerable groups.

ECDC DIRECTOR’S PRESENTATION Urban TB control in the EU – World TB Day 2012

10

Every patient’s right to the highest standard of care

The right to adequate treatment

16

Photo: moving_eye via flickr.com

It is every patient’s right to receive the highest standard of care.

Working jointly towards the elimination of TB in the EU.

It is every patient’s right to receive the highest standard of care.

TB should not and must not leave us indifferent.

TB control care and treatment are a right to everyone!

Thank you for your attention.