Tuberculosis Surveillance in Europe

EuroTB

update March 2008

WHO Collaborating Centre

About EuroTB, 1996-2007EuroTB was set up in 1996 to develop and

coordinate a European network of national tuberculosis surveillance institutions in the 53 countries of the WHO European Region. The project was based at the Institut de veille sanitaire (InVS) in France, and was financially supported by the European Commission. The mission statement of EuroTB was to improve the contribution of surveillance to tuberculosis control in the European Region. EuroTB promoted the standardisation of surveillance methods. Its mainstay was the collection and validation of national epidemiological information on tuberculosis, including drug resistance and treatment outcome. The main outputs were an annual report, scientific articles, oral communications and data dissemination on www.eurotb.org. Data presented here are the latest available at the end of the project in December 2007.

EUROPEAN UNION (EU) (dark blue)AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited Kingdom

WEST, non-EU (light blue)AndorraIcelandIsraelMonacoNorwaySan MarinoSwitzerland

BALKANS (yellow)AlbaniaBosnia & HerzegovinaCroatiaMacedonia, F.Y.RMontenegroSerbiaTurkey

EAST (orange)ArmeniaAzerbaijanBelarusGeorgiaKazakhstanKyrgyzstanMoldovaRussian FederationTajikistanTurkmenistanUkraineUzbekistan

WHO European Region, 2008

Case-based reporting to EuroTB in 2007

Andorra

Malta

Monaco

San Marino

Not included or not reporting to EuroTB

No case-based reporting (aggregate only)

Case-based notification data only

Case-based data, including drug resistance

Case-based data, including drug resistance and outcome*

* No case-based data for drug resistance in Greece and Poland. Outcome data in Greece started in report year 2006.

*

*

European definitions for TB surveillance (1)

Definite case* A patient with culture-confirmed TB disease due to Mycobacterium

tuberculosis complex. In countries where culture is not routine:

a patient with positive sputum smear

Other-than-

definite case*

A patient with clinical and/or radiological signs compatible with TB

and

clinician’s decision to treat with full treatment

Notifiable TB

case*

All definite and other-than-definite TB cases notified in the calendar

year of interest should be notified. Cases should only be counted

once in a given calendar year.

New case A patient who has never had treatment for TB in the past or who has

taken anti-TB drugs for less than one month.

Retreated case A patient previously treated for TB with combination chemotherapy for

4 weeks or more, excluding prophylactic therapy.

* In the new definitions proposed by the European Centre for Disease Prevention and Control, “definite” and “other-than-definite” will be replaced by “possible” (based only on clinical criteria or post-mortem findings), “probable” (if there is additional detection of acid-fast bacilli or granulomata or M.tb complex nucleic acid) or “confirmed” (by culture, or nucleic acid+AFB). All three categories will be subject to reporting, as well as cases reported only by laboratories without information on clinical criteria.

Pulmonary case A patient with TB of the lung parenchyma or the tracheo-bronchial tree (including larynx).

Extra-pulmonary case A patient with TB of organs other than the lungs or the tracheo-bronchial tree

Note: a patient with both pulmonary and extra-pulmonary TB is classified as pulmonary.

Primary drug resistance Resistance to one or more anti-TB drugs at start of treatment in a new TB case

Acquired drug resistance

Resistance to one or more anti-TB drugs at start of treatment in a retreated TB case

Multi-drug resistance (MDR)

Resistance to at least isoniazid and rifampicin

Extensive drug resistance (XDR)

MDR and

1) resistance to a fluoroquinolone and

2) resistance to one or more of the following injectable drugs: amikacin, capreomycin, or kanamycin

European definitions for TB surveillance (2)

Cured Treatment completion and:

-culture becoming negative on samples taken at the end of treatment and on at least one previous occasion, or

- sputum microscopy becoming negative for AFB at the end of treatment and on at least one previous occasion

Completed Treatment completion, not meeting the criteria to be classified as cure or treatment failure

Died Death before starting treatment or during treatment, irrespective of cause (including post-mortem diagnosis)

Failed Culture or sputum microscopy remaining positive or becoming positive again at 5 months or later during treatment

Defaulted Treatment interrupted for 2 consecutive months or more

Transferred Patient referral to another clinical unit for treatment and information on outcome not available / not obtained

Still on treatment

Patient still on treatment at 12 months and who did not meet any other outcome during treatment, including patients with:

- treatment prolonged because of side effects / complications, initial regimen planned for > 12 months

- initial treatment changed due to polyresistance (ie. resistance to at least two first line drugs) on the isolate taken at the start of treatment

- information on the reasons for being still on treatment not available

Unknown information on outcome not available

European definitions for TB surveillance (3) Treatment outcome categories (from 2001 cohorts)

Cohort All definite pulmonary cases notified in one calendar

year and followed up for TOM. Cohorts in use for

TOM are either smear positive or culture positive

(depending on the country of report) and stratified by

treatment history - new, retreated and unknown.

Period of

observation

Maximal duration of time from start of treatment or

registration for observing treatment outcome. This is

set at 12 months.

European definitions for TB surveillance (4)Cohort analysis for treatment outcome monitoring (TOM)

Source: WHO, 2008

No report

0–24

25–49

50–99

100 or more

* Notified TB cases (new and relapse) per 100 000 population

Tuberculosis notification rates (1)World, 2006*

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved

Tuberculosis notification rates (2) WHO European Region, 2006

TB cases per 100 000 population

Not includedNot reporting to EuroTB< 11 11 – 20 21 – 50> 50

Andorra

Malta

Monaco

San Marino

Tuberculosis notification rates (3) Trends by areas, 1996-2006

0

20

40

60

80

100

120

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

TB cases/100 000

East

European Region

Balkans

EU-27 & West

EU-15

Tuberculosis notification rates (4) Mean annual change in rate, 1998-2006*

* Excluding Monaco, San Marino (EU & West)

-10%

-5%

0%

5%

10%

1998-2002 2002-2006

% change in rate

EU & West Balkans East

Tuberculosis notification rates (5) Pulmonary smear positive rates, 2006

5

* Country range shown in brackets. Excluding countries with missing data (Monaco, San Marino) or using the respiratory classification (Belarus, Bulgaria)

(1-68)0

10

15

20

25

30

35

40Sputum smear positive

TB cases / 100 000

EU & West

Balkans

East

(6-15) (27-117)

Percentage of TB cases of foreign origin, 2006

AndorraMalta Monaco San Marino

Not included or not reporting to EuroTB0% – 4% 5% – 19% 20% – 49%> 49%

TB cases with positive culture, 2006*

(28-100%) (28-63%) (4-36%)Andorra

Malta

Monaco

San Marino

Percentage of TB cases with positive culture

Not included or no culture data reported to EuroTB

< 40%

40% – 54%

55% – 74%

> 74%

* Data from 2005 for Ireland and Romania (culture results incomplete in 2006)

TB cases with primary MDR, 2006*

AndorraMalta Monaco San Marino

Percentage of new TB cases with MDRNot included or not reporting to EuroTBNo nationwide data on drug resistance reported0.0% – 0.9% 1.0% – 1.9%2.0% – 5.9%6.0% – 19.4%

**

*

*

*

*

*

Showing only countries with nationwide data.Data from 2004 for Poland and Romania and 2005 for

Ireland.Data representativeness unknown in countries marked with

an asterisk.

Treatment outcome New definite pulmonary cases, 2001-2005*

* Countries with representative outcome data. EU & West (culture positive): Andorra, Austria, Belgium, Czech Rep, Denmark, Estonia, Germany, Hungary, Iceland, Ireland, Israel, Latvia, Lithuania, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Sweden, United Kingdom. Balkans (smear positive): Albania, Macedonia F.Y.R. East (smear positive): Kazakhstan, Kyrgyzstan

0%

20%

40%

60%

80%

100%

2001 2002 2003 2004 2005 2001 2002 2003 2004 2005 2001 2002 2003 2004 2005

EU & West Balkans East

% cases

Success Died Failed or Still on treatment Defaulted, Transferred or Unknown

TB mortality rates, 2001-2006*

Not includedNo data or data incomplete< 1.1 1.1 – 5.0 5.1 – 10.0> 10.0

TB deaths per 100 000 population

Andorra

Malta

Monaco

San Marino * Source: WHO Mortality Database, October 2007. Data shown for latest available year. Including only deaths from TB coded ICD-9 010-018 or ICD-10 A15-19.