Analysts from the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) reported today that overall tuberculosis (TB) incidence and mortality continue to decline throughout Europe, but trends among countries vary widely, and multidrug-resistant (MDR)-TB remains a major concern.

WHO officials say the data indicate that while the situation is improving in Europe, TB continues to be a major public health problem. They add that European health officials need to intensify their efforts if the region is to reach one of the milestones of the agency's End TB strategy—an 80% reduction in the TB incidence rate by 2030 compared with 2015.

"TB is preventable and curable; the time to take action is now to end TB by 2030," Zsuzsanna Jakab, MD, WHO regional director for Europe, said in an ECDC press release. "If we don't act rapidly and decisively, the drug-resistant forms of the disease will increase their hold on Europe."

Declines in incidence, mortality

The joint WHO/ECDC report covers TB incidence and mortality for both the WHO European region, which includes 52 countries, and the 31-country European Union/European Economic Area (EU/EEA).

In the WHO European Region, an estimated 275,000 new and relapse cases of TB occurred in 2017, for an average of 30 cases per 100,000 people. Eighty-seven percent of these patients (238,819) were notified. TB cases in the region represent nearly 3% of the global burden of the disease.

The absolute number of cases in the WHO European Region dropped by 15,000 from 2016, and the 4.7% average annual decline in incidence observed from 2008 through 2017 is significantly higher than the global rate of decline for TB incidence (1.8%).

TB mortality is also falling in the region. An estimated 24,000 deaths TB deaths occurred in 2017 among HIV-negative patients in the WHO European Region, and the rate of 2.6 deaths per 100,000 people represents a 59% drop from 2008, when it was 6.3 per 100,000 people. The 10% annual decline over the past 5 years is notably higher the 3.2% global decline observed from 2016 to 2017.

In the EU/EEA countries, 55,337 cases of TB were reported in 2017, for a notification rate of 10.7 per 100,000 people. The average annual decline in the notification rate was 4.5% from 2013 through 2017. The estimated number of TB deaths among HIV-negative patients in the EU/EEA was 4,000, down from an estimated 4,200 in 2016 and 6,700 in 2008.

Although the decline in the notification rate is significant, the authors of the report point out that the 2030 target is a notification rate of 2.4 per 100,000. If the mean annual change in rate in low-incidence countries continues at that pace, they write, "calculations suggest the WHO target of TB elimination by 2050 in European low-incidence countries will not be met by approximately four fifths of the countries currently in this group."

Much of the gap in estimated incidence rates between the WHO European Region and the EU/EEA is driven by 18 high-prevalence non-EU/EEA countries (HPCs)—including Russia, Ukraine, Uzbekistan, Romania, Turkey, and Kazakhstan—that account for nearly 83% of the regional TB burden. The largest proportion of new and relapse TB cases comes from Russia (84,510, or 35.4%).

MDR-, XDR-TB on the rise

In addition, nine of the countries with the highest burden of rifampicin-resistant (RR)/MDR-TB burden—Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Ukraine, and Uzbekistan—are non-EU/EEA countries. The report estimates there were 109,000 cases of RR/MDR-TB in the WHO European Region in 2017, and 27.9% of pulmonary TB cases tested for drug susceptibility had MDR-TB. The MDR percentage among new bacteriologically confirmed pulmonary TB cases in the non-EU/EEA countries rose from 16.8% in 2013 to 18.1% in 2017.

Extensively drug-resistant (XDR)-TB is also a rising problem in WHO European Region countries. Of the 33,530 MDR-TB cases subjected to second-line drug-susceptibility testing (DST), 6,759 (18.6%) were XDR-TB. In absolute numbers, XDR-TB cases rose from 575 in 2013 to 5,591 in 2017.

Drug-resistant TB poses a problem in some EU/EEA countries as well. Overall, MDR-TB was reported in 1,041 of 27,339 TB cases (3.8%) with relevant DST results in the EU/EEA in 2017, for an incidence rate of 0.2 per 100,000—a slight decrease from the rate of 0.3 per 100,000 observed from 2013 through 2016. But in Latvia, Lithuania, and Estonia, the proportion of MDR-TB cases ranged from 10.6% to 25.9%. And the authors of the report note that the high incidence of MDR-TB in some of the non-EU/EEA countries means the threat is ever-present.

"Given the high number of drug-resistant TB cases in the European Region HPCs bordering the EU/EEA, however, countries need to remain vigilant and prepared to diagnose and treat drug-resistant TB," they write.

XDR-TB was reported for 24.4% of 770 MDR-TB cases tested for second-line drug susceptibility in EU/EEA countries. An increasing trend in XDR-TB was observed in Latvia, Lithuania, Estonia, Romania, and Armenia.

The report also shows that disparities in treatment outcomes for TB and drug-resistant TB remain significant. Of the 54,612 TB cases with a treatment outcome reported in 2017 in EU/EEA countries, 38,614 (70.7%) were treated successfully, while only 545 of 1,712 MDR-TB cases (44.8%) were treated successfully. Of the 170 XDR-TB cases with treatment outcomes reported in 2017, 47 (27.6%) were treated successfully.

See also:

Mar 19 WHO/ECDC TB surveillance and monitoring report

Mar 19 WHO/ECDC press release