Overview of TB in the WHO European Region

Overview of TB in the WHO European Region "New Trends in Infectious Diseases" Lyon, France - 26 November 2008 Dennis FALZON, MD Stop TB Department - WHO/HQ

WHO Regions

Number of reported TB cases U.S.A.*, 1975-1993 MMWR; May 27, 1994 / 43(20);361-366

TB case rates (1) Total cases, 1985-2005* 100 (104 cases / 100,000) TB cases / 100,000 (log10 scale) Non-Baltic FSU New EU states (2004) Western Europe 10 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 * Countries with data represented in the groupings - Western Europe: Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, United Kingdom. New EU states (2004): Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, Slovenia (Malta & Cyprus included under West Europe). Non-Baltic FSU: (former Soviet Union countries; Baltic states included under New EU) Armenia, Azerbaijan, Belarus, Kyrgyzstan, Moldova, Russian Federation, Ukraine. Main source of 1985-1994 data : Global Tuberculosis Control: Surveillance, Planning, Financing. WHO/HTM/TB/2007.376; rest of data from EuroTB

TB case rates (2) By treatment history, 2001-2005

Mean annual change in TB case rates, 1998-2006* 10% % change in rate EU & West Balkans East 5% 0% -5% -10% 1998-2002 2002-2006 * Excluding Monaco, San Marino (EU & West)

Mean annual % change in TB incidence rate/yr (Y-axis) 1997 2006 vs health expenditure/cap. (Central & Eastern Europe)

Mean annual % change in TB incidence rate/yr (Y-axis) 1997 2006, vs. % TB cases of foreign origin (high income countries)

TB cases by geographic origin, EU & West,* 2000-2006 TB cases National Foreign Unknown 35 000 30 000 25 000 20 000 15 000 10 000 5 000 0 2000 2001 2002 2003 2004 2005 2006 * Excluding countries with incomplete data for any one year or change in criterion of origin: Andorra, Bulgaria, Cyprus, Greece, Luxembourg, Monaco, Poland, San Marino, Spain. Cases from Romania (>25,000 yearly; <0.1% foreign) are not included.

Foreign TB cases by area of origin, EU & West, 2006 (N=13,478)* Africa EU & West Balkans Former Soviet Union Asia Americas Other / Unknown * Cases native or citizens of a country other than the one of report. Former Soviet Union does not include Baltic States. Pooled for countries with case-based data on country of origin, excluding Bulgaria, France, Israel, Monaco, Norway, San Marino, Spain.

TB case rates by ethnicity, England & Wales, 2001 240 210 TB cases / 100,000 180 150 120 90 60 30 0 Black African Pakistani Indian White Source: National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London: Royal College of Physicians, 2006.

Tuberculosis notification rates (1) Estimated TB incidence rate, 2006* Estimated new TB cases (all forms) per 100 000 population No estimate 0-24 25-49 50-99 100-299 300 or more 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) European Region, 2006* TB cases per 100 000 population Not included Not reporting to EuroTB < 11 11 20 21 50 > 50 Andorra Malta Monaco San Marino Source: EuroTB, 2008

TB mortality rates, 2001-2006* TB deaths per 100 000 population Not included No data or data incomplete < 1.1 1.1 5.0 5.1 10.0 > 10.0 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.

Geographic expansion of the European Union Former Soviet Union countries

The EU is an increasingly disparate group of countries TB cases / 100,000 (2005) % TB cases who are foreign (2005) <11 11-20 21-50 >50 <16 16-35 36-55 >55

HIV infection Infectious diseases in the EU Total burden of disease* TB Campylobacteriosis Salmonellosis Influenza EHEC Measles 0 5 10 15 20 25 30 DALYs / yr / 100,000 population TB burden : wide country range = 3-263 DALY/yr/100K pop Highest in Baltic States, Hungary, Portugal & Poland * 12 countries with data available for all 7 diseases. All estimates incorporate mortality, morbidity, & disability; TB estimates relate to 2003-2005 Source: Pilot survey, RIVM (2007)

HIV / TB

Estimated prevalence of HIV infection in TB cases, global, 2003

HIV infection among TB cases (1) Selected countries*, 2000-2006 18 16 14 12 10 8 6 4 2 0 % TB cases Portugal United Kingdom Estonia Latvia 2000 2001 2002 2003 2004 2005 2006 * Completeness of information differs between countries.

HIV infection among TB cases (2) East*, 2006 6% % HIV positive 5% 4% 3% 2% 1% 0% Ukraine (New cases) Russian Federation (New cases) Armenia Uzbekistan Belarus (New cases, 2005) Kazakhstan Georgia Tajikistan (Dushanbe) Azerbaijan (2003) * Completeness of information differs between countries. No data from Kyrgyzstan, Moldova, Turkmenistan.

HIV infection among TB cases (3) HIV / MDR-TB LATVIA, 2001 2005 UKRAINE,* 2006 * DONETSK OBLAST The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance 2002-2007

Anti-TB Drug Resistance

Diagnostic DST by WHO region, 2006 30 NEW % of new cases tested 25 20 15 10 5 0 AFR (8, 10%) AMR (17, 50%) EMR (10, 11%) EUR (45, 77%) SEAR (2, 0.03%) WPR (15, 12%) World (97, 19%) RETREATED % of re-treatment cases tested 30 25 20 15 10 5 0 AFR (11, 14%) AMR (15, 65%) EMR (6, 13%) EUR (40, 82%) SEAR (3, 2%) WPR (12, 3%) World (87, 20%) Numbers under bars represent the number of countries reporting data followed by the percentage of total estimated cases of MDR-TB accounted for by reporting countries. Data for re-treatment cases from India and China excluded because testing of only 26 (India) and 10 (China) cases was reported.

High TB burden countries 22 countries with 80% of estimated global TB incidence

High MDR-TB burden countries 27 countries with 85% of estimated global MDR-TB incidence 15

MDR-TB among new TB cases 1994-2007

Combined MDR-TB by area of origin EU & West,* 2005 EU & West Balkans Former Soviet Union Rest of Asia Africa Americas & Oceania Unknown Total Cases tested for INH & RMP 7,708 722 583 2,509 2,421 239 823 15,005 N 100 4 90 28 23 2 9 256 MDR % 1.3 0.6 15.4 1.1 1.0 0.8 1.1 1.7 * Countries with case-based data (excluding Baltic States - Estonia, Latvia, Lithuania) : Andorra, Austria, Belgium, Cyprus, Czech Republic, Denmark, Finland, Germany, Hungary, Iceland, Ireland, Luxembourg, Malta, Netherlands, Portugal, Slovakia, Slovenia, Sweden, Switzerland, United Kingdom. The 12 countries in the East, and the Baltic States

Primary MDR-TB, EU & West, 2006 Cases and prevalence* 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Cases % 1ary MDR Cyprus Luxembourg Andorra Iceland Norway Finland Slovenia Malta Netherlands Sweden Denmark Slovakia Switzerland Czech Republic Austria Belgium France Israel United Kingdom Estonia Germany Latvia Lithuania * Presence of MDR among previously untreated cases in countries with nationwide representative data in 2006 (sentinel surveillance data in France); proportion MDR calculated as a percentage of new cases with results of initial testing for H & R.

Treatment & Control

WHA Targets, 1991 Detect at least 70% of new sputum smear positive cases Successfully treat at least 85% of cases detected

Millennium Development Goals Target 8. Have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases STB Indicators Prevalence and death rates associated with TB Proportion of TB cases detected and cured under DOTS

DOTS coverage by WHO region, 1994-2006 80 70 73 WHO target 64 13 292 7.5 WPR 5.6 Case detection rate (%) 60 50 40 30 20 AMR 701 835 531 SEAR 595 1714 1759 EUR EMR AFR 10 0 1994 1996 1998 2000 2002 2004 2006

Treatment outcome - Europe 2001-2005* Success Died Failed or Still on treatment Defaulted, Transferred or Unknown % cases 100% 80% 60% 40% 20% 0% 2001 2002 2003 2004 2005 2001 2002 2003 2004 2005 2001 2002 2003 2004 2005 EU & West Balkans East * New definite pulmonary cases reported by 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

DOTS status in 2006: countries close to targets 100 Iceland Bosnia & Herzegovina Target zone Treatment success (%) China El Salvador Kiribati China, Macao SAR Cuba Cambodia Lebanon Samoa Tunisia Bhutan Afghanistan Bangladesh Peru 90 Indonesia Lao PDR Somalia Nepal French Polynesia Philippines Portugal DPR Korea Costa Rica Honduras Sri Lanka Mongolia Turkey Benin Bulgaria India Marshall Islands Maldives Algeria Kyrgyzstan TFYR Macedonia Guam Nicaragua Slovenia Qatar DR Congo Uruguay Myanmar Dominican Republic Kenya Singapore Iran (islamic republic of) Venezuela Jordan Romania Haiti Morocco Turkmenistan 80 Vanuatu Bolivia Brazil Egypt Mexico Poland Liberia Madagascar Thailand Puerto Rico Cameroon Belize Armenia Latvia Estonia Georgia Angola Malaysia Brunei Darussalam Czech Republic Kazakhstan South Africa Fiji Lithuania 70 50 60 70 80 90 100 110 120 DOTS case detection rate (new smear-positive, %) 99 countries reported treatment success rates 70% or over and DOTS detection rates 50% or over 32 countries (including 2 countries out of range of graph) have reached both targets.

Estimated TB prevalence (a) and death rate (b), for the baseline year 1990 and for 2006, compared with the 2015 target and with prevalence and death rates projected for 2015 based on current trends (a) TB prevalence per 100 000 population (b) TB death rate per 100 000 population 600 100 500 80 400 60 300 40 200 100 20 0 AFR AMR EMR EUR SEAR WPR World 0 AFR AMR EMR EUR SEAR WPR World 1990 2006 2015 (current trends) MDG target 1990 2006 2015 (current trends) MDG target

30 Country projections of M(X)DR-TB patients to be enrolled on treatment in 2007 compared with the Global Plan 25 Russian Federation 20 15 10 South Africa India China 5 0 Global Country Global Projected Global Projected Plan report Plan Plan AFR AMR EMR EUR SEAR WPR

MDR-TB treatment outcomes Selected countries, 2003 cohort 100 90 Percentage of cohort 80 70 60 50 40 30 20 10 0 Germany (94) Lithuania (310) Brazil (316) Estonia (106) Latvia (165) Romania (585) Peru (1508) Success Died Failed Lost to F/U Numbers under bars are the number of patients in the cohort

Total TB control costs by country, High-burden countries, a 2002 2008 2500 All other HBCs 2230 2280 DR Congo US$ millions 2000 1500 1000 500 620 766 947 1075 1616 Kenya UR Tanzania Indonesia Nigeria Brazil India China 0 2002 2003 2004 2005 2006 2007 2008 South Africa Russian Federation a Total TB control costs for 2002 2006 are based on expenditure data, whereas those for 2007 2008 are based on budget data

Conclusion Huge disparity between and within countries in the EUR Region (even in EU!) Overall decrease in rates BUT countries far from TB elimination (1 TB case /10 6 pop) TB in vulnerable groups becomes more crucial M(X)DR-TB with/-out HIV

Action points More investment in prevention and control Targeting of risk and vulnerable groups Support for innovative technologies in diagnostics and treatment Operational research

www.who.int/tb/