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Tuberculosis : emergency situation in the European region

Richard Zaleskis
1 January, 2008  

Richard Zaleskis
MD PhD
Regional Adviser
TB Control
WHO Regional
Office for Europe

Tuberculosis (TB) remains an important public health problem worldwide and in countries ­belonging to the World Health Organization (WHO) European Region, or EUR (the WHO European Region comprises 53 Member States; see Resource). According to the most recent WHO estimates,(1) there were 8.8 million new TB cases in 2005 worldwide, and 1.6 million people died of TB, including 195,000 patients infected with HIV. There was an estimated 445,000 new TB cases and 66,000 deaths due to TB in 2005 in the EUR (see Figure 1).

[[HHE07_fig1_M15]]

The average estimated TB incidence rate in EUR is 50 per 100,000 inhabitants. However, there are variations in rates, increasing from west to east: from an average of 13 per 100,000 inhabitants in the first 15 members of the European Union (EU) to 25/100,000 in the 10 new members of the EU ­enlargement in 2004, to 51/100,000 in the four countries who entered the EU in 2007 and to 103/100,000 in the countries bordering the EU.

Epidemiological situations within the EUR vary among countries in two different ways. While TB notification rates are stable or have decreased in many EU countries since the start of the 1990s, there has been a resurgence of the disease, with a dramatic increase in TB notification rates, in Eastern Europe, ­particularly in the countries of the former Soviet Union, with increasing levels of multidrug-resistant TB (MDR-TB; resistance to at least isoniazid and rifampicin, the most powerful first-line anti-TB drugs) and TB/HIV co-infection. In 2005, 365,346 new TB cases were reported in the EUR, compared with 373,670 in 2002 (the highest figure in the last two decades). More than 80% of these cases occurred in 18 high-priority countries grouped under the WHO epidemiological region of Eastern Europe (EEUR; as defined by the WHO for epidemiological purposes, the EEUR consists of 18 countries: Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Republic of Moldova, Russian Federation, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan). The highest TB notification rates in 2005 were in Kazakhstan, Republic of Moldova, Kyrgyzstan and Romania: 174, 122, 120 and 120 cases per 100,000 inhabitants, respectively.

It should be mentioned, however, that there was stabilisation, or even a decline, in TB cases ­notification during recent years in the EEUR and in the EUR in general.(1) This improvement could be explained by consolidated efforts in TB control made by countries in close collaboration with the WHO and international partners. The WHO recommended TB control strategy, later termed the DOTS (directly observed treatment short-course) strategy,(2) started in the EEUR in 1995, when two countries adopted this strategy. By 2003, all EEUR countries had adopted it. By 2005, 43 out of 53 countries in the EUR had at least partially implemented DOTS; among them, 35 countries have implemented DOTS countrywide as the national TB control strategy. DOTS population coverage increased in the EUR from 17% in 2000 to 60% in 2005.(1)

Despite some progress in TB control achieved in the EUR, there are still many challenges, such as: insufficient political and financial commitment (lack of human and financial resources); insufficient health systems and infrastructure (lack of involvement of all care providers, including private sector and communities, poor integration with primary health services); the highest rates of MDR-TB in the world (up to 10–23% of all TB cases);(3) a sharp increase in cases of HIV/AIDS; TB in prisons (incidence 50 times and mortality 28 times higher than in the general population); and immigration from high-burden countries. Social marginalisation and immigration from TB high-burden countries have resulted in increasing TB incidence in some countries of Western Europe, in particular in large cities.

Recently, another serious challenge attracted the attention of the international community, the emergence of extensively drug-resistant TB (XDR-TB), defined today as MDR-TB plus resistance to: (i) any fluoroquinolone; and (ii) at least one of three injectable second-line anti-TB drugs (capreomycin, kanamycin and amikacin) used for the treatment of MDR-TB. The first report on XDR-TB, published in 2006, was based on a global survey of selected supranational reference laboratories from 49 countries.(4) Out of 17,690 TB isolates processed, 20% were MDR and 2% were XDR, among them the USA, Latvia and South Korea, where 4%, 19% and 15% of MDR-TB cases were XDR, respectively. According to the latest WHO information, XDR-TB has been confirmed on every continent and has been detected by national laboratories with drug susceptibility testing capacity to the second-line drugs in 29 countries, including in 14 countries of the EUR (with the highest rates).

As a response to these challenges, in 2005, through a letter to all EUR Member States, the ­Regional Director emphasised that TB was a regional emergency and called on Member States to strengthen political commitment and increase national expenditure on rational strategies to address TB. 

In order to fight TB effectively and address these challenges, the WHO launched in 2006 a new comprehensive strategy, the Stop TB Strategy.(5) The goal of this strategy is to reduce the global burden of TB by 2015, in line with the Millennium Development Goals (MDGs) and the Stop TB ­Partnership targets. The Stop TB Strategy consists of six components: (i) pursue high-quality DOTS expansion and enhancement; (ii) address TB/HIV, MDR-TB and other challenges; (iii) contribute to health system strengthening; (iv) engage all care providers; (v) empower people with TB and ­communities; and (vi) enable and promote research.

The implementation of the Global Plan to Stop TB (2006–2015), launched in January 2006 and based on the new Stop TB Strategy,(6) is a public health priority, globally and in the EUR in particular, to achieve the MDGs: “to have halted and begun to reverse the incidence of malaria and other diseases (including TB) by 2015”. In line with the Global Plan, the development of a Plan to Stop TB in the EEUR (2007–2015) is in progress. This plan describes the main challenges, strategies and activities to control TB and focuses on the 18 high-priority countries of the EEUR.

In order to address these problems and TB control challenges in the EUR, the WHO European ­Ministerial Forum on TB was held in Berlin, Germany, on 22 October 2007. The objectives of the Forum were: (i) to strengthen political commitment to implementing the WHO Stop TB Strategy in the EUR, as part of broader efforts to strengthen health systems; (ii) to obtain commitment from donor countries and countries badly affected by TB to increase their financial contribution to TB control; (iii) to endorse a European Stop TB Partnership launched in 2006; and (iv) to adopt a Regional ­Declaration on TB.

TB is a social problem. The future of its control and elimination therefore depends both on ­successes of healthcare systems and on consolidated efforts of national and international communities and strong partnerships.

References

  1. Global tuberculosis control: surveillance, planning, financing. WHO Report 2007. Geneva: World Health Organization (WHO/HTM/TB/2007.376, ISBN 92 4 156314 1).
  2. WHO tuberculosis programme: framework for effective tuberculosis control. Geneva: World Health ­Organization; 1994 (WHO/TB/94.179).
  3. Zignol M, Hosseini MS, Wright A, et al. Global incidence of multidrug-resistant tuberculosis. J Infect Dis 2006;194:479-85.
  4. Emergence of mycobacterium tuberculosis with extensive resistance to second-line drugs worldwide, 2000–2004. MMWR Morb Mortal Wkly Rep 2006;55:301-5.
  5. The Stop TB Strategy: building on and enhancing DOTS to meet the TB-related Millennium Development Goals. Geneva: World Health Organization; 2006 (WHO/HTM/TB/2006.368).
  6. The Global Plan to Stop TB 2006–2015. Geneva: Stop TB Partnership and World Health Organization; 2006 (WHO/HTM/STB/2006.35).