Tuberculosis -- Western Europe, 1974-1991

In several industrialized countries, declines in trends in reported tuberculosis (TB) have stablized or reversed. This phenomenon was first recognized in the United States (1) and subsequently observed in Western European countries (2). This report summarizes a 1992 assessment of trends in TB morbidity and mortality in 15 countries of Western Europe (Table 1) by the Tuberculosis Program of the World Health Organization (WHO) (3).

A case of TB was defined by the reporting criteria in the country studied. Data were obtained from national statistical reports produced by the ministries of health and/or reports from national TB associations. Country-specific mortality data for 1980- 1990 and annual population estimates were provided by WHO's Division of Epidemiological Surveillance and Health Situation and Trends Assessment.

Since the mid-1980s, TB case reports (Table 1) and reporting rates (Table 2) have generally declined in Belgium, Finland, France, Germany, Portugal, and Spain (except in 1991). A similar pattern of decline has not been observed in the remaining nine countries. Portugal had the highest rate (53 per 100,000 population) in 1991 and Denmark the lowest (six per 100,000) (Table 2). Except for Portugal, all countries reported rates lower than 25. Among the indigenous population of most countries, TB occurred largely among the elderly, except in Portugal where, in 1990, more than half of all cases occurred in persons aged 15-44 years.

In 1990, cases among foreign-born persons constituted 51% of all cases in Switzerland, 41% each in the Netherlands and Sweden, and 38% in Denmark (Table 3). In eight of the countries, an increasing number of cases were reported among foreign-born persons from developing countries with a high prevalence of TB. Data on the relation between TB and human immunodeficiency virus (HIV) infection are limited in most of the countries, although in some countries a high proportion of persons with acquired immunodeficiency syndrome (AIDS) have TB (Table 3).

Deaths caused by TB decreased in all countries; most deaths occurred among persons aged greater than or equal to 65 years. The death rate for the most recent year available in each country ranged from 0.3 to 2.8 per 100,000 population.

Reported by: MC Raviglione, MD, P Sudre, MD, K Esteves, S Spinaci, MD, A Kochi, MD, Tuberculosis Program, World Health Organization, Geneva. HL Rieder, MD, Tuberculosis Section, International Union Against Tuberculosis and Lung Disease, Paris. Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Interpretation of the data in this report is difficult because annual fluctuations in the number of reported TB cases may result from changes in case definitions and reporting criteria over time within and between countries (e.g., Switzerland modified its TB reporting system and case definition in 1987, Spain reported only pulmonary cases, and Italy reported only bacteriologically confirmed cases until 1990). Nonetheless, the general trends in TB morbidity suggest that the declines of the 1970s are no longer being sustained in several countries of Western Europe.

Factors contributing to the observed trends in TB morbidity probably vary between countries. An increasing proportion of cases among foreign-born persons probably has contributed to a change from expected downward trends. The impact of the HIV epidemic on TB in Western Europe may be limited to places where the HIV seroprevalence among TB patients is high (e.g., Paris, 12%) (4). The HIV seroprevalence among persons with TB is not widely available, however, and the prevalence of TB among persons with AIDS is used in this report as an indicator of the impact of HIV on TB morbidity. The HIV epidemic may have contributed to changing trends in reported TB in countries where TB is common among HIV-infected persons (5).

Properly designed disease surveillance systems and standardized case definitions are critical to monitoring TB trends and identifying high-risk groups. Analysis of standardized surveillance data will allow each country to more effectively prevent, diagnose, and treat TB and will make comparison of TB data between countries feasible. TB remains a global disease, and because of human migrations, its elimination in Western Europe cannot be achieved without improvement of control measures in countries with a high prevalence of TB.

References

1. CDC. Tuberculosis -- United States, first 39 weeks, 1985. MMWR 1985;34:625-7.

2. Rieder HL. Misbehaviour of a dying epidemic: a call for less speculation and better surveillance {Editorial}. Tuber Lung Dis 1992;73:181-3.

3. Raviglione MC, Sudre P, Rieder HL, Spinaci S, Kochi A. Secular trends of tuberculosis in Western Europe. Bull World Health Organ 1993;71:297-306.

4. Marshall B, Moyse C, Lepoutre A. Cases of tuberculosis reported in France in 1991 {French}. B E H 1992;53:247-9.

5. Raviglione MC, Sudre P, Rieder HL, Spinaci S, Kochi A. Secular trends of tuberculosis in Western Europe: epidemiological situation in 14 countries. Geneva: World Health Organization, Tuberculosis Program, Division of Communicable Diseases, 1992; publication no. WHO/TB/92.170.

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