International Notes Update: Acquired Immunodeficiency Syndrome -- Europe

As of June 30, 1985, 1,226 cases of acquired immunodeficiency syndrome (AIDS) have been reported to the World Health Organization (WHO) European Collaborating Centre on AIDS (Table 1). Two hundred eighty-five new cases were reported by 17 countries that were corresponding with the Centre by March 31, 1985 (1). The new cases represent an average increase of 22 cases per week.

The greatest increases in numbers of cases were observed in: France -- 85 new cases (six to seven per week); Federal Republic of Germany -- 58 (four to five per week), and the United Kingdom -- 36 (two to three per week). In each of four countries (Belgium, Netherlands, Spain, and Switzerland), an increase of one case per week was noted. In Italy, the number of reported cases has more than doubled since March 1985 (30 new cases) because of better contact between clinicians and the national reporting center. For the other 10 countries, zero to seven new cases were reported between March and June.

AIDS cases per million population were calculated using 1985 population estimates (Institut National d'Etudes Demographiques, Paris). The highest rates were noted in: Switzerland -- 9.7; Denmark -- 9.4; and France -- 7.0. These rates are low compared to the U.S. rate of 48.4 (2). The rate reported from Belgium must be interpreted in a unique context, as 74% of cases in Belgium originate from Africa.

The number of cases reported by the 10 countries that collaborated with the Centre in July 1984 (Denmark, Federal Republic of Germany, France, Greece, Italy, Netherlands, Spain, Sweden, Switzerland, and United Kingdom) increased from 421 cases as of July 15, 1984 (3) to 1,090 cases on July 30, 1985. This is an increase of 160% in 1 year. The number of cases reported from these 10 countries has doubled in the last 8 months.

A total of 626 deaths were reported for 1,226 cases (case-fatality rate: 51%) (Table 2). Seven hundred ninety-five patients (65%) presented with one or more opportunistic infections; 245 (20%) had Kaposi's sarcoma (KS) alone; and 171 (14%) had opportunistic infections with KS. The category, "Other" (15 cases), includes four cases of progressive multifocal leukoencephalopathy (France -- three; Denmark -- one), four cases of cerebral lymphoma (United Kingdom -- two; France -- one, and Switzerland -- one), one case of Burkitt lymphoma of the brain; five cases of B-cell non-Hodgkin's lymphoma (Federal Republic of Germany -- three; Netherlands -- two), and one unknown (Sweden).

Males accounted for 91% of the cases (Table 3). The sex ratio was 11:1. Forty-two percent of cases occurred in the 30- to 39-year age group. Twenty- nine pediatric cases (children under 15 years old) have been reported in 10 European countries. Eighteen children either had parents with AIDS or parents who were in a group at high risk for AIDS; for eight pediatric patients (four with hemophilia and four with blood transfusions), transmission was due to contaminated blood or blood products. In four of the pediatric patients, no risk factor was reported.

Total cases were distributed geographically and by risk group as follows (Table 4):

Europeans *: 1,011 cases (82% of total). Nine hundred seventy-six (97%) patients were living in Europe before onset of the first symptoms; 35 (3%) were living in non-European countries: Zaire -- 11; United States -- 10; Haiti -- two; and one each in Bermuda, Burundi, Congo, Gabon, Ghana, Malaysia, Nicaragua, South Africa, Togo, and Venezuela; the country of residence was not specified for two of the 35 patients.

Caribbeans: 36 (3%). Thirty-four patients were living in Europe before the onset of the first symptoms: 30 Haitians were diagnosed in France; and one, in Belgium; one Dominican and one Jamaican were living in the United Kingdom; one patient of unspecified origin was living in Switzerland. Two Haitian patients diagnosed in France were living in Haiti.

Africans: 141 (12%). These persons were diagnosed in seven European countries and originated from 21 African countries (62% from Zaire and 10% from the Congo). Among the remaining 19 countries, the number of cases varied from one to five. One patient was of unknown national origin. Seventy-five patients (53%) were living in Europe before onset of the first symptoms. Sixty-one resided in Africa, and one, in the United States. Two patients from Zaire and one each from Burundi and Rwanda were living in other parts of the world.

Other origins: 38 cases (3%). Most of these patients originated from the American continents: United States -- 19; Canada -- one; Argentina -- three; Brazil -- three; and one each from Chili, Nicaragua, Peru, and Uruguay. One patient each originated from Australia, Lebanon, Pakistan, Thailand, and Turkey; the origins of three were unknown. Thirteen of these patients were not living in Europe before the onset of the first symptoms (United States -- 10; Africa -- one; unknown -- two).

Among the 1,011 European patients, 809 (80%) were homosexual or bisexual (Table 4). Forty-eight (5%) patients were IV drug abusers, and 15 (1%), both homosexual and drug abusers. These 63 cases were diagnosed in: Italy -- 19; Spain -- 16, Federal Republic of Germany -- 12; France -- eight; Switzerland

• three; Austria -- two; United Kingdom -- two; and Sweden -- one. Thirty- eight (4%) of the reported patients had hemophilia and were diagnosed in: Federal Republic of Germany -- 16; Spain -- eight; United Kingdom -- six; France -- three; and one each in Austria, Greece, Italy, Norway, and Sweden. One German hemophilia patient was reported as being homosexual and a drug abuser. For 20 patients (2%), the only risk factor found was blood trans- fusion. These cases were diagnosed in: France -- 12; Belgium and Netherlands

• three each; and Federal Republic of Germany and United Kingdom -- one each. Among these 20 cases, five had received blood transfusions outside Europe: one diagnosed in the Netherlands had undergone heart surgery in the United States; one diagnosed in France had received blood transfusions in Haiti and Martinique; and two diagnosed in Belgium had received transfusions in Zaire. One child diagnosed in the United Kingdom had received a blood transfusion in the United States. For 74 patients (7%), no risk factor was found (sex ratio 2:1). Risk factor information was not obtained for seven patients.

Among the 36 Caribbean patients, four were homosexual, and no risk factors were identified for 31 (sex ratio 3:1). Risk factor information was not obtained in one case.

Among the 141 Africans, 10 were homosexuals; five had received blood transfusions; and one was both homosexual and an IV drug abuser. No risk factors were identified for 112 (sex ratio 2:1); and for 13, information was not obtained.

Among the 38 patients of other origins, 30 were homosexual; two, both homosexual and IV drug abusers (one Canadian diagnosed in the United Kingdom and one in Sweden); two did not present risk factors. Information was not obtained in three cases.

It is not possible to compare precisely the situations in the various European countries because of differences that may exist in the methods of data collection at national levels of surveillance. Furthermore, in countries where AIDS is still rare, distribution of case patients by risk group may be modified as the number of cases increases. However, by examining current risk group distributions, the following observations can be made:

Male homosexuals. AIDS patients belonging to this risk group account for 60%-100% of the total number of cases in 11 of 15 countries. In four other countries (Belgium, Greece, Italy, Spain), male homosexuals account for fewer than 50% of cases.

Patients not belonging to any identified risk group. Among European countries this group contributes the second largest number of cases. This situation is accentuated in four countries (Belgium, France, Greece, and Switzerland), since a high proportion of patients originate from regions where AIDS has developed outside the principal risk groups (in Belgium, 74% of the patients originate from Equatorial Africa; in France, 13% originate from the same region, and 8% from Haiti; in Switzerland 13% originate from Equatorial Africa).

IV drug abusers. Of the nine countries reporting cases among IV drug abusers, two have a high proportion in this risk group: Spain -- 16 (42%) of 38 cases; Italy -- 19 (37%) of 52. The spread of AIDS in Europe has been particularly marked in this group. In July 1984, only Spain (three cases) and Federal Republic of Germany (two cases) had reported cases among IV drug abusers.

Cases related to transfusion of blood and blood products. Nine countries have reported AIDS among hemophilia patients, and five have reported cases among blood transfusion recipients. Although the first known cases among hemophilia patients in Europe might be related to the importation of factor VIII concentrate from the United States, the development of cases among transfusion recipients shows that AIDS transmission from European national blood production networks has become a public health problem. Most European countries have or shortly will set up systemic screening programs in blood donor centers.

The number of cases diagnosed between January and June 1985 must be considered as provisional because of the time required for reports to reach national surveillance centers. By June 30, 1985, 55% of patients diagnosed between January and June 1984 had died (Figure 3).

Surveillance of AIDS in Europe began in 1982; data obtained before 1982 cannot be included in the present surveillance data because of an unknown proportion of patients lost to follow-up.

Preliminary incidence rates for AIDS in the first 6 months of 1985 ranged from 0.3 cases per million population (Spain, United Kingdom) to about three cases per million (Denmark, Switzerland) (Figure 4). Incidence rates calcu- lated from December 1984 data (4) showed that 6-monthly incidence rates increased constantly in only six countries: Denmark, France, Federal Republic of Germany, Netherlands, Switzerland, and United Kingdom. Six months later, the situation changed distinctly -- incidence rates increased in all countries that have reported cases.

The spread of AIDS in Europe has accelerated since the beginning of 1985. During 1984, an average of about 10 cases were diagnosed each week in Europe. The average number of new cases per week for the 3-month periods ending December 31, 1984, March 31, 1985, and June 30, 1985, were 11, 14, and 22 new cases, respectively. Although 65% of the cases have been reported in three countries (France, Federal Republic of Germany, and United Kingdom), an increase has been noted in most of the countries participating in the surveillance of AIDS. In the three countries, distribution by risk group is similar to that observed in the United States. All identified risk groups are represented; male homosexuals are the most affected. In other countries, distribution varies, and only certain groups are currently affected. Three situations stand out: (1) In northern Europe (Denmark, Finland, Netherlands, Norway, and Sweden), most cases occur among male homosexuals; (2) In certain countries in southern Europe (Italy, Spain), the majority of cases occur among persons with no identifiable risk factor, but IV drug abusers seem to be considerably more affected than in the other countries; and (3) In Belgium, most of the cases occur among patients from central Africa.

Risk group distributions may be modified if the epidemic spreads into countries that have reported relatively few cases. Analysis of European surveillance data will continue to monitor risk-group distribution.

Editorial Note

Editorial Note: As of June 30, 1985, 18 countries were participating in the surveillance of AIDS in Europe by reporting their respective data to the Centre. Since the previous report (March 31, 1985), Luxembourg has collaborated with the Centre.

The Centre uses the CDC case definition. One source per country, recognized by the respective national health authorities, provides the information. The national data are noted on standard tables, and each source is responsible for the quality of the data provided. The Union of Soviet Socialist Republics and Yugoslavia have now officially set up national reference centers for AIDS and will be participating in the work of the WHO European Centre for the next report.

Reported by JB Brunet, MD, R Ancelle, MD, Institute de Medecine et d'Epidemiologic Tropicales (WHO Collaborating Centre on AIDS), Paris France; Federal Ministry of Health and Environmental Protection, Vienna, Austria; Conseil Superieur de l'Hygiene Publique, Ministere de la Sante, Brussels, Belgium; Institute of Virology, Bratislava, Czechoslovakia; Statens Serum Institute, Copenhagen, Denmark; Institute of Biomedical Sciences, Tampere, Finland; Direction Generale de la Sante, Paris, France; Robert Koch Institute, West Berlin, Federal Republic of Germany; Ministry of Health, Athens, Greece; General Direction of Public Health, Reykjavik, Iceland; Instituto Superiore di Sanita, Rome, Italy; Ministere de la Sante, Luxem- bourg, Luxembourg; Staatstoezicht op de Volksgezondheid, Leidfehendam, Netherlands; National Institute of Public Health, Oslo, Norway; National Institute of Hygiene, Warsaw, Poland; Ministerio de Sanidad y Consumo, Madrid, Spain; National Bacteriological Laboratory, Stockholm, Sweden; Office Federale de la Sante Publique, Berne, Switzerland; Communicable Disease Surveillance Centre, London, United Kingdom.

References

1. WHO. Weekly Epidemiological Record 1985;60:189-96.

2. CDC. AIDS weekly surveillance report. June 17, 1985.

3. WHO. Acquired immune deficiency syndrome (AIDS). Report of the situation in Europe as at 15 July 1984. Weekly Epidemiological Record 1984;59: 305-7.

4. WHO. Acquired immune deficiency syndrome (AIDS). Report on the situation as of 31 December 1984. Weekly Epidemiological Record 1985;60:85-92.

The word European refers to patients originating from one of the countries belonging to the WHO European region.

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