Figures 1 and 2. Tuberculosis notification rates, 1985-2002, European Union. Source: EuroTB.

Figure 1. European Union mean, before and after 2004 enlargement*

*Old EU: Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and United Kingdom. Greece excluded owing to lack of data for 1993-94. 10 New EU countries: as listed in Figure 2. EU 2004: both groups together. 2002 data provisional.
 

Figure 2. Reported TB incidence in the 10 new EU countries

The decline in TB incidence observed until the early 1990s has stopped or even reversed in a number of countries in the EU (Figure 2), whereas the proportion of TB cases in migrants from high prevalence countries is increasing. In most of the 10 countries joining the EU this year, TB incidence is higher than the mean of the enlarged EU. In the Baltic states, incidence is five times greater, and there is a very high frequency of multidrug resistant TB (2), reflecting a widespread problem throughout the former Soviet Union (FSU), where TB medication programmes have been inadequate for many years. The borders between the EU and high incidence countries such as Russia (109 notifications per 100 000 in 2002) and Ukraine (83 per 100 000) will now be much longer, and the movement of people across them is expected to increase. In the FSU, the transmission of HIV is expected to fuel future incidence and drug resistance, a major threat for the rest of Europe warranting close monitoring and targeted interventions. Additionally, the target for treatment success is still not met in many European countries (Table), and the World Health Organization estimates that the European region has the lowest case detection rates worldwide (3).

Table. Summary tuberculosis surveillance data, Europe. Source: EuroTB.
 

	EU + West†		0	Other†			Total
	Countries			Countries			Countries
Total population	32	472.3 million		20	404.9		52	877.2 million
TB case notification, 2002*
Total number of cases	32	66 893		20	359 065		52	425 958
Notification rate per 100 000	32	14.1		19	89.6		52	48.8
Mean annual change in notification rate, 1995-2002	31	-3.5%		18	7.2%		49	3.5%
Foreign origin	31	29.0%		15	0.2%		46	8.7%
Surveillance of drug resistance, 2001II
Isoniazid resistance, new cases	22	5.1%		2	-	‡	24	4.7%
Multidrug resistance, new cases	22	0.9%		2	-	‡	24	0.8%
Treatment outcome monitoring, 2000 ††
Treatment success, new pulmonary sputum smear positive cases	18	72%		8	80%		26	75.0%
Treatment success, retreated pulmonary sputum smear positive cases	16	62%		8	67%		24	66.0%

^† EU+West includes the 25 EU countries (2004) as well as Andorra, Iceland, Israel, Monaco, Norway, San Marino and Switzerland. Other includes the 12 remaining states of the former Soviet Union, as well as Albania, Bosnia & Herzegovina, Bulgaria, Croatia, Macedonia, Romania, Serbia & Montenegro and Turkey
* Data for 2002 are provisional
^II Data for countries with representative, nationwide data; percents refer to median of country range
‡ Data only available for Croatia and Bosnia & Herzegovina – not indicative of group of countries
^††Data for countries with nationwide data, including >85% cases reported.

Surveillance of TB in Europe has been supported by European Commission (EC) through the funding of EuroTB between 1996-2003. EuroTB has been instrumental in increasing the contribution of surveillance to the control of TB in Europe through promoting a standardised approach to collection and analysis of data on incidence, drug resistance and treatment outcome. Its publications (available at http://www.eurotb.org/) represent an increasingly recognised and authoritative source of information.

From 2005, European monitoring of serious health threats such as TB will become the task of the newly established the European Centre for Disease Prevention and Control (ECDC) (4). EuroTB has received no funding from the EC since the start of 2004, and its work is destined to come to an end before the ECDC comes into being. Should the networking and experience accumulated by EuroTB over the past seven years be lost, it will be a setback that the European public can ill afford while TB remains a serious threat to human health in Europe.

Two previous WHO reports published in 1997 and 2000 (2,3) had already concluded that drug resistant TB was present in all settings surveyed, and multidrug resistance (MDR) in most, while good TB control practices were associated with lower or decreasing levels of resistance.

At a press conference in London, the Director of WHO’s Stop TB campaign (http://www.stoptb.org/) stressed the urgency of the situation for countries in the former Soviet Union and called for increased investment in TB prevention programmes. DOTS, the internationally agreed TB treatment strategy (http://www.who.int/gtb/dots/index.htm), is, according to WHO, the most effective strategy to prevent emergence of drug resistance, and needs to be fully adopted.

In countries where there are existing cases of MDR resistance, it is recommended that the DOTS-plus strategy is implemented through the Green Light Committee (http://www.who.int/gtb/policyrd/DOTSplus.htm). Investment in treatment programmes and surveillance needs to be strengthened, particularly in areas with a high prevalence of MDR TB, which is difficult and expensive to treat and has a high mortality.

The WHO 2004 Global TB Control Report will be released on World TB Day, 24 March, also the first day of the 2nd Stop TB Partners’ Forum in New Delhi (details available at http://www.stoptb.org/).

The KNCV Tuberculosis Foundation and the GGD Nederland (Dutch Association of Municipal Health Services, http://www.ggd.nl/) have previously called for TB control in the Netherlands to be strengthened, and for attention to be given to establishing quality TB control in eastern Europe.

Adapted and summarised from reference 1.