Research/Recherche. Secular trends of tuberculosis in Western. Europe. M.C. Raviglione,' P. Sudre,2 H.L. Rieder,3 S. Spinaci,' & A.

Transcription

1 Reserch/Recherche Seculr trends of tuberculosis in Western Europe M.C. Rviglione,' P. Sudre,2 H.L. Rieder,3 S. Spinci,' & A. Kochi4 Deths due to tuberculosis hve decresed uniformly in ll countries in Western Europe, nd most hve occurred mong those ged.65 yers. In recent yers, tuberculosis cse notifictions hve continued to decline in Belgium, Finlnd, Frnce, Germny, nd Spin, nd hve levelled off in Sweden nd the United Kingdom; increses hve, however, been recorded in Austri, Denmrk, Irelnd, Itly, Netherlnds, Norwy, nd Switzerlnd. In Denmrk, Netherlnds, Norwy, Sweden, nd Switzerlnd n incresing number of cses of tuberculosis mong foreign-born residents hs resulted in chnge from the expected downwrd trend. Humn immunodeficiency virus (HIV) infection ppers to contribute only mrginlly to the overll tuberculosis morbidity; however, it ppers to be importnt in Pris nd its surrounding res, nd tuberculosis is very common mong HIV-infected persons in Itly nd Spin. Despite these recent chnges in the incidence of tuberculosis, there is currently no evidence of its incresed trnsmission mong the youngest ge groups of the indigenous popultions. Properly designed disese surveillnce systems re criticl for monitoring the tuberculosis trends so tht ech country cn identify its own high-risk groups nd trget interventions to prevent, dignose, nd tret the disese. Tuberculosis remins globl disese nd becuse of incresing humn migrtions, its elimintion in Western Europe cnnot be envisged without concomitnt improvements in its control in high-incidence, resource-poor countries. Introduction In severl industrilized countries the regulr decline in tuberculosis notifictions, s expected from yers of observtion, ppers to hve become disturbed. The phenomenon ws first reported in the USA (1), where the verge 5.7% nnul decline in notifiction rtes over the period hlted in 1985, nd reversed from 1986 onwrds (2). As result, bout 28 more cses were notified over the period thn would hve been expected hd the I Medicl Officer, Tuberculosis Progrmme, World Helth Orgniztion, 1211 Genev 27, Switzerlnd. Requests for reprints should be sent to Dr Rviglione t this ddress. 2 Medicl Epidemiologist, Tuberculosis Progrmme, World Helth Orgniztion, Genev, Switzerlnd. 3 Chief, Bcteril nd Prsitic Diseses Section, Division of Epidemiology nd Infectious Diseses, Federl Office of Public Helth, Berne, Switzerlnd; nd Interntionl Union ginst Tuberculosis nd Lung Diseses, Pris, Frnce. 4 Progrmme Mnger, Tuberculosis Progrmme, World Helth Orgniztion, Genev, Switzerlnd. Reprint No previously observed downwrd trend continued (2). This hs been ttributed, in prt, to the spred of the humn immunodeficiency virus (HIV); homelessness, incresed drug buse, immigrtion from countries where tuberculosis is common, nd the deteriortion in the living conditions of nd helth cre delivery to the poor hve lso been proposed s fctors contributing to the increse (3, 4). A levelling off or reversed trend in tuberculosis notifictions hs been reported in recent yers lso from severl Westem Europen countries. The resons for this phenomenon re complex, differ from one country to nother, nd hve not been entirely elucidted (5). In order to fcilitte more precise ssessment of the epidemiologicl sitution in Westem Europen countries, we review here recent dt on tuberculosis mortlity rtes nd incidence nd their trends. Becuse reltively uniform reporting systems re comprtively recent development, the nlysis hs been limited only to the pst two decdes. With the ending of the epidemic, herlding the elimintion of the disese mong the generl indigenous popultions of Westem Europe, new fctors my become incres- Bulletin of the World Helth Orgniztion, 71 (3/4): (1993) World Helth Orgniztion

2 M.C. Rviglione et l. ingly importnt in contributing to reported tuberculosis morbidity. In this rticle we ttempt to nlyse tuberculosis notifictions in vrious Western Europen countries. The identifiction of specific fctors should permit better definition of the groups t risk, which cn then be trgeted with pproprite interventions. Methods Dt were obtined from the following sources: ntionl sttisticl reports produced by Ministries of Helth; reports of ntionl tuberculosis nd respirtory diseses ssocitions; published literture; nd personl communictions. Rtes (per 1 popultion) were obtined using popultion dt provided by WHO nd, for the popultions of some countries in , from estimtes provided by the United Ntions. Western Europen countries with very smll popultions or those whose dt could not be vlidted were not included in this study. Mortlity informtion for ws provided by WHO. A cse of tuberculosis ws defined s one officilly notified in the country studied. Results Mortlity Dt from 14 Western Europen countries were nlysed. Recent tuberculosis mortlity dt for the 14 countries re shown in Tble 1; for some countries informtion ws vilble only until 1987, 1988 or Tuberculosis deths decresed regulrly over the 1-yer period in ll the Western Europen countries studied, except the Netherlnds. The most recent mortlity rtes (per 1 ) vry from.3 in 1989 in the Netherlnds to 2.4 in 1987 in Spin. In 198 the mortlity rte rnged from.3 in the Netherlnds to 5. in Finlnd. In the Netherlnds, the totl number of tuberculosis deths, which hd regulrly decresed until 1984, reched its lowest vlue in 1987 fter 2 yers of temporry increse; however, increses of 3% nd 9%, respectively, were documented in 1988 nd The vst mjority (85% in 1989) of deths occurred mong those ged.65 yers. A recent nlysis showed tht over the period in the Netherlnds, the cse ftlity rte of bcteriologiclly proven pulmonry tuberculosis s well s the stndrdized mortlity rte incresed; this increse occured predominntly mong mle dults ged.65 yers (6). Demogrphic dt for helth sitution ssessment nd projections. Unpublished document WHO/HST/9.3. In ll the countries studied the mjority of tuberculosis deths hve incresingly occurred mong those ged.65 yers. No significnt increse in mortlity hs been reported mong dults ged yers. Morbidity The country-specific notifictions nd rtes re shown in Tbles 2 nd 3, respectively. The combined notifiction rtes for ll 14 countries declined lmost exponentilly over the observtion period t n verge rte of decline of 5.4% per nnum (Fig. 1), decresing by more thn 5% from 31.9 to 14. per 1 popultion between 1974 nd 199. However, the rte of decline differed in individul countries. Generlly, in countries with initilly higher rtes, tuberculosis declined more rpidly thn in those where the rtes were initilly lower. While the rnge of notifictions ws wider t the beginning of the observtion period ( per 1 in 1974, n lmost tenfold difference), this ws considerbly nrrower by the end of the period ( per 1 in 199, threefold difference). In lrge number of countries tuberculosis notifiction rtes hve not pprecibly declined in recent yers, nd in severl n increse hs occurred. However, the interprettion of surveillnce dt reported by some countries is problemtic becuse of the mrked nnul fluctutions in the number of cses; lrge chnges from one yer to the next re generlly unlikely to be ssocited with the tuberculosis epidemic, but rther to reporting bises. Notifictions of tuberculosis cses hve continued to decline in Belgium, Finlnd, Frnce, Germny, nd Spin. In Belgium, decrese in the rte of decline hs occurred over the lst 3 yers. In Finlnd, which hd the highest initil notifiction rte of the 14 countries studied, stedy nnul decrese occurred over the period ; however, in 1991 for the first time in 17 yers, the number of tuberculosis notifictions did not decrese substntilly. In Frnce the incidence of tuberculosis declined regulrly by 4% per yer over the period (7). In 1989 nd 199 the number of cses reported stbilized nd the rte remined unchnged (8). However, in 1991 there ws 6% decline over 199. There re some importnt regionl differences, nd notifiction rtes incresed slightly between 1988 nd 1989 in the Pris region, while decresing elsewhere (7). In Germny n nnul decline of bout 5% in the number of cses nd incidence ws observed between 1974 nd 1984; however, since 1984 the rte of decrese hs slowed down (9). In Spin, where only pulmonry tuberculosis is notified, declining trend begn in 1987 (1, 11, nd 298 WHO Bulletin OMS. Vol

3 Seculr trends of tuberculosis in Western Europe wo s- co ) ( U) CD C lot N- ) CD C ou o _ c 75 C'D * ) >n -o c C D o C C O C c C) (id 2 cu t CD I-I CM cu c] ' m U) (. D ) ) n c co co ) CDO U C. LtA _ D N- N- LA C t N- C C D CD r- C Nl- C N CD C C LA C N- N- CL 3 c C 1- c er U C t c v- c E l D c2.. cu H- cu C.) Cu cc N- N- I, N- C t N-... l:.-.1 C\. os.-cu N- ) o = _ C Z D t ULA C N IT-, ) OC -o 2? c ) oe C.c S C C C C D OD O D C O) - N- N- co CD O N- LO C t N- ) C D oto D!u D c) co w Cw, C C(D LO A N- N- _ If, _ CM z Co CD CM v- CY) N- ) cl N- N- v- CY) LO co U) LO CD v- co CY) v- LA co CY) ) v- CD CY T- N- LA LA UL CD CD ) N- LO LO E ~ Dc ) ' E { n 4> E n > O C x< c )D LL l) _ 4s m il il O - - z z cn T- o) CD E ) CJ) i C _..~ )~ =u cj > CD (D '- co E co* -, Q- WHO Bulletin OMS. Vol

4 M.C. Rviglione et l. Fig. 1. Number of notified tuberculosis cses over the period in 14 Western Europen countries combined (thin line) nd expected seculr trend fitted to observed dt by liner regression (bold line), logrithmic scle (dt for six countries only for 1991). 3 I-, D2 mcn observedexpected z1- ll. v4 z 1 I 1-1- * * * * I - -~~~ -t Yer of notifiction Ntionl Sttisticl Institute, Mdrid, 1991); however, n increse ws notified in In ddition, it hs been estimted tht s mny s 19 8 cses of tuberculosis my hve occurred in 199 (12). Age-specific dt from the Helth Deprtment of Brcelon nd other sources indicte tht in Spin tuberculosis is still problem mong the yer ge group (12). Notifictions of tuberculosis hve levelled off in Sweden nd the United Kingdom. In Sweden, more cses were notified in 1989 nd 199 thn in 1988, when the lowest number ever ws reported. In the United Kingdom, smll reversl in the decline of tuberculosis notifictions ws observed beginning in In Englnd nd Wles the highest notifiction rtes were mong mles ged >65 yers nd between 1987 nd 1989 smll increses occurred mong over- 65-yer-olds of both sexes nd femles ged yers (13, 14). Increses in tuberculosis notifictions occurred in Austri, Denmrk, Irelnd, Itly, Netherlnds, Norwy, nd Switzerlnd. In Austri, stbiliztion of notifiction rtes ws noted in , followed Tble 2: Reported number of cses of tuberculosis in 14 countries in Western Europe, Yer A B DK SF F D IRL NL N E S CH UK Totl NA 281 NA NA NA NA NA NA A: Austri; B: Belgium; DK: Denmrk; SF: Finlnd; F: Frnce; D: Germny; IRL: Irelnd; I: Itly; NL: Netherlnds; N. Norwy; E: Spin; S: Sweden; CH: Switzerlnd; nd UK: United Kingdom. b NA = no dt vilble. 3 WHO Bulletin OMS. Vol

5 Seculr trends of tuberculosis in Western Europe Tble 3: Reported number of cses of tuberculosis per 1 popultion in 14 countries in Western Europe Yer A B DK SF F D IRL NL N E S CH UK Totl NA 15.1 NA NA NA NA NA NA A: Austri; B: Belgium; DK: Denmrk; SF: Finlnd; F: Frnce; D: Germny; IRL: Irelnd; I: Itly; NL: Netherlnds; N: Norwy; E: Spin; S: Sweden; CH: Switzerlnd; nd UK: United Kingdom. b NA = no dt vilble. by decrese in 1989 nd 19% increse in 199 over the 1989 rte. In Denmrk, the lowest number of cses ever ws notified in 1986, but this hs subsequently incresed by 11%. In Irelnd the trend of declining notifictions ws reversed in 1989 nd 199 when increses occurred. In Itly, importnt increses in the number of tuberculosis cses were reported in 1989 nd 199 (Istituto Nzionle di Sttistic, Rome, ). However, no officil epidemiologicl dt hve ppered since 1978 (15); only bcteriologiclly proven cses were notified until 199, lthough inconsistently (16), nd under-reporting is recognized to be problem (17, 18). As result, it ws estimted tht pproximtely 2, (i.e., up to 35 cses per 1 popultion) my occur nnully (15, 17, 19). In the Netherlnds, the downwrd trend observed until 1987 hs subsequently been reversed (2). In Norwy, increses in cse notifictions nd rtes were observed in 199 nd In Switzerlnd, the reporting system nd the cse definition were modified in 1987, when in ddition to the reporting of cses by physicins, lbortories were lso required to report ny isoltion of the Mycobcterium tuberculosis complex. After the lowest number of cses ever ws notified in 1986 in Switzerlnd, mrked increses in notifictions occurred in 1987, 1988, nd 199 with decrese in 1991 (21, 22). The HIV pndemic nd tuberculosis in Western Europe Tble 4 presents n overview of the impct of the cquired immunodeficiency syndrome (AIDS) pndemic on tuberculosis in Westem Europe; no dt were vilble from Austri, Belgium, Finlnd, Irelnd, nd Switzerlnd. In Denmrk, the proportion of AIDS cses with tuberculosis hs not incresed recently. In Frnce, AIDS hs hd n importnt impct on tuberculosis in the Pris re, where HIVinfected tuberculosis ptients lone ccount for the increse in the number of cses over tht expected (8). Furthermore, HIV seropositivity mong ptients with tuberculosis in Pris nd n djcent deprtement ws much higher (12% nd 18%, respectively) thn tht in ll other res of the country (1%); bout 4% of ll the HIV-infected tuberculosis cses were mong those bom brod (of whom 46% were from sub-shrn Afric) nd bout hlf of the HIVseropositive French ptients with tuberculosis were WHO Bulletin OMS. Vol

6 M.C. Rviglione et l. Tble 4: Tuberculosis (TB) nd the HIV pndemic nd tuberculosis mong foreigners In selected Western Europen countries TB cses mong % HIV positives % TB mong foreigners: mong TB cses AIDS csesb % Trend Denmrk (199)C Up Frnce (1988)? Germny - >1 2 (1989) Up Itly (199) Up Netherlnds (199) Up Norwy (199) Up Spin (1987-9)? Sweden (199) Up Switzerlnd (199) Up United Kingdom b c HIV = humn immunodeficiency virus. AIDS = cquired immunodeficiency syndrome. Figures in prentheses re the yer. intrvenous drug users (8). In Frnkfurt, Germny, over the period more thn 1% of AIDS ptients suffered n episode of tuberculosis (23). In Itly, study of 1691 ptients with AIDS, i.e., 41% of ll cses reported in the country in , showed tht 11.4% hd tuberculosis (24). In the Netherlnds, n increse in the nnul incidence of tuberculosis from 16 cses per 1 in 1984 to 33 in 1988 occurred mong Dutch mles ged yers in Amsterdm, wheres no increse ws observed mong Dutch mles of the sme ge in other res of the country or mong other ge groups in Amsterdm (25). This my be due to the HIV epidemic, but the generlly low prevlence of tuberculosis infection mong Dutch yer-olds my minimize ny potentil impct of HIV infection (26). In Norwy, the proportion of "non-infectious cses" of tuberculosis hs incresed recently, but registry mtching of AIDS nd tuberculosis cses indictes tht infection with HIV does not ply significnt role in this respect or in the overll increse in tuberculosis notifictions; between 1985 nd 1991 only seven cses of tuberculosis were reported mong over 23 AIDS ptients. In Spin, the incidence of tuberculosis in two series of AIDS ptients ws high: 37% mong 434 ptients in Brcelon nd 36% mong 112 in Sn Sebstin (27, 28). In Sweden, mong the 645 cses of AIDS notified since 1982, tuberculosis hs been reported for 1.3% of the Swedes (6 of 464) nd for 6% of the foreigners (11 of 181) involved. In the United Kingdom, 4% of the 32 AIDS cses reported up to 199 hd tuberculosis (13). Becuse low rtes of tuberculosis were observed mong young White dults, who represent the lrgest proportion of AIDS cses in the United Kingdom, nd becuse this popultion t risk of HIV infection overlps only slightly with the foreign popultion t risk of tuberculosis, it is unlikely tht the HIV epidemic hs plyed n importnt role in the recent levelling off in tuberculosis notifictions in this country (13). Foreigners nd tuberculosis in Western Europe The impct of foreigners on tuberculosis in Western Europe is shown in Tble 4. The contribution of immigrnts vries between countries. For exmple, in Belgium, the incidence of tuberculosis in Brussels in 1991 mong ntive Belgins ws 23.5 per 1, compred with 61.2 mong foreigners. In Frnce, detiled informtion on non-rndom smple of 3863 cses of tuberculosis (43% of ll reported cses) is vilble for A totl of 27% of the cses occurred mong foreigners, who, in generl, were younger thn the French ntionls: lmost hlf (48%) were ged <35 yers, compred with 25% of the French ntionls. In contrst, 48% of the French ntionls were.55 yers of ge, while only 19.5% of the foreigners were in this ge group (29). In Sweden, vilble informtion for 1989 nd 199 indictes tht 37% of tuberculosis cses occurred mong foreigners. In 199, 7% of cses mong ntive Swedes involved ptients ged.65 yers, wheres 66% of cses mong individuls born brod were mong those ged 2-44 yers. The cse notifiction rte (per 1 ) in 199 ws 4.2 mong individuls born in Sweden, 3.1 mong ll individuls born brod, but 229 mong those born in Afric. In Switzerlnd, 49% of the tuberculosis cses reported in 199 occurred mong Swiss ntionls, with the remining 51% being individuls minly from Yugoslvi, Turkey, nd Portugl. The estimted notifiction rte (per 1 ) ws 11.3 mong Swiss nd 5.6 mong foreign residents. Age-specific notifictions over the period reveled tht there ws no increse mong Swiss ntionls, but mrked increse mong foreigners, prticulrly those ged yers. Of 791 bcteriologiclly confirmed cses in 199, totl of 428 (54%) involved Swiss ntionls nd 363 (46%) foreign residents: 49% of the Swiss were >65 yers of ge indicting tht mong Swiss ntionls tuberculosis hs become disese of the elderly; in contrst, 8% of the foreign ptients were ged <45 yers (21, 22, 3) (Fig. 2). Dt for Englnd nd Wles indicte tht the highest tuberculosis notifiction rtes WHO Bulletin OMS. Vol

7 Seculr trends of tuberculosis in Western Europe Fig. 2. Age-specific notifictions, by citizenship, in Switzerlnd, (lines smoothed over 5-yer ge groups). WHO Bulletin OMS. Vol re in res with high proportion of residents from the Indin subcontinent (13). Observtions on trends of reports by ntionlity re vilble for few countries. In Denmrk, 18% of bcteriologiclly confirmed cses in 1986 occurred mong foreigners, nd this proportion incresed to 38% in 199; this ccounts for most of the recent countrywide increse in tuberculosis notifictions. In Germny, the decline in tuberculosis mong Germn ntionls is continuing, wheres mong non- Germns the decline ended in 1986, nd there ws n verge nnul increse of 7.8% between 1986 nd In the former Federl Republic of Germny the notifiction rte mong foreigners lso hs incresed (from 51 per 1 in 1986 to 63 in 1989) with rising proportion of non-germn ntionls mong the totl (2%) in 1989 (9). In Itly, lthough only 3% of non-rndom smple of new cses of pulmonry tuberculosis in 1986 occurred mong immigrnts from south-est Asi nd Afric, this proportion hd incresed to 16% by 199 (17). In the Netherlnds, vilble dt indicte tht tuberculosis declined mong Dutch ntionls t n verge rte of 4.3% per yer between 1984 nd 199; in contrst, the number of tuberculosis notifictions incresed stedily over the sme period mong foreign residents t n verge rte of 13.6% per yer, nd in 199, 41% of the cses of tuberculosis occurred mong foreigners (Fig. 3). In Norwy, 4% of ll cses of tuberculosis in 1977 were mong those born brod but in 199 this hd incresed to 23%. Although this increse my explin, t lest in prt, the slow rte of decline in tuberculosis notifictions since 1977, the cse notifiction rte hs incresed both for Norwegins nd foreign residents over the pst 2 yers. In Sweden, the proportion of cses mong foreign residents incresed from 23% in 1985 to 41% in 199, thus contributing substntilly to the recent levelling off. No informtion on the ntionlity of cses ws vilble for Austri nd Irelnd, while immigrnts do not pper to mke significnt contribution to the tuberculosis sitution in Spin nd Finlnd. In Finlnd only 26 of the 771 reported cses (3.4%) in 1991 occurred mong foreign residents. Discussion The current epidemic of tuberculosis in Western Europe hs spnned severl centuries, killing t its height, perhps 1% of the popultion nnully in severl Europen metropolitn res (31). By the end of the 198s, the nnul deth rte from tuberculosis hd declined, with only few exceptions, to 1-2 per 1 popultion, 5- to 1-fold reduction. The vst mjority of these deths hve incresingly been mong those ged.65 yers of ge. Tuberculosis morbidity hs been recorded less relibly, nd only comprtively recently. Thus, vilble dt permit ssessment only of the tilingoff of the epidemic in Western Europe. At its zenith tuberculosis lwys clims its highest toll mong young dults, while epidemiologiclly shift towrds the elderly popultion is sign of success (32). In ll the countries exmined, tuberculosis mong the indigenous popultion hs become lrgely disese of the elderly, i.e., it my be occurring lr- Fig. 3. Number of tuberculosis notifictions in the Netherlnds, , by citizenship (logrithmic scle). 2 c * 1. 3UUU, z 5 3 Totl Dutch Foreigners Yer of notifiction...* is 33

8 M.C. Rviglione et l. gely s result of endogenous rectivtion of n infection cquired yers previously when the risk of infection ws much higher. In due course, this pool of infected individuls will be depleted, nd currently infected cohorts will successively be replced by those with lower infection. However, recent dt from some industrilized countries tht tuberculosis is no longer declining t the previously observed rte hve led to concerns tht the disese my be resurgent in such countries becuse of immigrtion nd/or the HIV epidemic. Comprtive nlysis of the tuberculosis notifiction dt in Western Europe is frught with problems: within ech country, cse definitions nd reporting criteri hve chnged; nd between countries, there re lrge differences in the qulity of surveillnce nd reporting criteri (33). Nevertheless, severl conclusions cn be drwn. Although dt reported in some countries my not be entirely relible, in Western Europe s whole, tuberculosis notifictions declined firly regulrly t n nnul rte of 5.4% from 1974 to The decline ws more rpid in countries with initilly higher rtes, nd by 199 the notifiction rtes per 1 popultion hd stbilized t 15-2 in such countries nd t 7-1 in countries where the initil rtes were lower. However, lthough the composite dt show regulr decline, the number of cses of tuberculosis hs recently filed to fll or hs even incresed in severl countries. A mjor fctor responsible for this chnge is the incresed migrtion of people from high to low incidence countries (Tble 4). For exmple, the incresed notifictions in the Netherlnds nd Switzerlnd over the pst few yers re lmost entirely ttributble to cses mong young foreign dults (Fig. 2 nd 3). Fig. 2 shows lso tht mong the Swiss contemporries of these foreigners no increse ws recorded, i.e., neither incresed trnsmission from the foreign to the indigenous popultion nor incresed endogenous rectivtion s result of HIV-induced immunosuppression hs been responsible for the observed overll increse. From public helth point of view, it is of utmost importnce wht hppens to the genertion of tody's prents. As tuberculosis is not esily trnsmitted beyond the context of close contcts, trnsmission will lrgely occur within fmilies. If prents re free from tuberculosis, their children re very likely to escpe infection. Currently, there is no indiction in Westem Europe tht there hs been n increse in trnsmission within the young segments of the popultion. On the other hnd, there is evidence tht the incidence of tuberculosis mong foreign residents of Westem Europen countries is similr to tht observed in their country of origin. Irrespective of whether these individuls come predominntly 34 from Afric (s is the cse in Frnce, Itly, nd Sweden), Yugoslvi, Portugl nd Turkey (Switzerlnd), or the Indin subcontinent (Englnd nd Wles), they hve ll been exposed to tuberculosis in their countries of origin, where the incidence of the disese is high. However, it is unlikely tht the high incidence of tuberculosis mong such groups will significntly influence the course of the epidemic in Western Europe. Nevertheless, interventions, such s the following, re needed to tckle the problem more efficiently: improvement of the trgeting of screening procedures to detect infection nd disese; provision of preventive therpy for those infected with M. tuberculosis; nd prompt curtive intervention for those with tuberculosis. Although there is temporl ssocition between the levelling off of the seculr trend of tuberculosis incidence in mny Europen countries nd the course of the AIDS pndemic, the contribution of HIV infection is currently very limited nd is likely to hve only slight influence on the tuberculosis sitution in Western Europe (34). This rises becuse the overll prevlence of infection is low mong the indigenous popultion of young dults t high risk for HIV infection. Notble exceptions to this my occur in res of Frnce, nd in Itly nd Spin, where tuberculosis is reltively frequent mong intrvenous drug users, who constitute the min pool of HIV-infected persons in those countries. Thus, vilble dt do not suggest tht interntionl migrtion or the HIV pndemic will lter substntilly the course of the tuberculosis epidemic in the generl indigenous popultions of most Western Europen countries. Bsic strtegies to counterct effectively the increse in the reported number of cses of tuberculosis in some Europen countries include the following (35): direct government responsibility for supervision of dignosis, tretment, nd prevention of tuberculosis; nd the mintennce of properly designed disese surveillnce systems (this my require new systems, like those dopted by Switzerlnd (5) nd Sweden, bsed on mndtory reporting of tuberculosis cses by both physicins nd lbortories). Tuberculosis control in Western Europe, with the ultimte gol of eliminting the disese, will require tht ech country identifies its own high-risk groups nd designs trgeted interventions to prevent the development of the disese mong infected individuls nd to ensure better dignosis nd follow-up tretment. Tuberculosis remins globl disese. In view of the increses in humn migrtion nd trvel, the elimintion of tuberculosis from industrilized countries is criticlly dependent on improvement of the sitution in poorer countries. WHO Bulletin OMS. Vol

9 Seculr trends of tuberculosis in Western Europe Acknowledgements We thnk the following individuls for providing ntionl dt nd useful suggestions: Dr W. Michtner (Austri); Professor F. Portels, Dr G. Crpels, nd Dr W. Brunson (Belgium); Dr A. Andersen, Dr A. Kok-Jensen, nd Dr J. Bennedsen (Denmrk); Professor E. Tl (Finlnd); Professor J. Grosset nd Dr A. Lepoutre (Frnce); Dr J. Hlluer (Germny); Dr L. Clncy nd Dr P. Kelly (Irelnd); Dr G. Antonucci, Dr E. Girrdi, Dr G. Ippolito, Dr G.B. Migliori, nd Dr S. Slmso (Itly); Dr J. Broekmns (Netherlnds); Dr K. Bjrtveit (Norwy); Dr R. Rey (Spin); Dr V. Romnus (Sweden); nd Dr J. Wtson, Dr D. Reid, nd Dr L. Mitchell (United Kingdom). We thnk lso Professor D. Enrson, Dr P. Nunn, Dr D.E. Snider Jr., Dr K. Styblo, nd Mr H. ten Dm for reviewing the mnuscript. A longer version of this rticle is vilble upon request from the Tuberculosis Progrmme, World Helth Orgniztion, CH-1211 Genev 27, Switzerlnd. Resume Les tendnces s6culires de l tuberculose en Europe occidentle Selon des indictions provennt de plusieurs pys d'europe occidentle, l regression des cs notifi6s de tuberculose s'est interrompue. Toutefois, l sitution, sur le pln de l mldie, n' fit l'objet d'ucune nlyse detill6e dns 1'ensemble de l r6gion consid6r6e. Le pr6sent rticle constitue un essi d'6vlution de l mortlite et de l morbidite pr tuberculose dns 14 pys d'europe occidentle. Nos donnees proviennent essentiellement de rpports sttistiques ntionux communiques pr les ministeres de l snte et de rpports emnnt d'ssocitions ntionles ntituberculeuses. Les d6ces imputbles l tuberculose ont diminue uniform6ment dns tous les pys enquet6s, et l pluprt d'entre eux sont survenus chez des sujets g6s de 65 ns et plus. Ces dernieres nn6es, les cs notifies ont continu6 de r6gresser en Allemgne, en Belgique, en Espgne, en Finlnde et en Frnce, lors qu'une stbilistion 6tit observee u Royume-Uni et en Suede; pr contre, on not6 une progression en Autriche, u Dnemrk, en Irlnde, en Itlie, en Norvege, ux Pys-Bs et en Suisse. L'interprettion des donn6es disponibles s'vere difficile, etnt donne les modifictions intervenues dns les pys memes en mtiere de description de l mldie et de criteres de notifiction, et eglement entre les pys. Nenmoins, il est possible de tirer des conclusions generles. Au Dnemrk, en Norvege, ux Pys-Bs, en Suede et en Suisse, une ugmenttion du nombre de cs chez les 6trngers entrin6 une inversion de l tendnce l bisse que l'on ttendit. 11 semble que l'infection VIH n'it constitue qu'un 6l6ment mrginl de l morbidite gen6rle pr tuberculose dns les pys enquetes. Toutefois, cette contribution prlt importnte Pris et dns les regions limitrophes, et l tuberculose est tres frequente chez les personnes infectees pr le VIH en Espgne et en Itlie. Mlgre cette evolution r6cente de l'incidence de l tuberculose, ucune ugmenttion de l trnsmission n' ete enregistree pour l'instnt prmi les groupes d'ge les plus jeunes des popultions utochtones. 11 est vitl de disposer de systemes ppropries de surveillnce de l mldie pour un contr6le permnent de son 6volution, fin que chque pys puisse identifier ses propres groupes hut risque et orienter ses interventions dns le sens de l prevention, du dignostic et du tritement de l mldie. L tuberculose reste une ffection d'envergure universelle et, en rison du developpement des migrtions humines, son elimintion d'europe occidentle ne peut etre relis6e sns un renforcement des mesures de lutte dns les pys puvres ou son incidence est 6levee. References 1. Centers for Disese Control. Tuberculosis-United Sttes, first 39 weeks, Morbidity nd mortlity weekly report, 34: (1985). 2. Jereb, A. et l. Tuberculosis morbidity in the United Sttes: finl dt, 199. Morbidity nd mortlity weekly report, 4(SS-3): (1991). 3. Snider, D.E. Jr. & Roper, W.l. The new tuberculosis. New Englnd journl of medicine, 326: (1992). 4. Brudney, K. & Dobkins, J. Resurgent tuberculosis in New York City. Humn immunodeficiency virus, homelessness, nd the decline of tuberculosis control progrms. Americn review of respirtory disese, 144: (1991). 5. Rieder, H.L. Misbehviour of dying epidemic: cll for less specultion nd better surveillnce. Tubercle nd lung disese, 73: (1992). 6. de Meer, G. & vn Geuns, H.A. Rising cse ftlity of bcteriologiclly proven pulmonry tuberculosis in the Netherlnds. Tubercle nd lung disese, 73: (1992). 7. Quenum, B. et l. L tuberculose en Frnce de Bulletin epid6miologique hebdomdire, No. 3/9: 1-11 (199). 8. Hubert, B. & Pelletier, A. Les cs declres de tuberculose en Frnce en 199. Bulletin 6pid6miologique hebdomdire, No. 48/91: (1991). 9. Deutsches Zentrlkomitee zur Bekmpfung der Tuberkulose. [Eighteenth report. Minz, 1991 (in Germn). 1. Ministerio de Snidd y Consumo, Espn. Boletin epidemiologico semnl, semn 1-2/199: No (in Spnish). WHO Bulletin OMS. Vol

10 M.C. Rvigilone et l. 11. Ministerio de Snidd y Consumo, Espn. Boletin epidemiologico semnl, semn 1/1991: No (in Spnish). 12. de Mrch Ayuel, P. [Current stte of tuberculosis in Spin]. Medicin clinic (Brcelon), 97: (1991) (in Spnish). 13. Wtson, J.M. et l. Notifictions of tuberculosis in Englnd nd Wles, Communicble disese report, 1 (review No.2): R13-R16 (1991). 14. Dvies, P.D.O. et l. Tuberculosis increse in Englnd nd USA compred: similr pttern but different cuses. Americn review of respirtory disese, 145 (2 of 2): A11 (1992). 15. Migliori, G.B. et l. Annul risk of tuberculosis infection nd its nnul decrese in Itly in the lst 2 yers. Europen respirtory journl, 4 (suppl. 14): 496S (1991). 16. Slmso, S. et l. Survey on tuberculosis reports in mjor Itlin region. Europen journl of epidemiology, 4: (1988). 17. Frvelli, B. et l. [Tuberculoses nd infectious respirtory diseses]. Rssegn di ptologi dell'prto respirtorio, 7: (1992) (in Itlin). 18. Mggini, M. et l. Epidemiologicl use of drug prescriptions s mrkers of disese frequency: n Itlin experience. Journl of clinicl epidemiology, 44: (1991). 19. Antonucci, G. et l. Tuberculosis nd humn immunodeficiency virus infection in Itly: preliminry results from multicenter study. Chest, 1: 586 (1991). 2. Broekmns, J.F. The point of view of low prevlence country: the Netherlnds. Bulletin of the Interntionl Union ginst Tuberculosis nd Lung Disese, 66: (1991). 21. Office f6derl de l snt6 publique. L tuberculose en Suisse en Bulletin de l'office f6d6rl de l snt6 publique, No. 25: (1989). 22. Office f6derl de l Snte publique. Tuberculose, Suisse, 199. Bulletin de l'office f6d6rl de l snt6 publique, No. 35: (1991). 23. Muller, R. et l. Tuberculosis nd AIDS in Frnkfurt. In: Proceedings of the V Interntionl Conference on AIDS, Montrel, Cnd, 4-9 June (Abstrct Th.B.P.59:425). 24. Antonucci, G. et l. Cumultive incidence of tuberculosis in Itlin AIDS cses: multicentre study. In: Proceedings of the VI Interntionl Conference on AIDS in Afric, Dkr, Senegl, December (Abstrct W.A.195:288). 25. vn Deutekom, H. A possible HIV-relted effect on the tuberculosis sitution in the Netherlnds. Europen respirtory journl, 4 (suppl. 14): 496S (1991). 26. Styblo, K. The elimintion of tuberculosis in the Netherlnds. Bulletin of the Interntionl Union ginst Tuberculosis nd Lung Disese, 65: (1 99). 27. Brber, J. et l. Tuberculosis nd AIDS. In: Proceedings of the Ill Europen Conference on Clinicl Aspects nd Tretment of HIV Infection, Pris, Mrch (Abstrct No. P39). 28. Iribrrn, J.A. et l. Tuberculosis in AIDS ptients. In: Proceedings of the V Interntionl Conference on AIDS, Montrel, Cnd, 4-9 June (Abstrct Th.B.P.65:426). 29. Grosset, J. et l. Les cs de tuberculose d6clres en Frnce en Bulletin 6pid6miologique hebdomdire, No. 15/9: (199). 3. Rieder, H.L. et l. [Epidemiology of tuberculosis in Switzerlnd]. Schweizerische Rundschu fur Medizin Prxis, 79: (199) (in Germn). 31. Dubos, R. & Dubos, J. The white plgue: tuberculosis, mn, nd society. New Brunswick, Rutgers University Press, Powell, K.E. & Frer, L.S. The rising ge of the tuberculosis ptient: sign of success nd filure. Journl of infectious diseses, 6: (198). 33. Tl, E. Registrtion of tuberculosis in Europe. Bulletin of the Interntionl Union ginst Tuberculosis nd Lung Disese, 62: (1987). 34. Styblo, K. The impct of HIV infection on the globl epidemiology of tuberculosis. Bulletin of the Interntionl Union ginst Tuberculosis nd Lung Disese, 66: (1991). 35. Clncy, L. et l. Tuberculosis elimintion in the countries of Europe nd other industrilized countries. Europen respirtory journl, 4: (1991). 36 WHO Bulletin OMS. Vol