1. Tuberculosis Surveillance in Europe EuroTB update March 2008 WHO Collaborating Centre

2. About EuroTB, 1996-2007 EuroTB was set up in 1996 to develop and coordinate a European network of national tuberculosis surveillance institutions in the 53 countries of the WHO European Region. The project was based at the Institut de veille sanitaire (InVS) in France, and was financially supported by the European Commission. The mission statement of EuroTB was to improve the contribution of surveillance to tuberculosis control in the European Region. EuroTB promoted the standardisation of surveillance methods. Its mainstay was the collection and validation of national epidemiological information on tuberculosis, including drug resistance and treatment outcome. The main outputs were an annual report, scientific articles, oral communications and data dissemination on www.eurotb.org. Data presented here are the latest available at the end of the project in December 2007.

3. EUROPEAN UNION (EU) (dark blue) Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom WEST, non-EU (light blue) Andorra Iceland Israel Monaco Norway San Marino Switzerland BALKANS (yellow) Albania Bosnia & Herzegovina Croatia Macedonia, F.Y.R Montenegro Serbia Turkey EAST (orange) Armenia Azerbaijan Belarus Georgia Kazakhstan Kyrgyzstan Moldova Russian Federation Tajikistan Turkmenistan Ukraine Uzbekistan WHO European Region, 2008

4. Case-based reporting to EuroTB in 2007 Andorra Malta Monaco San Marino Not included or not reporting to EuroTB No case-based reporting (aggregate only) Case-based notification data only Case-based data, including drug resistance Case-based data, including drug resistance and outcome* * No case-based data for drug resistance in Greece and Poland. Outcome data in Greece started in report year 2006. * *

5. European definitions for TB surveillance (1) Definite case*A patient with culture-confirmed TB disease due to Mycobacterium tuberculosis complex. In countries where culture is not routine: a patient with positive sputum smear Other-than- definite case* A patient with clinical and/or radiological signs compatible with TB and clinician’s decision to treat with full treatment Notifiable TB case* All definite and other-than-definite TB cases notified in the calendar year of interest should be notified. Cases should only be counted once in a given calendar year. New case A patient who has never had treatment for TB in the past or who has taken anti-TB drugs for less than one month. Retreated caseA patient previously treated for TB with combination chemotherapy for 4 weeks or more, excluding prophylactic therapy. * In the new definitions proposed by the European Centre for Disease Prevention and Control, “definite” and “other-than-definite” will be replaced by “possible” (based only on clinical criteria or post-mortem findings), “probable” (if there is additional detection of acid-fast bacilli or granulomata or M.tb complex nucleic acid) or “confirmed” (by culture, or nucleic acid+AFB). All three categories will be subject to reporting, as well as cases reported only by laboratories without information on clinical criteria.

6. Pulmonary caseA patient with TB of the lung parenchyma or the tracheo- bronchial tree (including larynx). Extra-pulmonary case A patient with TB of organs other than the lungs or the tracheo-bronchial tree Note: a patient with both pulmonary and extra-pulmonary TB is classified as pulmonary. Primary drug resistance Resistance to one or more anti-TB drugs at start of treatment in a new TB case Acquired drug resistance Resistance to one or more anti-TB drugs at start of treatment in a retreated TB case Multi-drug resistance (MDR) Resistance to at least isoniazid and rifampicin Extensive drug resistance (XDR) MDR and 1)resistance to a fluoroquinolone and 2)resistance to one or more of the following injectable drugs: amikacin, capreomycin, or kanamycin European definitions for TB surveillance (2)

7. CuredTreatment completion and: -culture becoming negative on samples taken at the end of treatment and on at least one previous occasion, or - sputum microscopy becoming negative for AFB at the end of treatment and on at least one previous occasion CompletedTreatment completion, not meeting the criteria to be classified as cure or treatment failure DiedDeath before starting treatment or during treatment, irrespective of cause (including post-mortem diagnosis) FailedCulture or sputum microscopy remaining positive or becoming positive again at 5 months or later during treatment DefaultedTreatment interrupted for 2 consecutive months or more TransferredPatient referral to another clinical unit for treatment and information on outcome not available / not obtained Still on treatmentPatient still on treatment at 12 months and who did not meet any other outcome during treatment, including patients with: - treatment prolonged because of side effects / complications, initial regimen planned for > 12 months - initial treatment changed due to polyresistance (ie. resistance to at least two first line drugs) on the isolate taken at the start of treatment - information on the reasons for being still on treatment not available Unknowninformation on outcome not available European definitions for TB surveillance (3) Treatment outcome categories (from 2001 cohorts)

8. Cohort All definite pulmonary cases notified in one calendar year and followed up for TOM. Cohorts in use for TOM are either smear positive or culture positive (depending on the country of report) and stratified by treatment history - new, retreated and unknown. Period of observation Maximal duration of time from start of treatment or registration for observing treatment outcome. This is set at 12 months. European definitions for TB surveillance (4) Cohort analysis for treatment outcome monitoring (TOM)

9. Source: WHO, 2008 No report 0–24 25–49 50–99 100 or more * Notified TB cases (new and relapse) per 100 000 population Tuberculosis notification rates (1) World, 2006* The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2006. All rights reserved

10. Tuberculosis notification rates (2) WHO European Region, 2006 TB cases per 100 000 population Not included Not reporting to EuroTB < 11 11 – 20 21 – 50 > 50 Andorra Malta Monaco San Marino

11. Tuberculosis notification rates (3) Trends by areas, 1996-2006 0 20 40 60 80 100 120 19961997199819992000200120022003200420052006 TB cases/100 000 East European Region Balkans EU-27 & West EU-15

12. Tuberculosis notification rates (4) Mean annual change in rate, 1998-2006* * Excluding Monaco, San Marino (EU & West) -10% -5% 0% 5% 10% 1998-20022002-2006 % change in rate EU & WestBalkansEast

13. Tuberculosis notification rates (5) Pulmonary smear positive rates, 2006

14. Percentage of TB cases of foreign origin, 2006 Andorra Malta Monaco San Marino Not included or not reporting to EuroTB 0% – 4% 5% – 19% 20% – 49% > 49%

15. TB cases with positive culture, 2006* (28-100%) (28-63%) (4-36%) Andorra Malta Monaco San Marino Percentage of TB cases with positive culture Not included or no culture data reported to EuroTB < 40% 40% – 54% 55% – 74% > 74% * Data from 2005 for Ireland and Romania (culture results incomplete in 2006)

16. TB cases with primary MDR, 2006* Andorra Malta Monaco San Marino Percentage of new TB cases with MDR Not included or not reporting to EuroTB No nationwide data on drug resistance reported 0.0% – 0.9% 1.0% – 1.9% 2.0% – 5.9% 6.0% – 19.4% * * * * * * * Showing only countries with nationwide data. Data from 2004 for Poland and Romania and 2005 for Ireland. Data representativeness unknown in countries marked with an asterisk.

17. Treatment outcome New definite pulmonary cases, 2001-2005* * Countries with representative outcome data. EU & West (culture positive): Andorra, Austria, Belgium, Czech Rep, Denmark, Estonia, Germany, Hungary, Iceland, Ireland, Israel, Latvia, Lithuania, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Sweden, United Kingdom. Balkans (smear positive): Albania, Macedonia F.Y.R. East (smear positive): Kazakhstan, Kyrgyzstan

18. TB mortality rates, 2001-2006* Not included No data or data incomplete < 1.1 1.1 – 5.0 5.1 – 10.0 > 10.0 TB deaths per 100 000 population Andorra Malta Monaco San Marino * Source: WHO Mortality Database, October 2007. Data shown for latest available year. Including only deaths from TB coded ICD-9 010-018 or ICD-10 A15-19.