Tuberculosis

Tuberculosis (TB) is a contagious disease that spreads when a person breathes in bacteria breathed out by an infected person. TB is mainly caused by Mycobacterium tuberculosis. About one third of the world’s population is infected with the latent form of the disease, and one-tenth of infected people become ill with active TB during their lifetimes. Symptoms differ depending on the area of the body infected. In pulmonary TB, common symptoms are a cough with sputum production (sometimes with blood), shortness of breath and chest pain. If properly diagnosed and treated, TB can be cured with six months of antibiotic therapy.

Multidrug-resistant TB (MDR-TB) is resistant to 2 of the most potent anti-TB drugs. It results from inadequate treatment of TB or poor airborne infection control in health care facilities and congregate settings. Treating MDR-TB is not only more expensive, it also requires about 2 years of treatment. Extensively drug-resistant TB (XDR-TB) is resistant to the main first- and second-line drugs, and therefore has very limited chances of cure.

TB remains a public health threat in the Region
Most affected groups and areas
Facts and figures on tuberculosis (TB) in the WHO European Region (2016)
Challenges in the WHO European Region
WHO/Europe’s response

TB remains a public health threat in the Region

Europe’s TB burden is among the lowest in the world, but the number of new multidrug resistant TB (MDR-TB) cases is the highest. The WHO European Region has achieved the Millennium Development Goal target of reversing the incidence of TB by 2015. In the past 10 years, the number of new TB patients has been falling at an average rate of 4.3% per year. Yet, despite this being the fastest decline in the world compared to other regions, TB remains a major public health threat in the Region because here the MDR-TB rates are the highest in the world. MDR-TB is one of the key drivers of the TB epidemic in Europe. WHO/Europe aims to end TB at all levels in line with the Sustainable Development Goals (target 3.3) and the WHO European policy framework Health 2020.

Most affected groups and areas

Most affected groups

TB can affect everyone, but is strongly associated with social determinants of health such as imprisonment, migration and social marginalization. People living with HIV or suffering from other conditions that weaken the immune system, such as diabetes, are at much higher risk of developing the disease. TB patients are most frequently young adults in the eastern part of the Region, migrants, and native-born elderly people in western European countries.

Most affected areas

Countries in the eastern part of the Region are the most affected by the TB epidemic: 18 high-priority countries for TB control bear 85% of the TB burden and 99% of the MDR-TB burden (Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the Republic of Moldova, Romania, the Russian Federation, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan).

Facts and figures on tuberculosis (TB) in the WHO European Region (2016)

According to estimates, 290 000 new TB cases and 26 000 TB deaths were reported in the Region in 2016, mostly in eastern and central European countries.
45% of new registered TB cases are among people aged 25–44 years; this adversely affects household and national economies due to loss of income in the most economically productive age group.
9 of the world’s 30 countries with a high burden of multidrug- and extensively drug-resistant TB (M/XDR-TB) are within the Region.
An estimated 19% of new TB cases and 55% of previously treated TB cases are multidrug-resistant TB (MDR-TB).
The Region has the highest proportion of new and retreated cases of MDR-TB – an estimated 71 000 cases.
18 high-priority countries for TB control bear 85% of the TB burden and 99% of the MDR-TB burden.
Children under 15 years of age represent approximately 4% of total notified TB patients.

Challenges in the WHO European Region

Europe’s TB burden is among the lowest in the world, but the number of new multidrug resistant TB (MDR-TB) cases is the highest.

Unequally distributed TB burden

New cases of tuberculosis (TB) have sharply decreased within the Region as a whole, but remain highly concentrated in the 18 high-priority countries (Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the Republic of Moldova, Romania, the Russian Federation, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan). Improved TB interventions in high-priority countries strongly influenced the Region’s declining trends, yet notification rates remain almost 8 times higher in these countries than in the rest of the Region.

Highest rates of multidrug-resistant TB (MDR-TB) in the world

Of the 30 countries in the world with the highest burden of MDR-TB, 9 are in the Region (Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Ukraine and Uzbekistan). The proportion of MDR-TB among new and previously treated TB cases in the Region is significantly above the global average, with 19% in new and 55% in previously treated cases compared to 4.1% and 19% respectively. Since 2011, and with the introduction and scale up of the WHO-recommended rapid diagnostics, the detection rate of MDR-TB has increased significantly, from 33% in 2011 to 73% in 2016. Data on extensively drug-resistant TB (XDR-TB) remain considerably under-reported; detected XDR-TB cases account for approximately 12,4% of MDR-TB cases, most of which also occur in the 9 high-burden countries. MDR-TB is one of the key drivers of the TB epidemic in Europe.

TB and HIV coinfection

TB is a leading killer among people affected by HIV. HIV and TB form a deadly combination, with each accelerating the other's progress. During the period 2007–2016, the WHO European Region faced an unprecedented increase in HIV prevalence in incident TB cases from 3% to 12%. This is higher than both the global average and the dynamic, which declined from 13% in 2007 to 10% in 2016.

Rapid detection and appropriate treatment are vital. However, only three quarters (25 844) of the estimated 34 000 three quarters were detected in 2016, and only 65% of them were offered antiretroviral treatment.

Unsatisfactory treatment results

Despite universal treatment coverage for TB and RR/MDR-TB patients, the treatment success rate in the Region is still below the 85% and 75% Regional targets respectively. Nevertheless, when data for 2012 and 2016 are compared, a slow but sustainable increase can be seen in both cohorts for all new and relapse TB and RR/MDR-TB cases, from to 72% to 75% and from 49% to 55% respectively.

Missing diagnoses

Laboratory capacities are underused in the Region, and laboratory confirmation is poor in the eastern part of the Region. This leads to missing cases – especially for MDR-TB, which can only be detected by laboratory tests.

Need for research

Innovative tools, such as new vaccine(s), diagnostic methods, medicines, preventive and treatment regimens, and innovative methods of service delivery are essential to addressing TB and especially MDR-TB.

Stigma and ethical issues

People living with TB often suffer from stigmatization and discrimination that seriously limit their access to effective TB prevention and treatment. Respecting ethics and human rights in delivering such services is a special challenge in the Region, where levels of MDR-TB are highest.

Demands on health systems

In many countries, TB and especially MDR-TB may be indications of partial health system failure. National health systems face increasing challenges in the context of the post-Soviet era, the economic downturn, and more dynamic and unpredictable movements of people both within countries and across borders. In addition, the fragility of national health systems may be worsened by an overall reduction in external donor funding for TB in the Region. Providing sustainable health financing, effective people-centred models of care and adequate human resource developments in rapidly changing environments is proving to be demanding for countries.

WHO/Europe’s response

WHO/Europe is pursuing the elimination of tuberculosis (TB) through the Tuberculosis action plan for the WHO European Region 2016–2020, the main instrument for European countries to implement the global End TB Strategy 2016–2035.

The new action plan identifies 3 regional targets to be achieved by 2020:

a 35% reduction in TB deaths;
a 25% reduction in TB cases; and
a 75% treatment success rate among MDR-TB patients.

The implementation of the action plan would save an estimated 3.1 million lives by curing 1.4 million patients and preventing 1.7 million new cases of all forms of TB. With an estimated cost of US$ 15 billion, the plan should prove highly cost-effective: it would result in savings of US$ 48 billion in terms of lives saved and avoidable suffering prevented.

Countries are encouraged to reach these targets by providing universal access to people-centred services for prevention, diagnosis and treatment, all of which will contribute to ending the TB epidemic. WHO supports countries by setting norms and standards, providing technical cooperation, fostering partnerships, building capacity, creating and disseminating evidence, and conducting monitoring and evaluation.