HIV Insight: Tuberculosis Treatment Outcome in the European Union & European Economic Area: An Analysis of Surveillance Data from 2002/2011

Monitoring the treatment outcome (TO) of tuberculosis (TB) is essential to evaluate the effectiveness of the intervention and to identify potential barriers for TB control. The global target is to reach a treatment success rate (TSR) of at least 85%. We aimed to assess the TB TO in the European Union and European Economic Area (EU/EEA) between 2002 and 2011, and to identify factors associated with unsuccessful treatment. Only 18 countries reported information on TO for the whole observation period accounting for 250,854 new culture-confirmed pulmonary TB cases. The 85% target of TSR was not reached in any year between 2002 and 2011 and was on average 78%. The TSR for multidrug-resistant (MDR)-TB cases at 24-month follow-up was 49%. In the multivariable regression model, unsuccessful treatment was significantly associated with increasing age (odds ratio (OR) = 1.02 per a one-year increase, 95% confidence interval (CI): 1.02–1.02), MDR-TB (OR = 8.7, 95% CI: 5.09–14.97), male sex (OR = 1.40, 95% CI: 1.28–1.52), and foreign origin (OR = 1.32, 95% CI: 1.03–1.70). The data highlight that special efforts are required for patients with MDR-TB and the elderly aged ≥65 years, who have particularly low TSR. To allow for valid monitoring at EU level all countries should aim to report TO for all TB cases.

Introduction

In 1991, the 44th World Health Assembly set targets to detect at least 70% of new tuberculosis (TB) cases and to cure at least 85% of those detected [1]. The Stop TB Partnership developed the Global Plan to Stop TB 2006–2015 to achieve these targets set for 2015 within the context of the Millennium Development Goals [2]. Monitoring the outcome of TB treatment is essential to evaluate the effectiveness of the intervention and to identify the potential barriers for TB control.

In Europe, a Working Group of the World Health Organization (WHO) and the International Union against Tuberculosis and Lung Disease (IUATLD) published recommendations for uniform reporting by TB surveillance and cohort analysis of treatment outcome (TO) across Europe [3,4]. A minimal set of six exclusive categories of TO was recommended as standard: cured, completed, failed, died, interrupted (defaulted) and transferred out. Furthermore, analysis of TO should be separate for new and retreatment cases [4]. In 2008, the European Centre for Disease Prevention and Control (ECDC) published the Framework Action Plan to fight Tuberculosis in the European Union following the WHO/IUATLD recommendations; including a core indicator of 85% treatment success rate for new pulmonary culture-confirmed TB cases and 70% for new pulmonary culture-confirmed multidrug-resistant (MDR) TB cases [5].

In 2013, in the European Union and European Economic Area (EU/EEA), the TB notification rate was 12.7 per 100,000 population [6]. Notification rates were heterogeneous: five countries had incidence rates ≥ 20 and 24 countries had incidence rates < 20 cases per 100,000 population in 2013) [6]. In the majority of countries the trend in case notification rate showed a sustained decline during the period 2009‒2013. In 2013, the overall treatment success rate was 73.5%.

In this study, we aimed to assess the TB TO in the EU/EEA and to identify factors associated with unsuccessful treatment applying the WHO/IUATLD recommendations for the EU/EEA for cohort analysis over a 10-year observation period.

Below: Treatment outcome of new culture-confirmed pulmonary tuberculosis cases in the EU/EEA by A. Reporting years B. Reporting countries, 2002–2011 (n=250,854)

Below: Treatment success rate of new culture-confirmed pulmonary tuberculosis in the EU/EEA. 3A. Age group 3B. Treatment outcome by reporting year, 2002–2011 (n=250,810)