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Report on the Epidemiology of Tuberculosis in Germany - 2016

Executive Summary

full report in German

In 2016, a total of 5,915 tuberculosis (TB) cases were notified in Germany. This corresponds to an annual TB incidence of 7.2 cases per 100,000 population. The number of total cases remained almost unchanged in comparison to the previous year (2015: 5,828 cases, incidence 7.1).

Analysis of demographic data: Tuberculosis incidence was 9.9 cases per 100,000 population in men and 4.6 in women (male to female ratio of 2.2). The age-specific incidence was highest in the age group 20–24 years (18.3 cases per 100,000 population; 25.9 in men and 9.7 in women).

Citizenship: Tuberculosis incidence in foreign nationals residing in Germany was 19 times higher than the incidence in German citizens (42.6 vs. 2.2 cases per 100,000 population, respectively). This difference between the two groups increased in comparison to the previous year (16.6 times higher).The largest difference was observed in young adults. Overall, Germans comprised of 30.9 % of all tuberculosis cases, whereas the remaining 69.1 % of all cases were foreign nationals. Foreign nationals affected by tuberculosis were younger than German nationals (median age: 28 vs. 58 years).

Country of birth: In comparison to the previous year, the proportion of patients born abroad increased further to 74.3 %. The most frequently registered foreign countries of birth in 2016 included Somalia, Eritrea, Afghanistan, Syria and Romania.

Tuberculosis in children: A total of 233 cases were reported in children younger than 15 years of age (incidence 2.1 cases per 100,000 children). The number of cases increased compared to 2015 (196 cases; incidence 1.8 per 100,000 children). Tuberculosis incidence was highest in the youngest age group below five years of age (104 cases; incidence 2.9 per 100,000). In children aged 5 to 9 years, the incidence of TB was 1.5 per 100,000 (53 cases), while in children aged 10 to 14 years, it was 2.1 per 100,000 (76 cases). Tuberculosis incidence in children of foreign nationality was almost 20 times higher in comparison to German children (14.2 vs. 0.7 per 100,000 population). The number of children with resistant TB (»any resistance«) increased (18/89 children, 30.5 %).

Case finding: The proportion of tuberculosis cases detected by active case finding was 25.2 % in 2016 (1,310 cases); this increase was mostly due to active case finding among asylum seekers in accordance with paragraph 36 of the IfSG (German Protection Against Infection Act), which accounted for 74.3 % of cases detected by active case finding (973/1,310 cases). In comparison to 2015, the numbers found through active screening of asylum seekers were lower (1,222/1,522 cases; 80.3 %). Similar to previous years, a high proportion of TB cases among children were detected through contact tracing (37.2 %). 74.8 % (3,886 cases) were identified by passive case finding in 2016, 262 more than in the previous year.

Site of disease: Pulmonary tuberculosis was diagnosed in 75.0 % of cases (4,397 cases; incidence 5.4 per 100,000) and was potentially infectious (sputum-smear or culture positive) in the majority of cases (3,362 cases, incidence 4.1) in comparison to non-infectious pulmonary tuberculosis (1,035 cases; incidence 1.3). Of the pulmonary TB cases, 43.0 % (1,774/4,397) were smear positive and, thus, were the most infectious cases. Extra-pulmonary tuberculosis solely was diagnosed in 1,468 cases (25.0 %). In about half of these extra-pulmonary cases, the main affected site was the lymph node (748/1,468; 50.9 %).

Drug-resistant tuberculosis: The proportion of multidrug-resistant tuberculosis (MDR-TB) was 2.7 % (104 cases) in 2016, a lower number than in 2015 (3.1 %, 123 cases).

The proportion of MDR-TB was highest in patients born in one of the newly independent states (NIS) of the former Soviet Union (15.3 % compared to 1.0 % in German born patients). Five extensively drug-resistant TB cases were notified in 2016. The overall proportion of TB cases resistant to at least one of five standard anti-TB drugs (isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin) was 12.8 % in 2016, which was slightly lower than in 2015 (13.0 %). The proportion of »any drug-resistant« TB cases was higher among patients born in an NIS country in comparison to those born in Germany (31.5 % vs. 8.4 %, respectively).

Deaths: A total of 100 patients died of tuberculosis in 2016 (2015: 110 deaths). This corresponded to a mortality rate of 0.12 cases per 100,000 population. The case fatality rate was 1.7 %, a slight drop in comparison to 2015 (1.9 %).

Treatment outcome can only be assessed after at least 12 months of follow-up and is, therefore, reported here for cases notified in 2015. The completeness of treatment outcome reporting was 82.5 % (4,828 of 5,852 reported cases). Among patients with available information, 77.2 % (3,728 cases) were treated successfully, 11.4 % (548 cases) experienced an unsuccessful treatment for different reasons, 6.4 % (307 cases) were still on treatment, and 5.1 % (245 cases) were reported as having transferred out. Treatment outcome showed age-specific differences with a higher proportion (>85 %) of treatment success reported for patients younger than 40 years of age; this proportion declined in older age groups. For patients aged 80 years or older, only 56.4 % completed treatment successfully.

Conclusion: After a significant increase in the number of notified TB cases in 2015 in comparison to previous years, which was mainly due to active case finding among asylum seekers, the number of TB cases in Germany remained largely unchanged in 2016 and were similar to the level of TB cases 11 years ago.

Available data indicates that recent developments in the tuberculous situation in Germany are influenced by migratory movements and demographic changes in the population – the number of foreign born cases has increased steadily over recent years, while the number of German born cases has continued to decline.

TB cases diagnosed by active case finding were also noteworthy in 2016, but less so than in 2015. Many asylum seekers to Germany come from countries with high tuberculosis incidence and, therefore, have a higher risk of developing active tuberculosis. The screening according to paragraph 36 (4) of the IfSG is, consequently, an important tool for early detection and treatment of persons with TB and helps in preventing a further spread of the disease. In 2016, however, the increase in the number of cases, especially in comparison to the years before 2015, is also explained by an increase in cases diagnosed via passive case finding. This development was somewhat expected, as the risk of developing active disease remains higher years after entry. This highlights the importance of maintaining continued vigilance against TB and the consideration for diff erential diagnosis. The increase in the number of cases among young children requires particular attention, not only because of their vulnerability, but also as an indicator of current transmission among the population.

The occurrence of multidrug-resistant and extensively drug-resistant tuberculosis is a challenge to tuberculosis control and also requires particular attention, with a focus on ensuring successful treatment outcomes.

The German TB-surveillance system is essential for timely identification of epidemiological trends and their interpretation in the context of factors that potentially influence the epidemiological situation. However, this requires a high level of data completeness and data quality.

Rising case numbers in the non-German population, multidrug-resistant and extensively drug-resistant TB, and a high proportion of infectious pulmonary TB indicate that TB remains a significant public health issue in Germany, with an increasing burden among high risk groups.

In order to maintain an effective tuberculosis control, the relevant strategies must take into account the current developments. In addition to screening measures for asylum seekers, active case finding by using contact tracing is also important so that infected persons and active cases can be identified as early as possible. However, these meas ures are only effective and successful if the patients subsequently receive appropriate treatment. Ensuring complete and successful therapy, including timely and accurate notification of treatment outcomes, is essential for ongoing effective tuberculosis control in Germany and requires a coordinated cooperation from all stakeholders.

Furthermore, it is essential that the knowledge and experience of those working with tuberculosis is maintained and enhanced through appropriate educational opportunities, both during professional training and later in the workplace.

Date: 13.10.2017