Report on the Epidemiology of Tuberculosis in Germany - 2014

full report in German

In Germany, 2014 a total of 4,488 tuberculosis (TB) cases were notified corresponding to a TB incidence rate of 5.6 cases per 100,000 population. Case numbers were about 3.9% higher than in the previous year (2013: 4,319 cases; incidence: 5.3) and were within the range of those observed in 2008 (4,538 cases) and 2009 (4,442 cases). In 2013, an increase of case numbers by 2.4% had already been noted compared to 2012. Thus, the long-term downward trend has come to an end and – confirmed by preliminary data for 2015 – a further increase of case numbers is observed.

Analysis of demographic data: Tuberculosis incidence was 7.2 cases per 100,000 population, in men, and 4.0 in women (men to women ratio of 1.8). The age-specific incidence was highest in the age group 20–24 years (9.6 cases per 100,000 population; 13.0 in men and 5.9 in women). Another peak was found in the elderly over 79 years of age (incidence 8.4 cases per 100,000 population; 12.5 in men, and 6.2 in women).

Citizenship: Tuberculosis incidence in foreign nationals residing in Germany was 33.6 cases per 100,000 population, 13 times higher than the incidence in German citizens (2.5 cases per 100,000 population). Compared to the previous year (factor 10) this discrepancy has increased further. The largest difference was observed in children and young adults. Overall, 44.3% were German and
55.7% had foreign nationality. Foreign nationals affected by tuberculosis were younger than German nationals (median age: 32 vs. 59 years).

Country of birth: The proportion of patients born abroad has increased further to 62.4% (2013: 57.0%). The most frequently registered foreign countries of birth include Somalia, Turkey and Romania. Looking at the data by country of birth confirms that analysis of citizenship information alone (see above) may lead to an underestimation of the proportion of TB patients with migration background.

Tuberculosis in children: A total of 150 cases were reported in children younger than 15 years of age (incidence 1.4 cases per 100,000 children). The number of cases has decreased compared to 2013 (175 cases; incidence 1.6). Tuberculosis rates were highest in the youngest age group below 5 years of age (62 cases; incidence 1.8). In children aged 5 to 9 years, incidence was 1.2 (41 cases) and in children aged 10 to 14 years it was 1.3 (47 cases). The tuberculosis incidence in non-national children was about 26 times as high as in German children (incidence 14.3 vs. 0.5).

Case finding: The proportion of tuberculosis cases detected by active case finding has increased over the last years and reached 19.1% in 2014 (734 cases). Tuberculosis cases found via active screening for asylum seekers according to § 36 IfSG (375 cases) have almost doubled compared to 2013. The proportion of childhood TB cases detected through contact tracing remained at a high level (42.1%).

Site of disease: Pulmonary tuberculosis was diagnosed in 3,378 cases (76.0%). It was found to be potentially infectious in the majority of cases (2,698 cases, incidence 3.3 cases per 100,000 population) compared to non-infectious pulmonary tuberculosis (680 cases, incidence 0.8). Of the pulmonary cases 45.7% (1,543/3,378) were smear positive and thus highly infectious. Extra-pulmonary tuberculosis alone was diagnosed in 1,066 cases (24.0%). The most common site of extra-pulmonary involvement was lymph node tuberculosis (537/1,066; 50.4%).

Drug-resistant tuberculosis: The proportion of multidrug-resistant tuberculosis (MDR-TB) was slightly lower with 3.0% (89 cases) in 2014 compared to 3.2% (100 cases) in 2013. MDR-TB rates were highest in patients born in one of the newly independent states (NIS) of the former Soviet Union (23.3% compared to 0.5% in German born patients). Nine extensively drug resistant TB cases were notified; all eight patients for whom information on country of birth was available were born in a NIS country. The overall proportion of TB cases resistant to at least one of the five standard anti TB drugs (isoniazid, ethambutol, pyrazinamide, streptomycin, and rifampicin; any drug resistance) decreased from 14.2% in 2013 to 13.2% in 2014. The proportion of any drug resistant tuberculosis cases was also higher in patients born in a NIS country compared to those born in Germany (37.9% vs. 9.0%).

Deaths: A total of 97 patients died of tuberculosis in 2014. This corresponded to a mortality of 0.1 cases per 100,000 population. The case fatality rate was 2.3%. No deaths were reported in children and young adults under the age of 25 years.

Treatment outcome can only be assessed after at least 12 months of follow-up and therefore is reported here for cases notified in 2013. The completeness of treatment outcome reporting was 86.3% (3,727 of 4,319 reported cases). Among patients with available information, 76.3% (2,843 cases) were treated successfully, 16.3% (606 cases) failed treatment for different reasons, 5.3% (197 cases) were still on treatment and 2.2% (81 cases) were reported as transfer out. Treatment outcome showed age-specific differences with a higher proportion (>80%) of treatment success reported for patients younger than 40 years of age. This declined in older age groups. For patients aged 70 years or older 65.3%, and for those aged 80 years or older only 50.7% were treated successfully.

Conclusion: Until recently tuberculosis case numbers had been declining for many years in Germany. This downward trend appears to have ended with increasing case numbers reported. Available data indicates that TB case numbers are influenced by a changing demographic context and migration. The increase and subsequent plateau in tuberculosis case numbers in young children observed since 2009 has not continued and showed a slight decrease in 2014. This group requires particular attention, because of their vulnerability and also as an indicator of current transmission.

The occurence of multidrug and extensively drug resistant tuberculosis needs special attention. Cases with a previous history of tuberculosis diagnosis or treatment and the influence of migration from high-prevalence countries are highly relevant to the assessment of the epidemiological situation in Germany.

The well established German TB-surveillance system is essential for timely identification of epidemiological trends and their interpretation in the context of factors potentially influencing the epidemiological situation.

Rising case numbers, especially in the non-German population, multi and extensively drug resistant tuberculosis, and a high proportion of infectious pulmonary TB indicate that tuberculosis remains a relevant public health problem with increasing burden in high risk groups in Germany.

These developments need to be taken into consideration in the strategic approach to maintaining effective tuberculosis control. The needs of persons with a migration background should be considered. Early and thorough case finding coupled with adequate treatment and case management are essential in preventing a further increase in tuberculosis in the long term. It is essential that knowledge and experience of working with tuberculosis is not only maintained but enhanced through appropriate educational opportunities both during training and in the workplace.