Report on the Epidemiology of Tuberculosis in Germany - 2019

full report in German

In 2019, a total of 4,791 tuberculosis (TB) cases were notified in Germany. This corresponds to an annual TB incidence of 5.8 cases per 100,000 population. After a significant increase in case numbers in 2015, the numbers have decreased in 2017 and remained stable in 2018. In 2019, the incidence decreased by 12.8 % compared to the previous year.

Analysis of demographic data: Tuberculosis incidence was 7.6 cases per 100,000 population in men and 4.0 in women (male to female ratio of 1.9). The age-specific incidence was highest in the age group 20–24 years (14.5 cases per 100,000 population; 19.0 in men and 9.5 in women).

Citizenship: Tuberculosis incidence in foreign nationals residing in Germany was 14.7 times higher than the incidence in German citizens (30.6 vs. 2.1 cases per 100,000 population, respectively). The largest difference was observed in young adults. Overall, Germans comprised of 32.9 % of all tuberculosis cases, whereas the remaining 67.1 % of all cases were foreign nationals. Foreign nationals affected by tuberculosis were younger than German nationals (median age: 31 vs. 59 years).

The analysis by country of birth showed that the proportion of foreign-born patients – as in the previous years – accounts for almost three-quarters of all patients. The most frequently registered foreign countries of birth in 2019 included Eritrea and Somalia, as also in the previous year.

Tuberculosis in children: A total of 196 cases were reported in children younger than 15 years of age (incidence 1.7 cases per 100,000 children). There was a slight decrease of 20 cases compared to 2018 (216 cases; incidence 1.9 per 100,000 children). Tuberculosis incidence was highest in the youngest age group below five years of age (94 cases; incidence 2.4). In children aged 5 to 9 years, the incidence of TB was 1.3 (46 cases), while in children aged 10 to 14 years, it was 1.5 (56 cases). Tuberculosis incidence in children of foreign nationality was almost 14 times higher in comparison to German children (9.1 vs. 0.7 per 100,000 population). The majority of the children have a migration background.

Case finding: The proportion of tuberculosis cases detected by active case finding was 13.0 % in 2019 (544 cases) – in particular due to contact tracing (5.8 %, 244 cases) and the mandatory screening of asylum seekers and refugees (5.0 %, 209 cases).

Site of disease:Pulmonary tuberculosis was diagnosed in 72.2 % of cases (3,435 cases; incidence 4.1) and was potentially infectious (sputum-smear or culture positive) in the majority of cases (2,832 cases, incidence 3.4) in comparison to non-infectious pulmonary tuberculosis (603 cases; incidence 0.7). Out off the pulmonary TB cases, 47.6 % (1,636 cases) were smear-positive and, thus, were the most infectious cases. Extrapulmonary tuberculosis solely was diagnosed in 1,321 cases (27.8 %). In about half of these extra-pulmonary cases, the main affected site was the lymph node (689 cases; 52.1 %). Foreign nationals are more frequently affected by extrapulmonary tuberculosis than German nationals (Incidence 9.7 vs. 0.4).

Drug-resistant tuberculosis: The proportion of multidrug-resistant tuberculosis (MDR-TB) was 2.6 % (87 cases) in 2019, and it is therefore decreased compared to 2018 (3.0 %, 119 cases).

The proportion of MDR-TB was highest in patients born in one of the newly independent states (NIS) of the former Soviet Union (20.2 % compared to 0.8 % in German born patients). Eight extensively drug-resistant TB cases were notified in 2019. The overall proportion of TB cases resistant to at least one of the five standard anti-TB drugs (isoniazid, rifampicin, ethambutol, pyrazinamide, and streptomycin) was 11.4 % in 2019, which was slightly lower than in 2018 (13.3 %). The proportion of any drug-resistant TB cases was higher among patients born in an NIS country in comparison to those born in Germany (38.1 % vs. 7.2 %, respectively).

Deaths: A total of 129 patients died of tuberculosis in 2019. This corresponded to a mortality rate of almost 0.2 cases per 100,000 population. The case fatality rate was 2.8 %, which was slightly higher than in the previous year (2018: 2.6 % 139 deaths) – although the absolute case numbers were lower in 2019.

Treatment outcome can only be assessed after at least 12 months of follow-up and is, therefore, reported here for cases notified in 2018. The completeness of treatment outcome reporting was 86.6 % (4,758 of 5,492 reported cases). Among patients with available information, 81.2 % (3,864 cases) were treated successfully, 10.8 % (513 cases) experienced an unsuccessful treatment for different reasons, 2.9 % (136 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 children and younger patients; this proportion declined in older age groups. For patients aged 80 years or older, only about 60 % completed treatment successfully.

Conclusion: Following the significant increase in tuberculosis in 2015 and 2016 followed by consistently lower numbers in 2017 and 2018, a significant decrease in the number of cases of almost 13 % compared to the previous year could be observed in 2019.

In order to achieve the goal set by the World Health Organization (WHO), which for low incidence countries like Germany expects the incidence to be reduced to less than one case per 100,000 inhabitants by 2035, an annual incidence decrease of at least 10 % would be required. The current decline would therefore have to continue. It remains to be seen how the trend will develop in the coming years.
The high proportion of infectious pulmonary tuberculosis illustrates the importance of contact tracing. In addition, the screening of refugees and asylum seekers when they are admitted to a shared accommodation facility remains an important measure in active case finding. However, most cases are discovered by passive case finding.

The majority of the patients were born abroad. Nevertheless, around a quarter of tuberculosis patients were born in Germany. Most of them are older people who became infected with TB in the war or post-war years and did not develop active tuberculosis until later in life. This highlights the importance of maintaining continued vigilance against TB and the consideration for differential diagnosis.
Children are a particularly vulnerable group and often develop a serious clinical picture. Despite declining and small case numbers, tuberculosis among young children requires still particular attention, not only because of their vulnerability, but also as an indicator of current transmission among the population.

Eff orts to further improve the treatment outcome are also of relevance. High 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, mainly affecting risk groups.

Ensuring an early diagnosis and a complete therapy according to guidelines is crucial for tuberculosis control and requires coordinated cooperation between all those involved in the healthcare system. Multi- and extensively resistant tuberculosis in particular require competent case management by well-trained doctors and an adequately equipped public health sector.

Finally, a well-established TB-surveillance system is essential for timely identification of epidemiological trends and their interpretation.