Report on the Epidemiology of Tuberculosis in Germany - 2022

full report in German

In 2022, a total of 4,076 tuberculosis (TB) cases were notified in Germany. This corresponds to an annual TB incidence of 4.9 cases per 100,000 population.

After the number of cases had increased significantly in 2015 and 2016 to almost 6,000 cases each, lower numbers were registered in 2017 and 2018 with around 5,500 cases. Another significant decrease of more than 12 % each was observed in 2019 and 2020, being half as high in 2021. For 2022, for the first time since 2016, a slight increase of 3.5 % compared to the previous year can be observed.

Analysis of demographic data: Tuberculosis incidence in men (6.5 cases per 100,000 population) was almost twice as high as in women (3.3/100,000). The age-specific incidence was highest in young adults (age group 20 – 24 years: 9.0; age group 25 – 29 years: 10.7).

Citizenship: Tuberculosis incidence in foreign nationals residing in Germany was almost 16 times higher than the incidence in German citizens (25.1 vs. 1.5 cases per 100,000 population, respectively). The largest difference was observed in young adults. Overall, Germans comprised of 29.0 % of all tuberculosis cases, whereas the remaining 71.0 % of all cases were foreign nationals. Foreign nationals affected by tuberculosis were younger than German nationals (median age: 31 vs. 61 years).

The analysis by country of birth showed that the proportion of foreign-born patients accounts for more than three-quarters (75.7 %) of all patients. The most frequently registered foreign countries of birth in 2022 included Afghanistan, Ukraine, and Romania.

Tuberculosis in children: A total of 190 cases were reported in children younger than 15 years of age (incidence 1.6 cases per 100,000 children), representing 4.7 % of all TB cases. There was a considerable increase compared to 2021 (157 cases; incidence 1.4 per 100,000 children), though case numbers are still on a low level. Overall, tuberculosis incidence was highest in the youngest age group below five years of age (86 cases; incidence 2.2). In children aged 5 to 9 years, the incidence of TB was 1.2 (45 cases), while in children aged 10 to 14 years, it was 1.6 (59 cases). Tuberculosis incidence in children of foreign nationality was around 16 times higher in comparison to German children (8.0 vs. 0.5 per 100,000 population).

Case finding: As in previous years, most cases (2,926; 84.0 %) were detected by passive case finding, including 8 cases (0.2 %) as part of a postmortem examination. The proportion of tuberculosis cases detected by active case finding was 16.0 % in 2022 (557 cases) – in particular due to increased case numbers detected by mandatory screening of asylum seekers and refugees (8.6 %, 300 cases; 2021: 5.1 %, 171 cases), and by contact tracing (5.3 %, 183 cases; 2021: 4.8 %, 162 cases).

Site of disease: Pulmonary tuberculosis was diagnosed in 76.1 % of cases (3,042 cases; incidence 3.7 per 100,000 population) and was potentially infectious (sputum-smear or culture positive) in the majority of cases (2,567 cases, incidence 3.1) in comparison to potentially non-infectious pulmonary tuberculosis (475 cases; incidence 0.6). Out of the pulmonary TB cases, 51.2 % (1,556 cases) were smear-positive and, thus, were the most infectious cases. Extra-pulmonary tuberculosis solely was diagnosed in 953 cases (23.9 %; incidence 1.1). In about half of these extra-pulmonary cases, the main affected site were the lymph nodes (500 cases; 52.5 %). Foreign nationals were more frequently affected by extra-pulmonary tuberculosis than German nationals (Incidence 6.4 vs. 0.3).

Drug-resistant tuberculosis: The proportion of multidrug-resistant tuberculosis (MDR-TB) was 5.7 % (166 cases) in 2022, and was therefore almost twice as high compared to the previous year (2021: 2.6 %, 77 cases).

The proportion of MDR-TB was highest in patients born in one of the postsovjet states (29.8 % compared to 1.7 % in German born patients). According to the new WHO case definition that has been implemented since 2021, 33 cases of pre-extensively TB (pre-XDR-TB) and four cases of extensively drug-resistant TB (XDR-TB) were notified in 2022.

Deaths: A total of 116 patients died of tuberculosis in 2022. This corresponded to a mortality rate of 0.14 cases per 100,000 population. The case fatality rate was 2.9 %, which was slightly lower than in the previous year (2021: 3.1 %, 123 deaths).

Treatment outcome can only be assessed after at least 12 months of follow-up and is, therefore, reported here for cases notified in 2021. The completeness of treatment outcome reporting was 85.3 % (3,359 of 3,939 reported cases). Of these 3,359 cases 76.8 % (2,581 cases) were treated successfully, 14.1 % (472 cases) experienced an unsuccessful treatment outcome for different reasons, 4.0 % (136 cases) were still on treatment, and 5.1 % (170 cases) were reported as having transferred out. Treatment outcome showed age-specific differences with a higher proportion (> 90 %) 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 50 % completed treatment successfully.

Conclusion: After the high increase in TB cases in 2015 and 2016 due to migration, followed by consistently lower numbers in 2017 and 2018, in 2019 and 2020 a significant decrease in the number of cases of more than 12 % compared to the previous years could be observed, slowing down to −6 % in 2021. For 2022, for the first time since 2016, a slight increase of 3.5 % compared to the previous year can be observed. This development can be explained primarily by the increased number of cases among people born in Ukraine as a result of the current war in a country where the incidence of tuberculosis and MDR/RR-TB rates are significantly higher than in Germany.

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. It remains to be seen how the trend will develop in the coming years. The current epidemiological situation is complex and mainly affected by demographic trends and global mobility – for example from high-burden countries or from areas with a high proportion of MDR-TB, such as currently from Ukraine.

The high proportion of infectious pulmonary tuberculosis illustrates the importance of contact tracing in order to diagnose and treat disease early and effectively prevent further transmission. 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. Here it is important to keep in mind that tuberculosis can also develop at a later point in time if the findings are unremarkable at the time of entry. Most cases in Germany are discovered by passive case finding.

The majority of the patients were born abroad. Around a quarter of tuberculosis patients were born in Germany, these are mostly elderly people. Irrespective of age and origin, tuberculosis therefore retains its importance in the differential diagnosis.

Children are a particularly vulnerable group and often develop a serious clinical picture. Although the case numbers in the age groups < 15 years are still low, these have increased compared to the previous year as a result of the current migration movements. Tuberculosis among young children requires particular attention, not only because of their vulnerability, but also as an indicator of current transmission among the population, and as a highly relevant target group for contact investigation.

Efforts to further improve treatment outcomes are also of relevance, which remain below the treatment target of 90 % set by the WHO – especially in older people. Furthermore, testing for resistance to antituberculosis drugs using all diagnostic methods, regardless of country of birth, is critical for successful tuberculosis control.

Early diagnosis and a complete therapy according to guidelines is crucial for tuberculosis control. This also applies with regard to the people currently fleeing from the war in Ukraine and are seeking protection.

The implementation of the necessary measures and strategies in Germany requires coordinated cooperation between all those involved in the healthcare system. Multi-, pre-extensively and extensively drug resistant tuberculosis in particular require competent case management by well-trained and experienced doctors in or in cooperation with treatment centers and an adequately equipped public health sector. In addition to medical aspects, patient-centred care also includes social aspects and communication that is sensitive to language, culture and discrimination. Finally, a well-established TB-surveillance system is essential for timely identification of epidemiological trends and their interpretation.

Tuberculosis in Germany still remains an important public health disease – especially in relation to international migration.