Tuberculosis trends in Eastern Europe and the former USSR

Abstract

The aim of this paper is to assess trends in tuberculosis morbidity and mortality in the countries of Eastern Europe and the former USSR. Data on morbidity and mortality were obtained from reports of the Ministries of Health, a 1992 WHO questionnaire, national tuberculosis associations, and other sources. The quality of surveillance of tuberculosis cases differs widely between countries. Ranging from 19 to 80 per 100 000 population in 1990–1992, tuberculosis notification rates of most Eastern European and former USSR countries are higher than those of Western European countries. The lowest tuberculosis notification rate is reported in the Czech Republic, while the highest are reported in Romania and Kazakhstan. While in Albania, Croatia and Slovenia notification rates have continued to decline, in the remaining countries of Eastern Europe the declining trend has recently stopped. Nevertheless, countries such as the Czech Republic, Hungary, Poland and the Slovak Republic have experienced a distinct rate decrease when the 3-year average rate around 1985 is compared to that around 1990, despite the very recent levelling-off or increase. In Romania, the previous decline in notification rate ended in 1985 and in the period 1986–1992 an average 5.4% annual increase was observed. In this country, two-thirds of all cases still occur among young adults. Among the Baltic countries of the former USSR, the declining trend continues in Estonia, whereas in Latvia and Lithuania notification rates decreased less markedly from 1985 to 1990 than in the first half of the 1980s. Among the other European countries of the former USSR, Russia and Ukraine had a slow decline in the first half of the 1980s and a more pronounced one from 1985 to 1990. During the latter period of time, in Belarus and Moldova the decrease has been steeper. In the Caucasian countries of the former USSR, where underreporting and low case-finding are recognized, case rates have stabilized in Armenia, while in Azerbaijan and Georgia there was a decrease from 1985 to 1990. Among the Asian countries of the former USSR, Kazakhstan and Tajikistan reported a lower decline in case rates from 1985 to 1990 than from 1980 to 1985. Kyrgyzstan, Turkmenistan, and Uzbekistan reported increases in notification rates from 1985 to 1990: in Turkmenistan an average 5.5% annual increase in rate was observed between 1987 and 1991. Tuberculosis mortality is steadily increasing in Romania, Armenia, Kyrgyzstan, Latvia, Lithuania, Moldova, and Turkmenistan, while no decline is seen in most of the other countries of Eastern Europe and the former USSR. With the exception of the Czech Republic, the Slovak Republic and Slovenia, mortality rates in all countries remain higher than those of Western Europe. HIV infection and immigration have not contributed importantly to the epidemiological situation in Eastern Europe and the former USSR. Only a few countries report the use of rifampicin-containing regimens for infectious cases and none the retreatment regimen which are recommended by the World Health Organization (WHO). In several countries drug supply is insufficient and/or erratic. While the post-war tuberculosis situation was grave, progress in tuberculosis control allowed some countries to substantially reduce the public health impact of the disease. However, malnutrition and poor living conditions in some countries favour reactivation of pre-existing latent infection. Lack of crucial antituberculosis drugs, such as rifampicin and pyrazinamide, results in inadequate treatment which causes increased mortality and prevalence of the disease. While adequate chemotherapy will result in a decrease of tuberculosis incidence in a country with a low prevalence of HIV infection, it is difficult to predict the future trend of tuberculosis incidence if treatment remains inadequate and the prevalence of HIV infection low. The main steps to be taken in Eastern Europe and the former USSR are to find the necessary resources to secure an uninterrupted supply of essential drugs, and to introduce WHO recommended short-course chemotherapy for new and retreatment cases, particularly for the infectious ones. Where necessary, inefficient national programmes will need structural adjustments and increased training activities for health care providers to allow for a better understanding of relevant issues in tuberculosis control.