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Tuberculosis Surveillance: Data for Decision-Making

Kenneth G. Castro
Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Department of Health and Human
Services, Atlanta, Georgia

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(See the article by Falzon and Aı̈t-Belghiti on pages 1261–7)

Disease surveillance has often been de- mented in 1996 [3]. Before the imple- cate that the analyses were neither adjusted
scribed as the “conscience” of an epi- mentation of EuroTB, tuberculosis sur- for underreporting nor independently
demic. Surveillance represents a discipline veillance data in the various European validated, and they disclose limitations of
that is often taken for granted in the prac- countries was heterogeneous and lacked the EuroTB data. Three important limi-
tice of epidemiology, yet surveillance data agreed-upon case definitions, which made tations must be borne in mind when in-
are commonly requested and quoted. Sur- it difficult to draw valid comparisons. terpreting these data, so that readers can
veillance data are crucial to measuring the Taken at face value, the report by Falzon readily temper each of the main findings
burden of diseases and, thus, serve as the and Aı̈t-Belghiti [2] provides a mixture of with a full understanding of the reported
basis for informed decisions regarding the good news and bad news about recent information.
planning and targeting of health care in- trends in tuberculosis. The good news is First, the HIV infection status of pa-
terventions. Ideal surveillance systems are that tuberculosis trends have decreased be- tients with tuberculosis was reported by
comprehensive, accurate, and timely. tween 1999 and 2003—the time period 13 (52%) of 25 countries. The exact num-
Analysis and reporting of information to examined—throughout all European Un- ber of persons tested in each country is
those “who need to know” completes the ion countries except for Italy and United not provided, thus restricting a full un-
“feedback loop” of robust and useful sur- Kingdom. However, the bad news includes derstanding of these findings. Second,
veillance systems. An early example of the worrisome new trends that suggest an in- drug-susceptibility data were reported for
analysis and use of tuberculosis mortality creasing convergence between the occur- 15 (60%) of 25 countries in which ⭓50%
trends in the United Kingdom was pub- rence of tuberculosis and HIV infection, of reported cases were confirmed by cul-
lished by Frost [1], who helped to eluci- a growing proportion of drug-resistant ture and in which drug-susceptibility test-
date the influence of cohort year of birth. Mycobacterium tuberculosis complex ing was performed for ⭓80% of patients
The article by Falzon and Aı̈t-Belghiti strains in some countries, and the inevi- with tuberculosis who had positive cul-
[2], published in this issue of Clinical In- table reflection of the global public health tures. This suggests that, in some coun-
fectious Diseases, reflects a commendable problem of tuberculosis in developing tries, as many as almost one-half of pa-
assessment of tuberculosis trends in the 25 countries, manifesting throughout Europe tients do not have their tuberculosis
countries belonging to European Union, as a larger proportion of foreigners re- infection status confirmed by culture, and
based on data collected and collated by ported with tuberculosis in countries with even fewer patients have drug-suscepti-
EuroTB, a surveillance network imple- low incidences of tuberculosis. These ap- bility test results. Third, data about place
pear to be the main messages inferred of birth is shown, but incidences were not
Received 22 January 2007; accepted 14 February 2007; from tuberculosis surveillance in Euro- calculated on the basis of systematically
electronically published 4 April 2007.
Reprints or correspondence: Dr. Kenneth G. Castro, Div. of
pean countries. collected information; the authors had to
Tuberculosis Elimination, National Center for HIV, STD, and Close scrutiny of these findings reminds rely on information provided by each
TB Prevention, Centers for Disease Control and Prevention,
us of the limitations of these valuable data. country about “population statistics … to
1600 Clifton Rd. (E-10), Atlanta, GA 30333 (kgc1@cdc.gov).
Clinical Infectious Diseases 2007; 44:1268–70
Surveillance data are influenced by the derive rates by geographic origin” [2, p.
 2007 by the Infectious Diseases Society of America. All completeness and comprehensiveness, as 1263]. Uncertainties associated with cen-
rights reserved.
well as the accuracy and validity, of the sus information regarding immigrant
DOI: 10.1086/514351 collected information. The authors indi- populations, who are often residing ille-

1268 • CID 2007:44 (15 May) • EDITORIAL COMMENTARY

gally in these countries, make these esti- tional standards for tuberculosis care offer European Union, to become fully engaged
mates suspect. the opportunity for broad-based imple- in the global fight against tuberculosis [13,
What are decision-makers to do with mentation of these sound practices [5]. 14]. Migration of persons from countries
these data? This question represents the Furthermore, European Union countries with a high burden of tuberculosis to Eu-
quintessential challenge of public health already have a robust and ambitious ropean Union countries with low tuber-
practice. Despite the aforementioned lim- framework for the elimination of tuber- culosis incidence clearly demonstrates
itations, informed interventions can and culosis in areas of low incidence [6]. In how local victories are being counteracted
should be undertaken while awaiting the this context, countries with established by global realities. This situation is very
collection of additional information. It is market economies ought to implement similar to that seen in the United States
reasonable to suggest, as the authors have, routine access to real-time culture and [15, 16]. A recent decision analysis sug-
that these European Union countries must drug-susceptibility testing for all persons gested that investments by the United
now strive to focus attention on the high- suspected of having tuberculosis. Once States in the control of tuberculosis in

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lighted findings. Thus, immediate inter- persons are identified as having multi- Mexico, the Dominican Republic, and
ventions are now required in 3 specific drug-resistant (MDR) strains, access to Haiti—where a large fraction of patients
areas. subject matter expertise and second-line with cases of tuberculosis in the United
First, all European Union countries drug regimens are necessary to help guide States originate—“is the most effective
must work to achieve better coordination clinicians through the complexities asso- long-term approach to reducing tuber-
between HIV infection and tuberculosis ciated with the administration of the rel- culosis morbidity and mortality among
services, to ensure that all persons with atively toxic drugs used to treat MDR tu- migrants from those countries and would
tuberculosis are offered testing for HIV berculosis. In response to the relatively produce net savings to the United States”
infection. Conversely, those individuals high prevalence of MDR tuberculosis, au- [17, p. 1018]. European Union countries
who are known to have HIV infection de- thorities in Latvia made a commitment to should consider undertaking similar de-
serve to be screened for the presence of develop collaborations to create a center cision analyses to ascertain the value of
latent M. tuberculosis infection or tuber- of excellence for care of persons with such foreign health policy investments.
culosis disease (a very common HIV-as- MDR tuberculosis, where training, edu- In sum, the EuroTB data are telling us
sociated opportunistic infection, as shown cation, and expertise can be accessed [7, that this is no time for complacency. They
by data reported to EuroHIV) and offered 8]. Furthermore, the recent description of suggest the need for concerted action to
safe and effective treatment. Attention to extensively drug-resistant tuberculosis— both sustain hard-won achievements and
infection-control precautions is also nec- including in samples obtained from pa- adapt to the changing epidemiology of tu-
essary, with special emphasis on settings tients in the European region—provides a berculosis in these countries if we are to
in which persons with HIV infection and rude “wake-up call” to cease long-stand- reduce unnecessary suffering, address the
tuberculosis converge and congregate. A ing hesitation and indecisive “hand- HIV infection and tuberculosis pandem-
policy framework is available from the wringing” and, instead, to mobilize re- ics, and develop safe and effective treat-
global Stop TB Partnership Working sources to promptly provide access to the ment regimens to protect future
Group on TB/HIV [4]. These interven- latest diagnostic tools for optimal patient generations.
tions will, in turn, serve to provide more- care [9–12]. Additional resource invest-
robust and more-representative data ments are required to carry out the nec- Acknowledgments
about the prevalence of HIV infection in essary research, development, and rapid Potential conflicts of interest. K.G.C.: no
persons with tuberculosis and the fre- translation of new rapid diagnostic meth- conflicts.
quency of tuberculosis as an HIV-associ- ods and new safe and effective drug
ated opportunistic disease. In addition, regimens for those with virtually untreat- References
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