EUGLOREH project




6.3. Data description and analysis

6.3.4. Respiratory tract infections

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6.3.4. Respiratory tract infections


This section addresses influenza, tuberculosis, legionellosis and SARS. Influenza


Seasonal influenza is an acute viral disease of the respiratory tract, caused by influenza virus A and B. Each year there are epidemics during the winter season, although sporadic cases do occur throughout the year. Seasonal influenza poses a considerable public health threat.


The 200405 influenza season in Europe started in late December 2004 with the first influenza activity occurring in the Northwest and Southwest (Spain, United Kingdom and Ireland). The intensity of clinical influenza activity in 10 out of 23 countries was higher than during the 200304 season, but lower or equal to the 200304 season in the other 13 countries. The highest consultation rates were generally observed among children aged 014 years. In all, the peak consultation rates due to influenza-like illness or acute respiratory infection were not especially high when compared with historical data. The predominant virus strain was influenza A/H3N2, and similar to the vaccine strain for the season. Influenza B viruses were co-circulating with the A viruses during the whole influenza season in 11 out of 24 countries. Seven of these were located in the North-East of Europe and in these countries the proportion of B viruses was higher than in the rest of Europe. The seasonal influenza strain of the 200405 and 200506 winter seasons was mainly of type A/H3N2, just like in previous years, and both epidemics were of ‘mediumsize in the EU.


Most EU Member States follow the WHO guidance that recommends vaccination against human seasonal influenza be offered annually in the early autumn for three major risk groups (the elderly, healthcare workers and those with chronic medical conditions of all ages, such as diabetes or heart disease). There is a WHO vaccination coverage target, accepted by all European countries but this vaccine is currently underused in the EU. Some countries cannot routinely monitor their coverage even for the elderly, and for those that can, they are seemingly not meeting the WHO target. Therefore, there still is a considerable potential for health gain in Europe not only through an improved vaccination coverage in these selected groups, but also by adopting other effective measures that minimise virus transmission. In this sense, better application of the ECDC recommended personal protection measures (regular hand-washing, good respiratory hygiene, mask-wearing in healthcare settings during acute febrile periods, early isolation of symptomatic personnel, etc.), would reduce the risk for all people.


The risk of an influenza pandemic


At irregular intervals new influenza A virus subtypes emerge, leading to an influenza pandemic which may last for six to eight months, and usually with a much higher disease and death rate than the seasonal variety. It is impossible to predict which will be the next pandemic strain, or when it will appear.


In recent years, a new strain of avian influenza (A/H5N1) has spread globally among birds, and also occasionally infected humans. The threat of avian influenza, and its potential for starting a human influenza pandemic was a main concern in 2005. Starting in late summer, the avian influenza virus A/H5N1 was detected in birds ever closer to Europe, with human cases as close as Turkey, but no human cases in Europe. This virus in its present form is poorly adapted to humans, and therefore, the human health issue is minor as long as the A/H5N1 virus stays in its current form. The risk of infection is almost entirely confined to people who own domestic poultry and have close and intense contact with sick birds or their droppings. However, they can protect themselves by applying the measures recommended by ECDC. People travelling to countries where A/H5N1 is prevalent can sometimes enter this category if they are staying with families with domestic poultry.


Since 2005 there has been an extraordinary concerted effort by all EU countries to strengthen their readiness for a pandemic. However, much remains to be done and it is believed that another two to three years of intense work is required by all Member States as well as EU institutions to reach an acceptable level of preparedness.


Key areas where further work is especially needed are:


·          integrated planning across governments;

·          making plans operational at local level;

·          inter-sectoral operability at national level;

·          stepping up prevention efforts against seasonal influenza;

·          extending influenza research;

·          improving EU influenza laboratory capacity.


TB is a bacterial disease, caused by inhaling a bacteria belonging to the Mycobacterium tuberculosis complex in droplets produced by another person with pulmonary disease, and less frequently through the ingestion of contaminated milk or through laboratory contamination. Only 10% of people infected develop active TB. HIV infection increases the likelihood of progression, while preventive therapy reduces this risk. The BCG vaccine may be effective in limiting severe disease in childhood, but has no effect on transmission. Therefore, TB control relies mainly on the detection of infectious patients and treatment for at least six months with a combination of antibiotics. Inadequate treatment may result in failure of cure, early relapse or the development of drug-resistant disease (see section on antimicrobial resistance, above).



In the early90s, a number of EU countries experienced an increase or stabilisation in their TB notification rates. Subsequently, rates declined in most countries and have reached very low levels in recent years. This is the result of the sustained efforts of public health authorities. In many EU countries TB is becoming a rare disease and many Member States are heading towards elimination. In the Baltic States rates increased in the late 1990s, but have similarly decreased since 2002. In Sweden and the United Kingdom, however, overall rates increased substantially between 2001 and 2005, largely as a result of TB in immigrants. With the exception of the Baltic States, Hungary, Poland and Portugal, rates have remained below 20 per 100 000 per year since 2001 in all countries.


Annex 6.1. Selected tables and figures from the Tuberculosis Annual Report




















Table 6.A1.1 Number of cases of tubercolosis




Figure 6.A1.1 TB cases per 100,000 selected countries and EU 25

Figure 6.A1.2 Tubercolosis cases by age and gender




Figure 6.A1.3 Combined MDR in 2005





Figure 6.A1.4 New culture positive cases (Sweden smear)



Table 6.A1.2 Cases of TB between 1995 and 2004




Table 6.A1.3 Cases of TB by age groups







The EU countries today fall into three broad patterns with respect to TB:


·          Industrialised countries with Westernised economies where TB rates are low and disease increasingly aggregates in sub-populations and settings associated with poverty and lowered immunity. Prevalence of HIV and drug-resistance among TB cases is low to moderate.

·          The Baltic States, characterised by high TB rates, low migrant TB and high frequency of drug resistance and where HIV is low but steadily increasing among TB patients.

·          Countries in central Europe which joined the EU in 2004, where TB rates are moderate, cases of foreign origin rare, and levels of HIV and drug resistance low.



In 2005, the 25 EU countries plus Iceland and Norway reported 59 497 TB cases corresponding to an overall rate of 13 per 100 000 per year, with a countrywide range from four to 75. Five countries (France, Germany, Poland, Spain and United Kingdom) had more than 5 000 cases each, accounting for 62% of all cases reported. With the EU expansion in 2007, Romania will be the country with the highest notification rate (135 per 100 000 per year in 2005) and will effectively increase total notifications in the EU27 by one half.


Risk factors


Recent demographic, political and socioeconomic changes in Europe, such as the increased immigration and the upheaval that followed the collapse of the former Soviet Union leading to a poorer control of the disease, have been major determinants of the tuberculosis situation in Europe. Trends show a continuous decline, at least in the western countries, but the general pattern has changed. In the EU, TB is most prevalent in migrants coming from high-prevalence countries outside the EU, the homeless, prisoners and drug users.


TB is more common in males (male to female ratio, 1.7:1). Cases aged over 64 accounted for 22% of the cases overall, while children under 14 represented 4%. Mean age is lower in western countries like Denmark, the Netherlands, Sweden and United Kingdom, where foreign-born individuals nowadays represent the majority of notified cases. In people of foreign origin, TB concentrates in young adulthood, while, in the indigenous population, rates increase slowly with age and are the highest in the elderly. Cases of foreign origin accounted for 30% of all cases reported in the 25 countries (range 078%). Most cases of foreign origin were from Africa, Asia or from other countries within the European Region itself. In countries with higher overall rates, the proportion of foreigners was lower in general, suggesting that local transmission was relatively important.


In the EU in 2005, 22% of AIDS cases had TB as the initial AIDS-indicator illness. The contribution of HIV to the TB caseload differs between countries. While 15% of TB cases in Portugal were HIV positive, the co-prevalence was much lower in other countries with data. However, a doubling in prevalence was registered in the UK in 200003 (from 4.2% to 8.3%) associated with recent migration. HIV prevalence among TB cases has also increased since 2000 in Estonia and Latvia, reaching 6.4% and 3.5%, respectively in 2005.


Control tools and policies


In the coming years there is a need to improve surveillance on risk groups and drug resistance and to better link laboratory results with epidemiological surveillance data. The overall decline in incidence also implies that several of the countries that still have a programme for general BCG vaccination of children could consider switching to vaccination of high-risk groups. Since the vaccine is not without adverse effects, there is a break point where the number of serious adverse reactions outweighs the few infections prevented.

Guidance on interventions for specific risk groups, including guidelines for prevention and control of TB in immigrants, needs to be promoted. Legionnairesdisease (legionellosis)


Legionnairesdisease is a respiratory disease caused by the bacteria Legionella pneumophila, which can give severe pneumonia with high case fatality rates, especially among elderly (figure 6.4) and immuno-compromised individuals. Sporadic cases and outbreaks occur worldwide. The most common mode of transmission is airborne and the reservoirs are aquatic systems such as cooling towers, evaporative condensers, humidifiers, decorative fountains, etc. Legionellosis can usually be treated effectively with antibiotics.


Figure 6.4. Trends of legionellosis 1995 - 2004.


The incidence of legionellosis increased between 1996 and 2002 in the EU. Since 2002, the incidence has remained stable at around one per 100 000 per year. In 2005, a total of 4 189 human legionellosis cases were reported by 23 countries. The highest incidence of 3.36 per 100 000 per year was seen in Spain, followed by Iceland with 2.38 per 100 000 per year. In 2005, 746 cases of travel-associated Legionnairesdisease with onset in 2005 were reported to the EWGLINET surveillance scheme by 15 Member States, Iceland and Norway. Ninety-three new clusters were identified. Prophylactic measures include regular cleaning and maintenance of the various water systems. Guidelines for water plants sanitation have been prepared by EWGLINET experts. Severe acute respiratory syndrome (SARS)


SARS is a viral respiratory illness with a high fatality rate, caused by a corona virus, the SARS-associated corona virus (SARS-CoV). The main way that SARS seems to spread is by close person-to-person contact, through respiratory droplets produced when an infected person coughs or sneezes.

SARS was first recognised as a global threat in mid-March 2003 in East Asia. By July 2003, the international spread of SARS-CoV had resulted in 8 098 SARS cases in 26 countries, with 774 deaths. In addition to the direct impact on health services, the epidemic caused significant social and economic disruption in areas with sustained local transmission of SARS and in the international travel industry. Although sporadic imported cases of SARS also appeared in Europe in 2005, the EU was largely spared from the infection. No SARS cases were reported in the world in 2005.

Today, the most likely sources of infection with SARS-CoV would be exposure in laboratories where the virus is used or stored for diagnostic and research purposes, or from animal reservoirs of SARS-CoV-like viruses. It remains very difficult to predict when or whether SARS will re-emerge in epidemic form. The resurgence of SARS leading to an outbreak remains a distinct possibility, and in the inter-epidemic period, all countries must remain vigilant for its recurrence and maintain their capacity to detect and respond to the re-emergence of SARS should it occur.