The Millennium Development Declaration target of 50% reduction in TB death rate was reached by the EU (28 countries) in 2014 compared to the first year with TB death data available for the EU (28 countries).
Comparing the decline in TB death rates in the EU with those in other areas shows that rates are comparable. However, the decline was more modest in the EU compared to the decline reported in the United States and Cuba. In the United States, the age-adjusted TB mortality rate declined from 2.22 per 100,000 person-years in 1990 to 0.47 per 100,000 person-years in 2006, i.e. a decline of 79% [11]. TB mortality in Cuba declined from 0.4 per 100,000 population in 1998 to 0.2 in 2007 [12]. TB mortality rates in Brazil seemed to be higher i.e. 5.9 per 100,000 in 1980 and 3.1 per 100,000 in 2001 [13]. Differences in the quality of the health care system, public health interventions and the socio economic situation of the population can explain the observed differences in TB death rates and their decline.
Six EU/EEA countries did not reach the target of a 50% reduction in death rate within the period of observation, i.e. up to 2014. They reported between 144 and 15,906 TB cases in 2014 [7]. The TB surveillance data do not show a uniform epidemiological pattern that can explain why they did not reach the target. Three countries showed a decrease in TB notification rates between 1995 and 2014; three showed an initial increase in TB notification rates followed by a decrease [14]. In Austria, Lithuania, and Portugal the TB treatment outcomes were less favourable than the average of the EU/EEA and in Romania, Slovenia, and the United Kingdom more favourable. With respect to drug resistance, the percentage of cases with multidrug-resistant TB differed considerably, from 0% in Slovenia to 21.5% in Lithuania and showed an increasing trend in Austria, a decreasing and then increasing trend in the United Kingdom, was stable in Lithuania, Portugal and Slovenia, and increased and thereafter decreased in Romania.
The TB mortality rate will likely further decline if TB cases are diagnosed early [15, 16]. Currently not all TB cases are diagnosed promptly in the EU as is shown by several studies [17, 18]. This may be due to insufficient knowledge of patients and health care workers about TB in areas with a low TB incidence [19]. Poor performing health systems may diagnose TB late with as a consequence a higher case fatality rate in diagnosed TB cases. In addition, a significant percentage of TB case may be diagnosed after death. In San Francisco, 4% of all TB cases were diagnosed after death between 1986 through 1995 [20]. In an earlier period, 1985–1988, 5.1% of the TB cases reported in United States were diagnosed at death [21]. Studies from other areas, such as Taiwan, show similar percentages [22]. Thus, a further reduction of the TB mortality rate will require investments in raising awareness of TB and early diagnosis.
To prevent mortality from TB, identified cases need to receive prompt and adequate treatment. Knowledge of health care workers about tuberculosis treatment is often insufficient [23]. This may be an explanation for the fact that the TB treatment success rate observed in the EU/EEA has not reached the target of successfully treating at least 85% of the TB cases [3, 7]. Eight percent of the TB cases diagnosed in 2013 died during treatment [7]. Those who die during TB treatment may die of TB, i.e. ICD-10 codes A15-A19 and B90, and be counted as TB death in the causes of death registration, however they may also die of other causes [24, 25]. In 2014, 4039 TB cases died during TB treatment [26]. In the same year, 4532 TB deaths were registered in the vital registration database of Eurostat. Not all deaths due to TB occur during TB treatment, also after TB treatment there seems to be increased mortality [27] which may be due to remaining sequelae [28, 29]. Adequate treatment and support to ensure treatment adherence may reduce TB mortality, both during TB treatment and after TB treatment [30, 31].
Our analysis has a few limitations, related to the available data. We used data reported by EU/EEA Member States to Eurostat. TB death data were not reported by all Member States for all years and they were only available from 1999 onwards for the EU (28 countries) and not from 1990, the baseline year for measurement of the targets. This may be due to the fact that Commission Regulation No 328/2011 on Community statistics on public health and health and safety at work, as regards statistics on causes of death only became effective on 5 April 2011 [9].
By comparing the first year with causes of death information available, 1999, with the last year with causes of death data available (2014), we have made a conservative estimate of the decline in TB death rates since the MDG target is for a reduction in TB death rate between 1990 and 2015. Also, there is no evidence for an increase in TB death rates between 1990 and 1999. The total TB death rate in the EU in countries with data available for the years 1994 and 1999 decreased in this period.
The quality of vital registration systems can be measured using several indicators, e.g. coverage and completeness, and percentage of ill-defined conditions (ICD–10 codes R00–R99) [32]. More recently the vital statistics performance index was suggested [33]. Most EU/EEA Member States, except for Italy and Greece, had a high vital statistics performance index suggesting that the quality of the data is sufficient to draw conclusions.
A global assessment shows that the world will not reach a 50% reduction in mortality rate by 2015 compared with 1990 [5]. This assessment is mainly based on indirect estimates, using case fatality ratios and estimates of TB incidence, since vital registration cause of death data are not widely available. The strengths of our analysis is that it is based on direct data on causes of death reported by countries to Eurostat.
In 2016, the implementation of the World Health Organization ‘End TB Strategy’ has started [34, 35]. This strategy contains ambitious targets, including a target for a 35% reduction in tuberculosis deaths by 2020 and a 95% reduction by 2035 (compared with 2015). For the EU/EEA this results in a death rate of approximately 0.58 and 0.04 per 100,000 population respectively. Reaching this will be challenging for TB prevention and care services in the EU/EEA and will need a whole of government approach [36].
The MDGs are succeeded by the sustainable development goals. In its summit on 25 September 2015 in New York, the General Assembly of the United Nations adopted the 2030 Agenda for Sustainable Development. This agenda includes a target on ending several epidemics including the tuberculosis epidemic by 2030 [37]. It remains to be seen what indicators will be used to measure this. However, there will be a need for reliable surveillance and vital registration systems to measure progress towards this target.