Evolution of tuberculosis in Spain: Will the objectives of the End TB Strategy be achieved in Western European countries?

Abstract

Objectives

End TB Strategy aims to reduce the incidence of tuberculosis between 2015 and 2025 milestone by 50%. We analyse whether the decreasing incidence objectives of this strategy can be achieved in Spain with the impact of COVID-19 pandemic and to review the incidence evolution in Western European countries (WEC).

Study design

Retrospective longitudinal ecological study with forecasting.

Methodology

An exponential curve was fitted to the Spanish and WEC data prior the pandemic period and projected with the model until 2025 using a 90% confidence interval to have better precision due to the sample size.

Results

The mean annual % change in incidence rates of TB in the three most affected WEC during 2018–2022 decreased by 6.5% in Spain, by 6.0% in Portugal, by 3.8% in Belgium and by 5.7% in France. The annual decrease in Spain in the first year of COVID-19 pandemic was 16.6%. Lower declines than in Spain were observed in most WEC. The probability of achieving the objective of reducing the incidence by 50% between 2015 and 2025 in Spain is, with a certainty of 90%, 0%, but with important differences by regions from 0% to 79%. These probabilities in Portugal, Belgium, France and Italy are also 0%.

Conclusion

With this epidemiological evolution, the main objective of the End TB Strategy for 2025 milestone (50% incidence decline) will not be achieved in Spain. The 80% decline will probably not be reached by 2030 unless surveillance and control are improved, and TB Programmes are provided with sufficient resources. The same situation could be happening in other WEC.

Resumen

Objetivos

La Estrategia fin de la TB tiene como objetivo reducir la incidencia de la tuberculosis entre 2015 y 2025 en un 50%. Analizamos si los objetivos de disminución de la incidencia de esta estrategia pueden lograrse en España con el impacto de la pandemia de COVID-19 y revisamos su evolución en los países de Europa occidental (PEO).

Diseño del estudio

Estudio ecológico longitudinal retrospectivo con pronóstico.

Metodología

Se ajustó una curva exponencial a los datos de España y de los PEO antes del período pandémico y se proyectó con el modelo hasta 2025 utilizando un intervalo de confianza del 90% para tener una mejor precisión debido al tamaño de la muestra.

Resultados

El cambio porcentual medio anual en las tasas de incidencia de TB en los 3 PEO más afectados durante 2018-2022 disminuyó en un 6,5% en España, en un 6,0% en Portugal, en un 3,8% en Bélgica y en un 5,7% en Francia. La disminución anual en España en el primer año de la pandemia de COVID-19 fue del 16,6%. Se observaron descensos menores que en España en la mayoría de los PEO. La probabilidad de alcanzar el objetivo de reducir la incidencia en un 50% entre 2015-2025 en España es, con una certeza del 90%, del 0%, pero con importantes diferencias entre regiones, desde el 0% hasta el 79%. Estas probabilidades en Portugal, Bélgica, Francia e Italia también son del 0%.

Conclusión

Con esta evolución epidemiológica el objetivo principal de la Estrategia fin de la TB para el hito de 2025 (reducción del 50% en la incidencia) no se logrará en España. La disminución del 80% probablemente no se alcanzará para 2030, a menos que se mejoren la vigilancia y el control y se proporcionen suficientes recursos a los programas de TB. La misma situación podría estar ocurriendo en otros PEO.

Background

In 1993, tuberculosis (TB) was declared a worldwide public health threat of international concern by the World Health Organization (WHO) due to its high morbidity and mortality rate.^1,2 This is despite being a preventable and curable disease. In fact, until the COVID-19 pandemic, TB had been the leading cause of death from a single infectious agent, responsible for twice as many deaths as HIV/AIDS. More than 10 million people still fall ill with TB each year.³ With the progressive reduction in COVID-19-related mortality, TB has re-emerged as the leading cause of death from infection worldwide, causing approximately 1.3 million deaths annually.

This high morbidity and mortality in many contexts, is the result of the low effectiveness of TB prevention and control programmes (PPCTBs).⁴ In response to this situation, the WHO launched the End TB Strategy in 2015,⁵ aiming to reduce TB incidence by 50% between 2015 and 2025, by 80% by 2030, and by 90% by 2035, while also aiming to reduce TB mortality by 95% between 2015 and 2035.⁶

In Spain, the PMIT study (Multicentric Project of TB Investigation), conducted between 1995 and 1996, detected significant underreporting of TB cases.^7,8 In the years that followed, TB remains an underreported disease. In 2007 and 2019, two Plans for the Prevention and Control of TB were published, with the main objective of controlling TB transmission through universal access to prevention, diagnosis, and treatment.^9,10 However, first the 2009 H1N1 pandemic flu and after the COVID-19 pandemic diverted the focus of many healthcare professionals and services away from TB.^11–13

As a result of these challenges, this study was designed with the following objectives: (a) to study the evolution of TB incidence in Spain (both nationally and by autonomous communities (CCAA)); (b) to evaluate the variation in incidence between the pre- and post-COVID periods; (c) to assess whether the objectives about TB incidence of the WHO's End TB Strategy are being met; and (d) to evaluate the status of the main control indicators required from the CCAA.

Methodology

Ethical clearance

The authors of this paper declare no conflicts of interest and all data was treated confidentially following the ethical principles of the Declaration of Helsinki and the European General Data Protection Regulation No. 2016/679. This study is part of the project on TB organisation in Spain, which was approved by the Ethics and Clinical Research Committee of the Municipal Institute of Health Assistance (No. 2013/5389/I).

Data source

Crude incidence of TB cases per 100,000 inhabitants in Spain between the years 2015 and 2022, both included, was gathered from the National Network for Epidemiological Surveillance (RENAVE)¹⁴ stratified across the 17 CCAA and the autonomous cities of Ceuta and Melilla.

A survey was also prepared with the main control indicators based on the key objectives to be met according to national and international recommendations, and it was sent to the heads of the PPCTBs in the 17 CCAA and the autonomous cities of Melilla and Ceuta, to be completed with data pertaining to 2022. These variables are listed in the Table 3a and 3b.

To compare the results obtained from our study with the evolution of TB incidence in other Western European countries (WEC), the data published in 2024 by the European Centre for Disease Prevention and Control (ECDC) were reviewed.

Statistical analysis

Complementing the descriptive analysis of the crude incidence of TB cases per 100,000 inhabitants in Spain a linear regression was added to the plot creating a line using two points: the incidence at year 2015 and the threshold value expected in 2025 to meet the end TB goals.

To measure the impact of the COVID-19 pandemic period (2020–2022) on TB incidence and evaluate its expected evolution, in order to determine the likelihood of achieving the WHO incidence targets for 2025 in Spain and its CCAA, an exponential curve was fitted to the crude incidence prior to the pandemic period [2015–2019] as the dependent variable and used time as the independent variable, and projected with the model up to 2025, using a 90% confidence interval (to gain greater accuracy given the small sample size) confidence intervals were calculated based on the standard errors of the predicted values derived from the covariance matrix, which accounts for the variability in the estimated coefficients. R² was used as the measure of the quality of the regression. The same methodology was applied to the other Western European countries (WEC) with the highest TB incidence (Portugal, Italy and Belgium) and to the WEC with the largest population (Germany and France).

Following the projection, the probability of achieving the end TB 2025 incidence reduction goal, was calculated using the prediction intervals (PI) of the exponential model. After checking for the model linearity, normality of residuals, homoscedasticity, and independence of the residuals, the PI was used as a normal distribution, if the area under the curve contained the expected value, the probability was measured as the area under the curve between the expected value and its furthest PI limit, if the expected value fell below the lower PI limit the probability was considered 0%, and if the expected value fell above the upper PI limit the probability was considered 100%.

The first descriptive representations and tables were done with Excel version 16.77.1. All statistical analysis was done using R and R studio, version 4.3.1 Beagle Scouts.

Results

The overall incidence in Spain showed a decrease between 2015 and 2019, but this decrease was greater during the first year of the COVID-19 pandemic (Fig. 1). All CCAA, except Ceuta, Navarra, and the Basque Country, experienced a significant decrease or remained at around the same incidence level (Table 1). When the percentage variation in incidence rates between the pre and post/COVID-19 periods was calculated, it was observed that only Navarra, the Basque Country, and the city of Ceuta saw an increase in incidence, while the country's overall rate decreased by 13.5% (Table 2).

Fig. 1.

On the primary and axis, the evolution of the crude incidence rates per 100,000 inhabitants of tuberculosis in Spain (2015–2022) and estimated linear trend towards achieving the target of reduction of incidence of the WHO End TB Strategy. On the secondary axis, the inter-year.

Table 1.

Incidence rates of the 17 autonomous communities published by the National Network of Epidemiological Surveillance (RENAVE) (2015–2022).

CCAA	2015	2016	2017	2018	2019	2020	2021	2022
Andalucía	7.85	7.59	6.59	7.19	6.32	6.44	5.53	5.48
Aragón	10.9	12.9	10.2	8.71	9.9	5.9	7.9	8.1
Asturias	10.73	12.25	8.35	10.15	9.71	12.01	7.73	5.56
Baleares	9.91	8.40	8.96	10.77	8.43	6.83	5.82	5.8
Canarias	7.52	5.32	5.13	7.04	6.30	4.50	3.25	5.37
Cantabria	9.43	11.18	9.98	13.08	8.42	7.73	6.00	6.32
C. Mancha	6.52	8.22	6.83	NC	6.08	4.11	3.42	5.17
C. León	10.06	10.11	8.62	NC	8.45	6.40	6.46	5.64
Cataluña	14.06	12.82	12.93	12.93	13.3	10.84	12.11	12.61
C. Valenciana	8.56	8.87	8.60	6.59	8.34	7.25	7.34	5.6
Extremadura	5.61	6.29	5.13	6.65	4.99	1.98	3.98	2.65
Galicia	21.58	20.79	19.60	19.60	18.75	14.56	13.08	11.7
Madrid	10.61	10.44	9.30	NC	8.74	6.54	6.96	7.43
Murcia	9.49	7.49	8.01	NC	8.70	7.82	7.52	8.28
Navarra	7.70	6.58	4.05	5.26	3.98	4.87	4.42	6.08
País Vasco	11.84	12.70	10.47	9.99	9.07	10.64	8.54	10.61
La Rioja	8.63	11.51	9.28	NC	9.22	6.96	8.55	6.01
Ceuta*	16.57	23.61	10.59	NC	15.40	1.19	20.53	28.87
Melilla*	20.08	17.71	9.43	NC	9.49	7.12	7.19	7.2
Global	10.59	10.38	9.43	9.39	9.33	7.77	7.61	8.07

*

Autonomous cities.

Table 2.

Incidence rate variation between the pre- and post-COVID periods (2019–2022).

CCAA	2019	2022	Variation pre–post COVID (%)
Andalucía	6.32	5.48	↓13.3
Aragón	9.9	8.1	↓18.2
Asturias	9.71	5.56	↓42.7
Baleares	8.43	5.8	↓31.2
Canarias	6.30	5.37	↓14.8
Cantabria	8.42	6.32	↓24.9
C. Mancha	6.08	5.17	↓14.9
C. León	8.45	5.64	↓33.3
Cataluña	13.3	12.61	↓5.2
C. Valenciana	8.34	5.6	↓32.9
Extremadura	4.99	2.65	↓46.9
Galicia	18.75	11.7	↓37.6
Madrid	8.74	7.43	↓14.9
Murcia	8.70	8.28	↓4.8
Navarra	3.98	6.08	↑52.8
País Vasco	9.07	10.61	↑16.9
La Rioja	9.22	6.01	↓34.8
Ceuta*	15.40	28.87	↑87.5
Melilla*	9.49	7.2	↓24.1
Global	9.33	8.07	↓13.5

*

Autonomous cities.

After fitting the exponential curve to each CCAA it was observed that Navarra and the Basque Country were the only regions that showed a significant increase in incidence. CCAA such as Galicia showed a drastic decrease, falling below the lower limit of the confidence interval (Fig. 2b). The probability of reaching the WHO-2025 incidence target, based on the overall trend from pre-pandemic years, was 0% with 90% certainty and an R² of 0.84 in the fitted exponential curve (Fig. 2a). The probabilities for the three most populous CCAA – Andalusia, Catalonia, and Madrid – were 15.9%, 0%, and 13.7%, respectively, while the highest probabilities were found in Navarra, the Basque Country, and Castilla-León, with 79.1%, 43.4%, and 19.7%, respectively (Fig. 2b). When applying the exponential curve to the WEC referred to in the study, it was observed that the probability of reaching the WHO-2025 incidence target, based on the general trend of the years prior to the pandemic, was also 0% (Fig. 3).

Fig. 2.

(a) Exponential curve adjusted to the evolution pre-COVID (2015–2019) and its projection until year 2025 together with its 90% confidence interval in Spain. Red colour dots represent the pre-COVID period and blue dots the COVID period. The intersection between the yellow lines and between the red dashed lines represent for 2020 and 2025 respectively the WHO incidence reduction targets. The reported value of probability (P) is the estimated according to the prediction intervals to reach the WHO-2025 incidence target. (b) Exponential curve adjusted to the evolution pre-COVID (2015–2019) and its projection until year 2025 together with its 90% confidence interval in six autonomous regions that represent the different patterns observed, from increase of incidence above projected values to incidence reduction below projected values. Red colour dots represent the pre-COVID period and blue dots the COVID period. The intersection between the yellow lines and between the red dashed lines represent for 2020 and 2025 respectively the WHO incidence reduction targets for each autonomous region. The reported value of probability (P) is the estimated according to the prediction intervals to reach the WHO-2025 incidence target, estimated P for each autonomous region is reported either in the plot or below as a footnote. Probability of reaching the WHO-2025 incidence target (P): Andalusia = 15.9%; Aragón = 11.4%; Asturias = 15.9%; Balearic Islands = 5.9%; Canary Islands = 11.5%; Cantabria = 6.0%; Castilla-La Mancha = 11.4%; Castilla y León = 19.7%; Catalonia = 0%; Valencian Community = 13.5%; Extremadura = 7.3%; Galicia = 0%; Madrid = 13.7%; Murcia = 9.9%; Navarre = 79.1%; Basque Country = 43.4%; La Rioja = 5.8%.

Fig. 3.

Exponential curve adjusted to the evolution pre-COVID (2015–2019) and its projection until year 2025 together with its 90% confidence interval in some Western European countries. Red colour dots represent the pre-COVID period and blue dots the COVID period. The intersection between the yellow lines and between the red dashed lines represent for 2020 and 2025 respectively the WHO incidence reduction targets for each autonomous region. The reported value of probability (P) is the estimated according to the prediction intervals to reach the WHO-2025 incidence target.

The analysis of the impact of COVID-19 on each autonomous community revealed that Galicia was the most affected, with the greatest reduction in incidence, followed by Cantabria, Extremadura, Aragón, and the Balearic Islands, which experienced a smaller reduction. Castile and León, Castile-La Mancha, La Rioja, and the Canary Islands had even lower reductions, while Catalonia, the Valencian Community, Murcia, Andalusia, and Asturias saw a negligible reduction. In contrast, Navarre and the Basque Country had a slight increase in incidence.

The results of the main control indicators for 2022, according to the surveys completed by the PPCTBs, are shown in Table 3a and b. Notably, 94.7% of the programmes carry out active case finding; 100% have sensitivity results (78.9% have recorded cases of drug-resistant TB, with 73.3% of these being RR-MDR or XDR); 89.5% have information on treatment outcomes (with abandonment rates between 1.6% and 6.9%, and mortality rates between 1% and 10.9%). Additionally, 57.9% have TB clinical units, 78.9% offer directly observed treatment (DOT), and only 21.1% have community health workers (CHWs). The median reported diagnostic delay was 44 days (IQR: 26–75); contacts were reviewed in 89.5% of cases (100% of contacts of patients with pulmonary TB and 70.6% of contacts within 5 years); 89.5% of the programmes detect outbreaks; and 57.9% of them perform screening for latent tuberculosis infection (LTBI).

Table 3.

Evaluation of Tuberculosis Prevention and Control Programmes of Autonomous regions in Spain and the autonomous cities of Ceuta and Melilla (2022).

(a)	Andalusia	Aragon	Asturias	Balearic Islands	Canary Islands	Cantabria	Castile la Mancha	Castile and León	Catalonia
Personnel									^#
Doctor	1	1	2	3	2	2	8	10	1
Nurse	0	1	0	3	2	3	6	9	1
Administrative	0	0	0	0	0	0	0	0	1
Others	0	0	0	0	0	0	0	0	2^$
Number of cases
Total	550	99	58	82	149	39	117	146	1.017
Pulmonary	412	64	50	56	120	30	84	104	732
No. of foreigners	237	8	2	58	29	9	57	35	590
No. of HIV	27	7	0	0	2	0	0	1	32
No. meningitis (<5 y/o)	0	0	0	0	0	0	0	0	0
Incidence rate
Global	5.48	8.1	5.56	5.8*	5.37	6.32	5.17	5.64	12.61
Smear positive	3.03	NA	2.4	NA	3.10	2.6	4.10	2.9	3.28
Register availability
Cases	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Contacts	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Link cases/contacts	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes
Outbreaks	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
LTI screenings	No	Yes	Yes	No	No	Yes	No	No	Yes^Ç
Register mode
EDO	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Active search	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Active search source
Microbiology	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Hospital discharge	Yes	No	Yes	Yes	Yes	Yes	Yes	No	Yes
AIDS registry	Yes	No	No	Yes	Yes	Yes	Yes	No	No
Mortality registry	No	Ye	Yes	Yes	No	Yes	No	No	Yes
Others	No	No	No	AP^&	No	No	Yes	No	No
Sensitivity study	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Resistances
No. of resistant cases	40	0	3	4	3	1	6	0	89
No. RR-MDR-preXDR-XDR	4	1	2	1	1	0	2	0	15
% of primary resistances	NA	NA	100	75	1	1	0	0	0
% of acquired resistances	NA	NA	0	25	NA	NA	NA	NA	NA
Treatment result	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
% of dropouts	3.2	3	6.89	4.4	3.35	0	6.8	NA	2.4
% of mortality	7.6	1	8.62	4.4	4.69	5.1	6.8	NA	NA
DOT treatment	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes
No. DOT	NA	NA	1	4	29	0			236
% of DOT from all cases	NA	NA	0.02	4.9	19.5	0			24.2
ACS	No	No	No	No	No	No	No	No	Yes
Clinical units of TB	Yes	No	Yes	Yes	No	Yes	No	Yes	Yes^Ç
Diagnostic delay	No	NA	No	Yes	Yes	Yes	Yes	Yes	Yes
Average of days				36	43	26	51	34	59
Contacts reviewed
% of pulmonary TB	85.5	81.25	39.65	95.7	84.7	100	71.4	51	70.8
% on extrapulmonary TB	50.7	NA	6.89	NA	23.3	44.4	NA	19	30.9
% on <5 y/o	100	100	100	100	NA	100	NA	100	NA
Outbreaks directionality	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
No. of localized outbreaks	18	NA	NA	4	10	0	3	3	56
Screening of LTI	Yes	NA	Yes	No	No	No	No	NA	Yes
Public health	Yes	NA	NA					NA	Yes
TB units	No	NA	NA					NA	Yes
Primary healthcare	Yes	NA	NA					NA	Yes
Drug attention center	Yes	NA	NA					NA	Yes
NGOs	No	NA	NA					NA	Yes
Other	No	NA	NA					NA	NA
Report publication date^@	2021	2021	2019	2022	2018	No	2019	2018	2021

(b)	C. Valenciana	Extremadura	Galicia	Madrid	Murcia	Navarra	P. Vasco**	Rioja	Ceuta	Melilla
Personnel
Doctor	1	2	2	1	1	1	0	0	1	1
Nurse	1	1	0	0	1	1	6	1	1	1
Administrative	0	0	0	0	1	1	0	0	1	0
Others	0	0	1	0	1	0	0	0	0	0
Number of cases
Total	292	28	310	502	134	45	183	19	20	9
Pulmonary	226	16	191	NA	101	35	118	14	15	7
No. of foreigners	114	5	40	NA	72	34	62	9	4	3
No. of HIV	14	1	0	NA	3	2	7	1	0	0
No. meningitis (<5 y/o)	0	0	0	25	0	0	0	0	0	0
Incidence rate
Global	5.64	2.65	11.5	7.43	8.28	6.08	10.61	6.01	28.87	7.2
Smear positive	2.10	1.13	2.7	1.70	2.3	2.73	2.3	3.2	NA	3.52
Register availability
Cases	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Contacts	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes	Yes
Link cases/contacts	Yes	Yes	Yes	No	Yes	No	Yes	No	Yes	No
Outbreaks	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
LTI screenings	No	No	Yes	No	Yes	Yes	Yes	No	Yes	Yes
Register mode
EDO	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Active search	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes
Active search source
Microbiology	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes
Hospital discharge	No	No	Yes	Yes	No	Yes	Yes	Yes	NA	Yes
AIDS registry	No	No	Yes	Yes	No	Yes	No	No	NA	Yes
Mortality registry	No	No	Yes	Yes	No	Yes	Yes	Yes	NA	No
Others	Yes	No	Yes	Yes	No	Yes	Yes	No	NA	No
Sensitivity study	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Resistances
No. of resistant cases	30	0	26	NA	7	3	12	2	NA	2
No. RR-MDR-preXDR-XDR	3	0	0	NA	2	1	2	0	NA	0
% of primary resistances	12.8	0	92.3	NA	100	6.7	NA	NA	NA	100
% of acquired resistances	15.4	NA	7.7	NA	0	NA	NA	NA	NA	0
Treatment result	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	No	Yes
% of dropouts	5.9	3.25	4.2	NA		2.2	1.6	NA		NA
% of mortality	2.29	0	1.4	NA		3.7	10.9	NA		NA
DOT treatment	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
No. DOT	25		136	NA	6	2	NA	NA		0
% of DOT from all cases	6.4		44.6	NA	4.5	4.4	NA	NA		NA
ACS	No	No	Yes	No	No	Yes	No	No	No	No
Clinical units of TB	No	Yes	Yes	Yes	No	Yes	Yes	No	No	Yes
Diagnostic delay	Yes	No	Yes	Yes	Yes	Yes	Yes	No	No	Yes
Average of days	60		56	NA	33	45.5	37			75
Contacts reviewed	Yes	Yes	Yes	NA	Yes	Yes	NA	Yes	Yes	Yes
% of pulmonary TB	70.7	60	77.5	NA	94.2	100	NA	100	69.23	100
% on extrapulmonary TB	26.9	0	19.3	NA	9.3	100	NA	100	33.3	100
% on <5 y/o	33.3	0	100	NA	NA	100	NA	NA	11.11	NA
Outbreaks directionality	Yes	Yes	Yes	NA	Yes	Yes	NA	Yes	Yes	Yes
No. of localized outbreaks	18	0	11	NA	4	3	NA	NA	1	0
Screening of LTI	No	Yes	Yes	NA	Yes	Yes	Yes	Yes	Yes	Yes
Public health		No	No	NA	NA	No	No	No	No	Yes
TB units		No	Yes	NA	NA	No	Yes	No	No	No
Primary healthcare		Yes	No	NA	NA	Yes	No	Yes	No	Yes
Drug attention center		Yes	No	NA	NA	Yes	No	No	No	No
NGOs		No	No	NA	NA	Yes	No	No	No	No
Other		No	No	NA	NA	No	No	No	CETI	CETI
Report publication date^@	2022	No	2021	2021	2022	2022	2021	2020	No	No

ACS: Community Health Officers; CETI: Temporary Residence Centre for Immigrants.

#

It does not include staff working in the Territorial Epidemiological Surveillance Services or the Barcelona Public Health Agency.

$

Pharmaceutical.

Ç

Not routinely or homogeneously throughout the territory of Catalonia.

&

Primary Care: Electronic Clinical History.

@

Last year of publication of the annual report by the Tuberculosis Prevention and Control Program of each Autonomous Community.

*

In indigenous people.

**

Results year 2021.

Discussion

The incidence of TB in Spain during the period 2015–2022 decreased by 23.8%, possibly influenced by underreporting in the early years of the COVID-19 pandemic observed around the world.¹² The increase in Europe in 2022 is likely due to a good recovery after the COVID-19 pandemic in access to and provision of TB services in many countries and the introduction of active TB case-finding activities.¹⁵

Nevertheless, this decline, along with the increase observed in 2022, will not be sufficient to meet the End TB Strategy target of incidence reduction by 2025 in Spain and probably in most European countries. According to ECDC data¹⁶ Spain had between 2018 and 2022 a mean change in incidence rate of −6.5% while others WEC with the highest incidences experimented lower declines (Portugal −6.0%, Belgium −3.8% or France −5.7%), and worse was the situation in most of the WEC, with lowers declines than Spain. Interestingly, in Spain, Navarre and the Basque Country, the only CCAA that showed an increase in incidence during 2020–2022, are the ones most likely to achieve the 2025 targets.

Regarding the global targets set in 2023 at the second high-level meeting of the United Nations on TB,³ Spain meets the targets for treatment coverage (89.5% vs the target of 90%), drug susceptibility testing for anti-tuberculosis drugs (100%), and healthcare coverage (100%). However, the target for latent TB infection treatment coverage (>90%) is not met, with only 57.9%. This is despite the recommendations of the WHO European Region 2023–2030,¹⁶ which advises screening high-risk groups such as migrants, refugees from TB hyperendemic areas, prisoners, healthcare workers, homeless people, and drug users.

All the indicators assessed in the completed surveys, based on a study conducted in 1997 to evaluate the situation of the PPCTBs in the different CCAA,¹⁷ have improved in 25 years compared to that study, although not all have reached the recommended targets.

The End TB Strategy, proposed by the WHO in 2015, aims by 2025 – among other objectives – to reduce TB deaths by 75%, reduce the incidence rate by 50%, and ensure that the percentage of families facing catastrophic costs due to TB is 0%.⁵ The pillars on which this strategy must be based are: integrated patient-centred TB care and prevention, bold policies and supportive systems, and intensified research and innovation.⁶ Its elimination requires the planning of activities that can contribute to reducing incidence through public health and programmatic care.¹⁸ However, the non prioritization of End TB Strategy in Spain complicates the achievement of these objectives, and this probably occurs the same in other countries as well.¹⁹

The drop in the number of people diagnosed with TB in 2020 suggested an increase in mortality (7000 excess deaths from TB in the WHO European Region), a decrease in the rate of successful treatment and an increase the burden of RR-TB and TB/HIV in 2021 and 2022.¹⁶

TB, within the mandatory declaration diseases, is one of the most demanding in terms of the effort needed for surveillance; a surveillance that should be proactive in case and contact tracing, and in the implementation of prevention and control measures. A good PPCTB is essential for controlling TB, and these programmes must be based on coordination between clinicians, microbiologists, epidemiologists, and others, as well as the link between surveillance, control, and research.^20,21 This would help improve the completeness and quality of epidemiological survey data and TB control^22–24 without forgetting the need to address social determinants^25,26 and conduct ongoing evaluations.²⁷

A limitation of this study is that some of the data analysed has not yet been consolidated, as it is obtained from various sources (RENAVE, SIVIES, or the CCAA).¹² Some upward fluctuations could be due to occasional improvements in surveillance in certain CCAA or influenced by diagnostic delays caused by COVID-19. After the COVID-19 pandemic crisis, it is necessary for the CCAA to reach a consensus on the information collected about reported cases, in order to achieve uniformity of this data, improve the quality of the data collected in the national database, and have reliable information on the TB situation in Spain.²⁸

To achieve the End TB Strategy targets for 2030 and 2035 in Spain and probably in most affected WEC, surveillance, prevention, and control measures for TB need to be improved, especially, define objectives that are deemed appropriate, incorporate the definition of the indicators and their calculation in order to obtain quality and comparable information and design a system for monitoring and evaluating indicators and designate individuals responsible for collecting information, analyzing data, and making decisions.²⁸ It is essential to prioritize the TB control with sufficient and experienced personnel.

CRediT authorship contribution statement

TR: conception and design of the study; acquisition, analysis and interpretation of data, and writing of the article, final approval of the version presented.

JPM, EMT, JAC: conception and design of the study, critical review of the intellectual content, final approval of the version presented.

MB: methodology design, statistical analysis of data, and translation, final approval of the version presented.

Tuberculosis Prevention and Control Programmes of the Autonomous Communities Working Group: completion of the survey with the main monitoring indicators evaluated.

Ethical approval

The Biomedical Research Ethics Committees of the different participating centres approved this study.

Funding

The present study has not received funding from any institution.

Conflicts of interest

The authors declare no conflicts of interest.