Introduction
The World Health Organization (WHO) Regional Office for Europe and the European Centre for Disease Prevention and Control (ECDC) have published a joint report — “Tuberculosis Surveillance and Monitoring in Europe,” which is based on 2024 data.
According to the document, the WHO European Region, which encompasses 53 countries — including 30 member states of the European Union and the European Economic Area — continues to fall short of reaching the regional and global targets set for tuberculosis elimination.
The report focuses on two primary strategic challenges. The first relates to low diagnostic rates and underreporting of cases, as a result of which one in five cases in the region remains undiagnosed. The second critical aspect is the alarmingly high level of drug-resistant tuberculosis incidence (monoresistant, polyresistant, rifampicin-resistant, multidrug-resistant, and extensively drug-resistant), which significantly exceeds the corresponding indicators of other WHO regions.
Epidemiological Burden of Tuberculosis
According to 2024 data, the estimated number of tuberculosis cases in the WHO European Region stood at 204,000, which equates to an average of 22 cases per 100,000 population. Although this figure represents only 1.9% of the global epidemiological burden of tuberculosis, the region is still characterized by a high prevalence of resistant strains.
According to epidemiological analysis, tuberculosis incidence in the region decreased by 39% between 2015 and 2024. However, this figure falls short of the target indicator of the WHO “End TB Strategy,” which envisioned a 50% reduction in incidence by 2025.
Geographical Inequality and High-Priority Countries
The distribution of tuberculosis cases in the European Region reveals stark geographical inequality. According to existing data, approximately 81% of the regional epidemiological burden is concentrated in 18 high-priority countries (HPCs). This group includes: Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the Republic of Moldova, Romania, the Russian Federation, Tajikistan, Turkey, Turkmenistan, Ukraine, and Uzbekistan.
In these countries, the average tuberculosis incidence rate reaches approximately 40 cases per 100,000 population, which substantially exceeds the corresponding data of the countries of the European Union and the European Economic Area (EU/EEA). In the EU/EEA zone, a stable low-incidence profile is maintained — averaging 9 cases per 100,000 population.
Hotspots of Incidence
A detailed country-by-country analysis reveals the primary hotspots that determine the epidemiological burden of tuberculosis in the European Region. In 2024, the number of tuberculosis cases exceeded 10,000 in five countries. The highest figure was recorded in the Russian Federation — 49,000 cases. It is followed by Ukraine with 33,000 cases, Uzbekistan with 18,000 cases, while approximately 11,000 cases each were registered in Turkey and Romania.
However, assessing the epidemiological burden solely based on absolute numbers does not fully reflect the actual spread of the disease. Incidence rates calculated per population size show a different picture. The highest incidence was recorded in Kyrgyzstan — 118 cases per 100,000 population. Next come Ukraine, Tajikistan, Azerbaijan, and Moldova, while in Romania the rate stood at 60 cases per 100,000 population.
This disproportion demonstrates that the epidemiological burden of tuberculosis in the European Region is unevenly distributed. The disease continues to be characterized by high incidence in specific countries of Eastern Europe and Central Asia, where the high rate points to ongoing active transmission and systemic public health challenges.
Dynamics of Incidence
The multi-year dynamics of the decline in disease incidence provide important information regarding the effectiveness of regional public health interventions. Between 2015 and 2024, the average annual rate of reduction in tuberculosis cases in the European Region was 5.3%. However, this trend was significantly influenced by a sharp decline in baseline data in the Russian Federation, where incidence decreased by an annual average of 7.3%.
Notably, a high rate of decline in tuberculosis prevalence was recorded in several high-priority countries. In this ten-year period, the highest average annual rate of decline in incidence was recorded in Armenia (12.5%), Belarus (12.1%), and Bulgaria (10.6%). Estonia and Georgia (9.9%–9.9%), as well as Latvia (9.8%) and Lithuania (9.1%), were distinguished by similar positive dynamics.
These dynamics confirm that a sustainable public health infrastructure, a strong diagnostic base, and effective treatment monitoring systems play a decisive role in improving the epidemiological picture of the disease.
Dynamics of Mortality Decline
The dynamics of mortality in the region reflect both positive trends and systemic healthcare challenges. In 2024, the estimated number of tuberculosis-induced deaths among HIV-negative individuals in the European Region stood at 15,000, which corresponds to an average of 1.6 cases per 100,000 population. When summarizing the data of HIV-negative and HIV-positive patients, cumulative regional mortality decreased by 49% between 2015 and 2024, as a result of which the number of annual fatal cases was reduced from 37,000 to 19,000. Despite this, the region still failed to achieve the goal of the “End TB” strategy, which envisioned a 75% reduction in mortality by 2025.
The presented data is sharply asymmetric in terms of regional distribution, as 87% of lethal cases caused by tuberculosis occur precisely in the 18 high-priority countries (HPCs). While the mortality rate in the countries of the European Union and the European Economic Area (EU/EEA) is stably low and constitutes less than 1 case per 100,000 population, the average data for the HPC group equates to 4 cases per 100,000 population. In this group, the highest mortality was recorded in Turkmenistan (10 cases per 100,000 population), followed by Tajikistan and Ukraine.
Notification Systems and Post-Pandemic Effects
Tuberculosis case notification rates reveal significant gaps from a regional epidemiological surveillance perspective. In 2024, the centralized monitoring network was notified about a total of 184,191 patients suffering from tuberculosis across 51 countries of the region, of whom 161,569 were classified as new cases. This figure is 7% lower compared to 2023 data.
The interpretation of this declining trend must be done with caution, since it was preceded by a three-year period of post-pandemic notification stabilization. For its part, the systemic healthcare disruptions caused by the COVID-19 pandemic in 2019–2020 led to an unprecedented, 24% drop in tuberculosis registration.
Consequently, the treatment coverage rate in the region decreased to 79% in 2024, which is a noticeable decline compared to the 85% recorded in 2019. This imbalance indicates that approximately one-fifth of active tuberculosis cases remain unregistered, which facilitates hidden transmission of the disease within the population.
Regional Imbalance and Case Detection Dynamics
The sharp asymmetry of data existing between countries demonstrates that national health systems are managing to detect undiagnosed cases accumulated during the pandemic period at varying paces. Following the sharp recession of 2020, a continuous, four-year increase in tuberculosis notifications is observed in a certain group of countries — specifically, Croatia, the Czech Republic, Italy, the Netherlands, Tajikistan, and the United Kingdom. Rather than an actual increase in bacterial transmission, this trend is likely linked to improvements in epidemiological surveillance, detection of hidden cases, and strengthening of cross-border control.
According to the general registration rate, Moldova registered the highest coefficient of new and relapse cases (63.6 cases per 100,000 population), followed by Kyrgyzstan (55.5). Conversely, thirty countries — predominantly in Western and Central Europe — maintained a stable level of epidemiological control; in this zone, the case notification rate constitutes less than 10 units per 100,000 population. Israel and Iceland are distinguished by minimal rates (only 2.1 cases per 100,000 population).
Prior Treatment History and Repeated Cases
Almost one-third of new and relapse cases in the region (49,283 patients) occur in the Russian Federation alone. This figure is particularly noteworthy given that the population of this country represents only 15% of the WHO European Region.
Furthermore, patient history reveals systemic challenges regarding treatment effectiveness and epidemiological surveillance. In 2024, the proportion of patients who had already undergone treatment in the past stood at 13.8% in European Union and European Economic Area (EU/EEA) countries, whereas in non-EU countries this figure reached 27.7%. In the 18 high-priority countries (HPCs), the average rate reached 30.0%, which significantly exceeds the pan-European data (24.8%). The proportion of individuals treated in the past within the HPC group is particularly high in Azerbaijan (48.9%), the Russian Federation (37.5%), Turkmenistan (36.6%), Moldova (27.6%), Kazakhstan (26.1%), and Ukraine (24.2%).
Such a high proportion of repeated treatment directly points to treatment failure, low patient adherence (violation of the treatment regimen), diagnostic deficiencies, and a high risk of reinfection.
Epidemiological Profile of Clinical Forms
The pulmonary form of tuberculosis continues to dominate on the continent and accounts for 83% of cases. Moreover, pulmonary forms are recorded slightly more frequently in non-EU countries than in the countries of the European Union and the European Economic Area (EU/EEA).
The remaining 17%, which comes from extrapulmonary forms, represents a specific diagnostic and therapeutic challenge due to the small number of bacteria in specimens (paucibacillarity) and atypical clinical signs. In eleven countries, more than 30% of confirmed cases were characterized precisely by extrapulmonary forms — among them were Denmark, Finland, Ireland, Italy, Luxembourg, the Netherlands, Norway, Sweden, Turkey, the United Kingdom, and Uzbekistan.
This phenomenon is often linked to the demographic profile of patients in countries with low tuberculosis incidence. In such regions, the disease is tightly concentrated within the elderly native population or young migrants arriving from countries with high endemicity.
Laboratory and Diagnostic Gaps
Out of 134,040 registered new and relapse cases of pulmonary tuberculosis in the region, 72.4% (96,985 cases) were bacteriologically confirmed. Despite this, six countries failed to cross the 70% threshold for bacteriological confirmation of pulmonary forms. Specifically, the Russian Federation confirmed only 56.7% of its cohort, followed by Tajikistan (62.1%), Slovakia (63.7%), Bulgaria (65.4%), France (68.7%), and Israel (69.4%).
Low confirmation rates increase diagnostic risks, as clinicians are frequently forced to rely solely on presumptive radiological or clinical criteria. This, in turn, increases the likelihood of both overtreatment (hyperdiagnosis) of non-tuberculosis pathologies and improper management of resistant forms.
Challenges in Implementing Molecular Diagnostics
The use of WHO-recommended rapid diagnostic tests (e.g., Xpert MTB/RIF) continues to play an important role in the early detection of cases. Despite an uneven geographical distribution, the regional trend shows a stable increase in the use of these tests — rising from 72.4% recorded in 2020 to 79.7% in 2024.
Contrary to expectations, the rate of rapid molecular testing is noticeably lower in the countries of the European Union and the European Economic Area (EU/EEA) (53.2%) than in non-EU states (89.6%). This paradox is explained by the fact that developed countries of Western Europe, due to the relatively low incidence of the disease, continue to rely on traditional, centralized methods — sputum smear microscopy and culture studies. On the other hand, the high-priority countries (HPCs) of Eastern Europe are rapidly implementing decentralized molecular testing in response to the high burden of resistance.
National implementation rates of tests differ sharply among countries: while in France, Andorra, Lithuania, and Malta this rate equals 0%, universal, 100% coverage of rapid testing has been achieved in Azerbaijan and Montenegro.
Multidrug-Resistant Tuberculosis (MDR-TB) Crisis
One of the most critical clinical challenges of tuberculosis control in the European Region is represented by the high scale of prevalence of rifampicin-resistant and multidrug-resistant forms (RR/MDR-TB). Out of those 30 countries globally identified by the WHO where the highest prevalence rates of RR/MDR-TB are fixed, nine are located directly within the European Region; these are: Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Ukraine, and Uzbekistan.
In 2024, approximately 55,000 new (incident) cases of RR/MDR-TB were recorded in the region. Among newly notified, bacteriologically confirmed pulmonary form patients alone, resistance to rifampicin was confirmed in up to 29,000 cases.
The proportion of drug resistance in Europe sharply exceeds global averages. Specifically, approximately 23% of newly diagnosed patients and 51% of individuals with a history of treatment in the region exhibited RR/MDR-TB strains, whereas on a worldwide scale, these figures constitute only 3.2% and 16%, respectively.
Secondary Crisis: Prevalence of pre-XDR and XDR Tuberculosis
In the region, 92% of bacteriologically confirmed pulmonary form patients underwent screening for rifampicin-resistance. In the tested population, the prevalence of RR/MDR-TB strains constituted 28%. According to history, the resistance rate differs significantly: it constitutes 21% in the group of new cases and 48% in cohorts with a history of treatment, which points to a significant proportion of both primary and acquired resistance.
This epidemiological picture indicates an active transmission process and creates a high risk for the development of pre-XDR-TB and XDR-TB forms. Taking this risk into account, in 2024, fluoroquinolone susceptibility testing was performed for 87% of notified pulmonary RR/MDR-TB cases.
Among patients tested for fluoroquinolones, the prevalence of pre-XDR-TB constituted 28%. Additionally, in the subgroup of patients where expanded testing was carried out on WHO Group A reserve drugs (including bedaquiline and linezolid), the prevalence of XDR-TB reached 15%. These results point to the limitation of therapeutic alternatives and a significant proportion of patients with high management complexity. This situation leaves clinicians facing limited and, at the same time, highly toxic therapeutic choices.
Tuberculosis and HIV (TB/HIV) Syndemic
The clinical management of tuberculosis is further complicated under conditions of coexistence with HIV infection, which turns TB/HIV coinfection into a high-priority syndemic problem in Eastern Europe. According to 2024 data, the estimated prevalence of HIV among incident cases of tuberculosis constituted 11% (approximately 23,000 coinfected patients). The stabilization of this indicator within the range of 11%–12% recently was preceded by an alarming historical escalation from 2007 to 2016, when the regional coinfection level increased from 4% to 12%.
The spread of the syndemic is concentrated within a quite narrow geographical area. Approximately 80% of all HIV-positive tuberculosis cases registered in the region occur in just two countries: the Russian Federation (52% of total cases, or 12,000 patients) and Ukraine (28%, or 6,400 patients). They are followed by Moldova, where the national coinfection rate constitutes 7.9%.
In 13,243 cases (84%), HIV-positive patients were receiving antiretroviral therapy (ART). Although ART coverage has been characterized by an increasing trend over the past five years, it still falls short of the WHO target indicator, which envisions universal coverage among TB/HIV coinfected patients.
Treatment Outcomes and Therapeutic Effectiveness
The main indicator of the effectiveness of any regional public health intervention is the treatment success rate. In this regard, the 2024 data reveals serious challenges — across all patient cohorts, outcomes fall sharply short of established therapeutic goals.
In the cohort of new, drug-susceptible tuberculosis cases, the regional treatment success rate constituted only 74%. This datum is particularly noteworthy considering that standard, non-resistant regimens for treatment with first-line drugs, under proper programmatic monitoring conditions, typically ensure a clinical effectiveness higher than 85%.
As the degree of resistance increases, the treatment outcome worsens further: for complex RR/MDR-TB cohorts, the success rate hovered within 66%, while in high-resistance pre-XDR/XDR-TB cohorts, the rate reached only 58%.
Impact of New Treatment Regimens and Long-Term Trends
Despite historically low indicators of treatment outcomes, the analysis of long-term trends shows a steady improvement within the drug-resistant population. This dynamic indicates that the implementation of new, shorter, and fully oral treatment regimens has already yielded the first positive clinical results in high-vulnerability groups.
The gradual replacement of old therapeutic regimens — which relied on long-term, second-line injectable drugs — noticeably reduced cases of arbitrary treatment discontinuation by patients. However, since the treatment cycle for patients with drug-resistant forms frequently lasts from 18 to 24 months, the full epidemiological impact of these innovative courses will become apparent only in the surveillance data of future years.
Comparative Analysis of Treatment Outcomes by Country
To better comprehend this clinical picture, it is important to review the data of cohorts registered in 2023, whose treatment outcomes were evaluated in 2024. Treatment success rates for new and relapse cases vary significantly by country. For example, Estonia showed the highest effectiveness (85.7%), in Bulgaria this rate constituted 76.7%, in Austria — 76.2%, and in the Czech Republic — 70.6%. Relatively low rates were recorded in Germany (67.4%), Hungary (63.2%), and Croatia (61.9%).
At the same time, the statistical picture of several countries is unrealistically low due to deficiencies in patient monitoring and a high proportion of “unevaluated” cases. Specifically, in France, the treatment success rate nominally constituted only 19.5%, because 76.8% of the active cohort remained unevaluated within the 12-month interval. A similar trend was revealed in Finland, where parallel to a 34.3% success rate, 63.3% of cases are unevaluated, while in Cyprus, therapy success constituted 39.7%, against the background of an undetermined status for 51.3% of the cohort. Such data gaps significantly complicate comparative epidemiological analysis between countries.
Mortality Rates and Clinical Interpretation
An in-depth analysis of patient mortality in tuberculosis cases registered in low-incidence countries reveals additional aspects of public health. Several countries with a low incidence of tuberculosis recorded relatively high proportional mortality rates in active registries, which is mostly driven by the advanced age of patients and the severity of comorbidities. For instance, according to Croatia’s data, 13.5% of the population suffering from tuberculosis died during the treatment period in 2023. It is followed by Estonia (13.0%), Bulgaria (12.4%), Hungary (12.4%), and the Czech Republic (10.0%), while in Austria and Germany, the mortality rate constituted 7.2% respectively.
In this context, tuberculosis frequently does not represent the primary cause of death; it more often appears as a contributing factor in elderly patients who are in long-term care facilities or have multiple chronic diseases (multimorbidity).
Patients Left Beyond Monitoring and Migratory Factors
The proportion of patients left beyond monitoring highlights local challenges regarding treatment continuity and accessibility to healthcare services. The data shows significant differences across countries: in the Czech Republic, the rate of monitoring discontinuation among patients suffering from tuberculosis constituted 14.4%. It is followed by Hungary (9.7%), Austria (9.2%), Belgium (8.2%), and Bulgaria (8.1%).
At the same time, a number of countries face unique demographic shifts. According to Cyprus’s data, 90.2% of the entire 2024 tuberculosis registry was accounted for by foreign-born individuals. Moreover, the average age of foreign-born patients constituted 34.7 years, which sharply differs from the indicator of the local population (62.3 years). A high proportion of foreign-born patients was also recorded in Germany (73.6%), Denmark (71.0%), Austria (66.6%), Belgium (62.4%), and France (59.1%).
Laboratory Infrastructure and Quality Control
When assessing the state of laboratory infrastructure in the region, significant inequality reveals itself in terms of quality assurance. Monitoring of national reference laboratories, through the External Quality Assessment (EQA) system, showed that only a few countries maintain high international standards of proficiency testing. During 2024, Belgium, Bulgaria, the Czech Republic, Estonia, Finland, and Hungary achieved 100% compliance in the process of drug susceptibility testing (DST) for both isoniazid and rifampicin.
In contrast, France, Italy, and Ireland failed to meet the established criteria or did not submit External Quality Assessment (EQA) data at all for the 2024 cycle. Such gaps noticeably reduce confidence in regional drug resistance data and point to critical problems in the process of standardizing European laboratory networks.
Georgia
In 2024, 1,467 cases of tuberculosis were registered in Georgia, of which 1,194 come from new and relapse forms, which corresponds to 38.5 cases per 100,000 population. The majority of cases (79.0%) represent pulmonary tuberculosis. The country is distinguished by a high quality of laboratory diagnostics: 94.2% of pulmonary tuberculosis is bacteriologically confirmed, while drug susceptibility testing (DST) coverage reaches 97.1%. Despite this, resistance remains a significant challenge — the proportion of RR/MDR-TB among confirmed cases constitutes 12.1%, while pre-extensively drug-resistant (pre-XDR) forms were detected in 31.3% of those checked for fluoroquinolones. In the case of TB/HIV coinfection, testing coverage reaches 98.9%, while coinfection is fixed in 2.9% and all patients are provided with antiretroviral therapy (ART).
According to treatment outcomes, the success rate in the drug-susceptible tuberculosis (DS-TB) cohort constitutes 85.3%, while in the RR/MDR-TB group it decreases to 74.2%. Mortality is 4.1% and 5.7%, respectively. The proportion of patients left beyond monitoring constitutes 5.7% in the DS-TB cohort and 10.7% in the RR/MDR-TB group. Demographically, the average age of patients suffering from tuberculosis in Georgia is 46.2 years.
Conclusion and Recommendations
Ultimately, epidemiological surveillance data shows that despite significant progress, the pace of reducing the disease burden in the WHO European Region remains insufficient to achieve the long-term strategic goals of tuberculosis elimination. The achieved results cannot ensure a sustainable decline in epidemiological indicators, which indicates the necessity of implementing additional, coordinated regional interventions.
Taking these trends into account, countries with a high incidence of tuberculosis must continue expanding the use of rapid molecular diagnostics (specifically, Xpert MTB/RIF and its alternative platforms), which will noticeably reduce diagnostic delay and under-detection of cases. In parallel, optimization of patient clinical follow-up systems must become a priority in low-incidence Western European countries, so that the proportion of unregistered and incompletely evaluated cases, which negatively affects the accuracy of the actual epidemiological picture, is minimized.
Furthermore, the control of resistant tuberculosis must remain one of the main priorities of regional policy. For this purpose, it is necessary to increase the availability of short, fully oral treatment regimens, as well as to ensure universal coverage with antiretroviral therapy (ART) among TB/HIV coinfected patients. Without targeted, strategic investments in these directions, the European Region will not be able to effectively manage and finally eliminate tuberculosis as a global public health challenge.
Source: ecdc.europa.eu
