INT J TUBERC LUNG DIS 18(2):134–140© 2014 The Unionhttp://dx.doi.org/10.5588/ijtld.13.0419

Epidemiology of tuberculosis in Galicia, Spain, 16 years after the launch of the Galician tuberculosis programme

E. Cruz-Ferro,* M. I. Ursúa-Díaz,* J. A. Taboada-Rodríguez,* X. Hervada-Vidal,* L. Anibarro,† V. Túñez;‡ The Galician Tuberculosis Prevention and Control Programme Working Group§

* Galician Tuberculosis Prevention and Control Programme, Dirección General de Innovación y Gestión de la Salud Pública, Xunta de Galicia, Santiago de Compostella, † Tuberculosis Unit, Department of Internal Medicine, Complexo Hospitalario de Pontevedra, Pontevedra, ‡ Tuberculosis Unit, Department of Preventive Medicine, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain

Correspondence to: Elena Cruz-Ferro and María Isabel Ursúa-Díaz, Edifi cio Administrativo de la Consellería de Sanidad, Rúa San Lázaro s/n 15703 Santiago de Compostela, A Coruña (Galicia), Spain. Tel: (+34) 981 540 206; (+34) 981 540 290. Fax: (+34) 981 542 971. e-mail: elena.cruz.ferro@sergas.es; Isabel.Ursua.Diaz@sergas.esArticle submitted 11 June 2013. Final version accepted 11 October 2013.

S E T T I N G : Galicia, Spain.

O B J E C T I V E : To describe changes in tuberculosis (TB)

epidemiology and characteristics in Galicia, Spain, dur-

ing the period 1996–2011.

D E S I G N : Retrospective observational descriptive study

of data obtained from the Tuberculosis Information Sys-

tem. The Galician Tuberculosis Prevention and Control

Programme, created in 1994, is based in seven tubercu-

losis units that actively collect data on case finding and

follow-up of all cases of TB in the region.

R E S U LT S : TB incidence fell from 72.9 cases per 100 000

population in 1996 to 24.6 in 2011 (respectively 40.5

and 14.2 in patients aged <15 years). In 2011, 49.8%

(n = 343) of patients were aged between 25–54 years;

62.3% (n = 429) were male; 52.1% (n = 359) had pul-

monary TB (PTB) alone, of whom 33.5% (n = 144)

had cavitary lesions; 50.7% (n = 218 PTB cases) were

sputum smear-positive and 80.5% (346 PTB cases) were

culture-positive. The median diagnostic delay was 56 days;

4.6% (n = 32) were human immunodeficiency virus

positive and 5.2% (n = 36) were immigrants. The treat-

ment success rate was close to 90%. Contacts of 86.7%

of the smear-positive index cases were evaluated.

C O N C L U S I O N : TB incidence in Galicia is progressively

decreasing; however, it is still higher than that of neigh-

bouring regions. A long diagnostic delay was observed,

which may have contributed to the high incidence rate

in children.

K E Y W O R D S : programme; evolution; surveillance

TUBERCULOSIS (TB) is an important public health problem; it is essential to analyse its current epidemio-logical situation to understand the disease. According to the World Health Organization (WHO), there were 8.7 million new TB cases and 1.4 million deaths due to TB worldwide in 2011; the absolute number of TB cases has fallen since 2006, and incidence has decreased since 2002. The treatment success rate for new smear-positive pulmonary TB (PTB) cases was 87% in 2010.1

The resurgence of TB in the 1980s shows how Mycobacterium tuberculosis can reappear if TB con-trol and care are neglected.2 As major steps forward are being achieved in public health, now is the time to continue with efforts to fi nd better diagnostic and

S U M M A R Y

treatment tools, and strategies aimed at permanently reducing TB rates worldwide.3 The Regional Ministry of Health in Galicia, Spain, created the Galician Tuber-culosis Prevention and Control Programme (GTPCP) at the end of 1994 to actively identify and monitor TB through its TB prevention and control units (TBU).4

In accordance with the 4 December 1998 law on TB surveillance in Galicia, all medical professionals practising in Galicia are required to notify all TB cases, their follow-up and treatment outcomes, their contact tracing studies, and their follow-up and pre-ventive treatment outcomes to the Tuberculosis In-formation System (TIS). Based on the epidemiologi-cal data of the TIS, detailed information is now available on the behaviour of TB.

The present study aims to analyse the impact of the GTPCP and evaluate the current epidemiological situation, its 16-year evolution (1996–2011) and the main characteristics of TB in Galicia, an area with an average level of incidence, 16 years after the GTPCP was created.

§ The Galician Tuberculosis Prevention and Control Programme Work-ing Group: E Cruz-Ferro, M I Ursúa-Díaz, J A Taboada-Rodríguez, L Anibarro, V Túñez, A Abdelkader-Hasan, M A Castro-Paz Álvarez-Buylla, M Otero-Santiago, J Paniagua-López, A Penas-Truque, M L Pérez del Molino Bernal, A Rodríguez-Canal, P Valiño-López, R Vázquez Gallardo, E Vázquez García-Serrano, H Verea-Hernando.

Epidemiology of TB in Galicia 135

STUDY POPULATION AND METHODS

Galicia, an Autonomous Region in north-western Spain (area 29 574.4 km2, population 2 762 198, pop-ulation density 94.5 inhabitants/km2) is characterised by highly dispersed settlements, accounting for half of all the population centres in Spain (30 000 of a to-tal of 60 000). The region is divided into seven major health districts, each of which has a TBU with medi-cal and nursing staff and social workers. A retrospec-tive descriptive observational study of the period from 1 January 1996 to 31 December 2011 was carried out in this setting.

This article describes the characteristics of new TB cases from 2011, while the tables and fi gures show the trends and characteristics for the entire period (1996–2011).

TB epidemiological data in Galicia are obtained from the TIS, in which data are recorded from 1) pas-sive case fi nding and 2) active search for undeclared cases, using existing records and documentation (from the microbiology, pathological anatomy and pharmacy departments, hospital discharge reports, information on acquired immune-defi ciency syndrome [AIDS], prison records and mortality rates), and review of the clinical records of presumed TB cases and patient in-terviews. European Centre for Disease Prevention and Control (ECDC; Stockholm, Sweden) case defi ni-tions were used for the study,5 and WHO and Euro-pean defi nitions were used for treatment outcomes.6,7

The following epidemiological, clinical and micro-biological variables recorded by the GTPCP’s epide-miological questionnaire include: age, sex, source of information, diagnostic delay, site of disease, radio-logical patterns, microbiological results (bacillos-copy, culture and drug susceptibility testing [DST]), associated risk factors (human immunodefi ciency vi-rus [HIV] positive, drug use, immigration), directly observed treatment (DOT), treatment outcomes, and follow-up of contact tracing and results. Diagnostic delay was defi ned as the median number of days be-tween symptom onset and treatment initiation.

DST was performed at the Galician Mycobacte-rial Reference Laboratory, which was created in 1998 and fulfi ls all quality control requirements established

by the WHO for resistance studies; Galicia is in-cluded in the WHO/International Union Against Tu-berculosis and Lung Disease Global Project on Anti-Tuberculosis Drug Resistance Surveillance.8,9 In this study, we present DST results since 2008, follow-ing changes in the computerised registration system. Multidrug-resistant TB (MDR-TB) cases are regularly reviewed by the Galician Committee for the Evalua-tion of the Control of Drug-Resistant Tuberculosis.

DOT is organised with the help of TBU social workers. In accordance with the provisions of the Organic Law 3/1986 dated 14 April 1986 on Special Public Health Measures, health authorities have the legal power to compel smear-positive patients to take their medications if necessary.

To calculate the TB incidence rate, we used popu-lation data obtained from the Galician Institute of Statistics as the denominators. A descriptive analysis was performed of the selected variables, using Epidat 4.0 (Xunta de Galicia, Santiago de Compostela, Spain; http://www.sergas.es/MostrarContidos_N3_T01.aspx?IdPaxina=62713). Age as a quantitative vari-able was characterised by mean and standard devia-tion (SD). The frequency distribution of the different variables and the percentage of cases with data on these variables was calculated.

RESULTS

Number of cases and tuberculosis incidenceThe percentage of cases reported to the GTPCP of to-tal recorded cases increased progressively up to the last 4 years of the study period, when it once again de-creased (in 2011, 55.8% of cases were declared, while the remainder were obtained by active case fi nding). Information sources of undeclared cases and their evolution during this period are shown in Table 1.

The number of new TB cases fell from 1994 in 1996 (72.9 cases per 100 000 population) to 689 in 2011 (24.6/100 000), an overall reduction of 65.4% and a mean annual decrease of 6.8%. All PTB cases and smear-positive PTB cases show similar trends (Figure 1). Among patients aged <15 years, the number of cases fell from 118 (40.5/100 000) to

Table 1 Tuberculosis cases by source of notification and year (in %), Galicia, Spain, 1996–2011

Cases registered 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Passive 42.2 50.1 58.4 63.0 65.5 68.0 73.9 76.7 75.3 76.1 73.9 72.6 65.9 55.8 55.0 55.8

Active case finding 57.8 49.9 41.6 37.0 34.5 32.0 26.1 23.3 24.7 23.9 26.1 27.4 34.1 44.2 45.0 44.2 Microbiology departments 16.5 15.5 13.3 15.0 13.2 14.0 11.5 10.5 10.7 8.9 11.8 14.7 18.1 25.1 25.1 27.4 Patient contacts 6.7 5.9 6.2 6.1 4.6 6.6 5.8 5.2 5.1 5.3 4.7 3.1 4.9 4.6 5.4 3.6 Hospital admission registers 9.6 8.3 7.6 6.5 4.5 3.6 3.4 1.6 2.3 3.3 2.4 1.5 1.1 0.9 2.2 2.0 AIDS registers — — — — — — — — — — — 0.2 — — — 0.1 Pathological anatomy departments 2.5 2.4 2.2 1.7 1.6 1.6 1.2 1.1 1.3 0.5 0.7 0.8 1.4 1.7 2.4 1.3 Pharmacy departments 2.8 1.8 1.4 1.3 1.0 1.4 1.9 0.9 0.6 0.4 0.4 0.5 0.6 0.6 0.6 1.0 Other services 19.8 16.0 10.8 6.4 9.6 4.8 2.4 4.1 4.8 5.5 5.7 5.3 6.9 10.5 8.4 8.6 Not stated — 0.1 — — — — — — — — 0.3 1.2 1.2 0.7 0.9 0.1

AIDS = acquired immune-deficiency syndrome.

136 The International Journal of Tuberculosis and Lung Disease

46 (14.2/100 000), with a 61.0% reduction overall and a mean annual rate of 6.1%.

In 2011, 49.8% of cases (n = 343) were aged 25–54 years, with the highest number of cases occurring in the older age groups throughout the period studied (in 1996, the highest proportion occurred in those aged 15–34 years); 62.3% (n = 429) were male; and the mean age was 46.7 years (SD 22.2): 77.3 in men and 45.8 in women. Figure 2 shows changes in the incidence rate in 1996 and 2011 by age group. Al-though in 1996 the highest incidence was in the 15–24 years age group (100.0/100 000), by 2011 it had changed to the over-70s age group (30.0/100 000); however, this rate is similar to that of the 25–34 and 35–44 year age groups.

Characteristics of new tuberculosis cases Based on the WHO classifi cation, 52.1% (n = 359) of new TB cases were exclusively pulmonary, 37.6%

(n = 259) were extra-pulmonary and the rest were both (n = 71, 10.3%). The main site of TB was pul-monary (n = 430, 62.4%), followed by pleural TB (n = 109, 15.8%) and TB of the peripheral nodes (n = 70, 10.2%), with other sites being less frequent.

The most common radiological pattern in PTB pa-tients at the time of diagnosis was non-cavitary, in 62.3% (n = 268), while 33.5% (n = 144) had cavi-tary lesions and 4.0% (n = 17) had a normal chest X-ray (CXR). Results were unknown in the remain-ing 0.2% (n = 1). At the time of diagnosis, 50.7% (n = 218) of the 430 PTB cases were smear-positive, and 80.5% (n = 346/430) were confi rmed by culture. A defi nitive diagnosis was obtained for 36.3% (n = 94) of the 259 extra-pulmonary cases, which was lower than the mean for the period (40%).

During the period 2008–2011, 72 cases who had never previously been treated were resistant to isoni-azid (3.9%, range 3.2–4.4) and 0.4% had MDR-TB

Figure 1 TB, pulmonary TB and smear-positive pulmonary TB incidence per 100 000 population, Galicia, Spain, 1996–2011. TB = tuberculosis; PTB = pulmonary TB.

Figure 2 TB incidence per 100 000 population by age group, Galicia, Spain, 1996 and 2011. TB = tuberculosis.

Epidemiology of TB in Galicia 137

(n = 8), with two MDR-TB cases diagnosed per year. Detailed resistance data for 2011 is given in Table 2.

Diagnostic delayIn symptomatic cases, the date of onset of symptoms was recorded in 70.1%; the median time until initia-tion of treatment was 56 days. The median patient and health care system delays were respectively 21 and 15 days. The diagnostic delay in PTB and smear-positive PTB cases was 59 and 63 days respectively, causing 37 outbreaks of TB.

Tuberculosis in vulnerable populationsThe proportion of TB-HIV co-infection overall was 4.6% (n = 32), 1.5% (n = 10) among drug users. Immigrants from countries highly endemic for TB ac-counted for 5.2% of cases (n = 36). The evolution of TB during the period 1996–2011 in these vulnerable populations is shown in Figure 3.

Treatment outcomes, 1996–2010With a treatment success rate of approximately 90% in Galicia, DOT is given only in cases where non-a dherence is suspected:10–12 38.1% (n = 299) of pa-tients received DOT in 2010, leading to treatment suc-cess in 86.4% of patients (n = 677). Table 3 gives data and treatment outcomes for cases who began treat-ment in 1996–2010. Since 2000, compulsory in-patient treatment has been prescribed for 16 cases, compul-sory out-patient treatment under strict supervision for 2 cases, and compulsory home isolation for 1.

Contact studyIn 2011, 4742 contacts of TB patients were regis-tered; contact investigations (tuberculin skin test [TST] and/or CXR) were carried out for 86.7% of the

Figure 3 Total number of TB cases in Galicia among HIV-positive individuals, drug users and immigrants, 1996–2011. TB = t uberculosis; HIV = human immunodeficiency virus.

Table 2 Prevalence of drug resistance, Galicia, Spain, 2011

Never treatedn (%)

Previously treatedn (%)

Totaln (%)

Total patients with culture-positive results 416 24 440

Total patients with DST 406 (97.6) 21 (87.5) 427 (97.0)

Drug resistance H 17 (4.2) 2 (9.5) 19 (4.4) R 2 (0.5) 0 2 (0.5) E 1 (0.2) 0 1 (0.2) S 24 (5.9) 0 24 (5.6) Z 7 (1.7) 0 7 (1.6) Total 45 (11.1) 2 (9.5) 47 (11.0)

Monoresistance H only 10 (2.5) 2 (9.5) 12 (2.8) R only 0 0 0 E only 0 0 0 S only 21 (5.2) 0 21 (4.9) Z only 6 (1.5) 0 6 (1.4) Total 37 (9.1) 2 (9.5) 39 (9.1)

MDR-TB* H+R 1 (0.2) 0 1 (0.2) H+R+E+ETH 1 (0.2) 0 1 (0.2) Total 2 (0.5) 0 2 (0.5)

Polyresistance H+S 3 (0.7) 0 3 (0.7) H+ETH 1 (0.2) 0 1 (0.2) H+S+ETH 1 (0.2) 0 1 (0.2) H+Z 1 (0.2) 0 1 (0.2)

Total polyresistance (other than MDR-TB) 6 (1.5) 0 6 (1.4) Total susceptible 361 (88.9) 19 (90.5) 380 (89.0) Total resistance 45 (11.1) 2 (9.5) 47 (11.0) Total MDR-TB 2 (0.5) 0 2 (0.5) Resistance to 1 drug 37 (9.1) 2 (9.5) 39 (9.1) Resistance to 2 drugs 6 (1.5) 0 6 (1.4) Resistance to 3 drugs 1 (0.2) 0 1 (0.2) Resistance to 4 drugs 1 (0.2) 0 1 (0.2)

* None of these cases met the criteria for extensively drug-resistant TB.DST = drug susceptibility testing; H = isoniazid; R = rifampicin; E = etham-butol; S = streptomycin; Z = pyrazinamide; MDR-TB = multidrug-resistant tuberculosis; ETH = ethionamide.

138 The International Journal of Tuberculosis and Lung Disease

smear-positive index cases. An early diagnosis was obtained for 46 new patients; 1517 were found to be infected (TST induration ⩾5 mm).

In the period 1996–2011, the number of contacts studied in order to detect either latent tuberculous in-fection [LTBI] or active TB disease was 134 857, of which 1552 had TB and 42 400 were infected (ap-proximately one third per year). The percentage of patients who adhered to LTBI treatment increased in the years 1996–2010 from 57.1% in 1996 to 84.2% in 2010. Table 4 summarises the main characteristics of new TB cases diagnosed in Galicia during the pe-riod 1996–2011.

DISCUSSION

The GTPCP was created due to the high incidence of TB, and succeeded in reducing it considerably, al-though incidence remains higher than in many indus-trialised countries;1 however, in recent years the dis-ease has begun to reappear in some of the region’s

larger cities due to social problems and limitations of the existing TB control activities.13 The reduction in the average annual TB incidence in recent years has been more pronounced in Galicia than in the WHO Europe region14 and elsewhere in Spain, where there has been a national TB control programme since 2008. Disease control is still the responsibility of regional authorities, whose programmes are not uniform ei-ther in terms of structure or development.15,16

A phenomenon often observed in industrialised countries has been the decrease in the number of TB cases among the native-born population, and a recip-rocal increase in foreign-born populations (United States,17 European Union [EU] countries and Euro-pean Economic Area [EEA] countries14). While in Spain the percentage of immigrants with newly diag-nosed TB in 2010 rose to 32.7% (49.6% in Catalo-nia, 0.0% in Ceuta),16 in Galicia this percentage is still very low, although there has been a simultane-ous increase in the (TB-free) immigrant population that has settled in Galicia. We will need to see what

Table 3 Final status of new cases of TB who started treatment in Galicia, Spain, 1996–2010

1996n (%)

1997n (%)

1998n (%)

1999n (%)

2000n (%)

2001n (%)

2002n (%)

2003n (%)

Treatment success 1631 (81.8) 1503 (84.7) 1471 (86.9) 1362 (86.3) 1389 (88.0) 1197 (88.5) 1151 (89.2) 1104 (87.6) Bacteriological cure 148 (7.4) 190 (10.7) 186 (11.0) 182 (11.5) 228 (14.4) 213 (15.7) 216 (16.7) 234 (18.6) Completed treatment 1483 (74.4) 1313 (74.0) 1285 (75.9) 1180 (74.8) 1161 (73.5) 984 (72.7) 935 (72.5) 870 (69.0)

Potentially unsatisfactory results 190 (9.5) 135 (7.6) 89 (5.3) 91 (5.8) 66 (4.2) 65 (4.8) 48 (3.7) 57 (4.5) Default, loss to follow-up, treatment interruption 140 (7.0) 93 (5.2) 36 (2.1) 31 (2.0) 20 (1.3) 16 (1.2) 20 (1.6) 26 (2.1) Transferred 7 (0.4) 16 (0.9) 24 (1.4) 18 (1.1) 16 (1.0) 25 (1.8) 11 (0.9) 14 (1.1) Not stated 43 (2.2) 26 (1.5) 29 (1.7) 42 (2.7) 30 (1.9) 24 (1.8) 17 (1.3) 17 (1.3)

Deaths 173 (8.7) 137 (7.7) 132 (7.8) 125 (7.9) 124 (7.9) 91 (6.7) 91 (7.1) 99 (7.9) Due to TB 38 (1.9) 37 (2.1) 27 (1.6) 30 (1.9) 19 (1.2) 12 (0.9) 12 (0.9) 17 (1.3) Other causes 135 (6.8) 100 (5.6) 105 (6.2) 95 (6.0) 105 (6.6) 79 (5.8) 79 (6.1) 82 (6.5)

Supervised treatment 7 (0.4) 8 (0.5) 12 (0.7) 29 (1.8) 176 (11.1) 204 (15.1) 197 (15.3) 186 (14.8)

TB cases 1994 1775 1692 1578 1579 1353 1290 1260 Pulmonary culture-positive 969 843 884 827 836 713 693 722 Satisfactory results 792 (81.7) 734 (87.1) 760 (86.0) 712 (86.1) 751 (89.8) 639 (89.6) 628 (90.6) 635 (88.0) Pulmonary smear-positive 764 665 646 584 552 463 493 487 Satisfactory results 620 (81.2) 577 (86.8) 570 (88.2) 502 (86.0) 489 (88.6) 415 (89.6) 455 (92.3) 430 (88.3)

2004n (%)

2005n (%)

2006n (%)

2007n (%)

2008n (%)

2009n (%)

2010n (%)

Treatment success 927 (87.8) 934 (89.5) 839 (89.7) 755 (88.0) 817 (89.8) 767 (89.0) 677 (86.4) Bacteriological cure 164 (15.5) 155 (14.9) 200 (21.4) 188 (21.9) 184 (20.2) 154 (17.9) 138 (17.6) Completed treatment 763 (72.3) 779 (74.7) 639 (68.3) 567 (66.1) 633 (69.6) 613 (71.1) 539 (68.8)

Potentially unsatisfactory results 43 (4.1) 30 (2.9) 25 (2.7) 36 (4.2) 32 (3.5) 34 (3.9) 42 (5.4) Default, loss to follow-up, treatment interruption 18 (1.7) 17 (1.6) 8 (0.9) 16 (1.9) 14 (1.5) 23 (2.7) 13 (1.7) Transferred 15 (1.4) 10 (1.0) 16 (1.7) 14 (1.6) 13 (1.4) 7 (0.8) 12 (1.5) Not stated 10 (0.9) 3 (0.3) 1 (0.1) 6 (0.7) 5 (0.5) 4 (0.5) 17 (2.2)

Deaths 86 (8.1) 79 (7.6) 71 (7.6) 67 (7.8) 61 (6.7) 61 (7.1) 65 (8.3) Due to TB 9 (0.9) 5 (0.5) 6 (0.6) 6 (0.7) 10 (1.1) 9 (1.0) 11 (1.4) Other causes 77 (7.3) 74 (7.1) 65 (7.0) 61 (7.1) 51 (5.6) 52 (6.0) 54 (6.9)

Supervised treatment 146 (13.8) 175 (16.8) 122 (13.0) 156 (18.2) 232 (25.5) 309 (35.8) 299 (38.1)

TB cases 1056 1043 935 858 910 862 784 Pulmonary culture-positive 578 561 508 465 469 476 421 Satisfactory results 519 (89.8) 505 (90.0) 461 (90.7) 408 (87.7) 425 (90.6) 424 (89.1) 368 (87.4) Pulmonary smear-positive 355 352 297 277 301 293 270 Satisfactory results 322 (90.7) 320 (90.9) 270 (90.9) 254 (91.7) 271 (90.0) 264 (90.1) 236 (87.4)

TB = tuberculosis.

Epidemiology of TB in Galicia 139

happens to the incoming immigrant population in fu-ture years.

In line with many other studies, there is a clear predominance of males. The distribution of cases by age group is relatively uniform, a profi le that corre-sponds to a low-incidence country with effective dis-ease control.18 The high TB incidence in children is still cause for concern, and possibly results from the sig-nifi cant diagnostic delay observed. Galicia has not been able to reduce the diagnostic delay to <30 days,15 which is a challenge for the GTPCP as it leads to de-lays in treatment initiation. Reasons for diagnostic delays include delay by patients in seeking care and a

lack of clinical suspicion on the part of health care professionals. The latter indicates the need for im-proved health education.

As in other parts of our country, in Galicia the pre-dominant site of TB is the lung; the national average for Spain is slightly higher (74.7%), likely due to the fact that in some regions not all extra-pulmonary TB cases are notifi ed. In addition, a higher percentage of PTB patients in Galicia have cavitary images on CXR than other regions, such as Barcelona,19 or Area 15 in the Community of Valencia;20 this could also be re-lated to the diagnostic delay observed.

The percentage of confi rmed new PTB cases

Table 4 Main characteristics of new cases of TB, Galicia, Spain, 1996–2011*

1996n (%)

1997n (%)

1998n (%)

1999n (%)

2000n (%)

2001n (%)

2002n (%)

2003n (%)

New TB cases 1994 1775 1692 1578 1579 1353 1290 1260

Sex Male 1178 (59.1) 1034 (58.3) 1016 (60.0) 925 (58.6) 957 (60.6) 799 (59.1) 755 (58.5) 717 (56.9)

Age, years 0–14 118 (5.9) 121 (6.8) 102 (6.0) 99 (6.3) 107 (6.8) 93 (6.9) 75 (5.8) 84 (6.7) 15–24 435 (21.8) 377 (21.2) 345 (20.4) 290 (18.4) 290 (18.4) 250 (18.5) 270 (20.9) 211 (16.7) 25–44 652 (32.7) 604 (34.0) 565 (33.4) 566 (35.9) 514 (32.6) 480 (35.5) 426 (33.0) 453 (36.0) 45–64 360 (18.1) 299 (16.8) 291 (17.2) 282 (17.9) 300 (19.0) 236 (17.4) 232 (18.0) 231 (18.3) ⩾65 429 (21.5) 374 (21.1) 389 (23.0) 341 (21.6) 368 (23.3) 294 (21.7) 287 (22.2) 281 (22.3)

Site of TB Pulmonary 1281 (64.2) 1108 (62.4) 1082 (63.9) 989 (62.7) 1005 (63.6) 820 (60.6) 775 (60.1) 781 (62.0) Extra-pulmonary 512 (25.7) 495 (27.9) 456 (27.0) 439 (27.8) 438 (27.7) 397 (29.3) 384 (29.8) 358 (28.4) Both 130 (6.5) 121 (6.8) 122 (7.2) 104 (6.6) 91 (5.8) 96 (7.1) 106 (8.2) 91 (7.2)

Sputum bacteriology†

Positive AFB 754 (57.1) 660 (58.6) 643 (58.0) 585 (58.0) 548 (54.6) 457 (54.7) 492 (60.3) 486 (60.8) Positive culture 930 (70.5) 814 (72.2) 856 (77.2) 799 (79.2) 803 (80.1) 685 (82.0) 673 (82.5) 702 (87.9)

Chest X-ray‡

Normal 55 (3.9) 38 (3.1) 47 (3.9) 30 (2.7) 36 (3.3) 25 (2.7) 21 (2.4) 29 (3.3) Abnormal No cavitary lesions 826 (58.5) 738 (60.0) 708 (58.8) 677 (61.9) 677 (61.8) 599 (65.4) 556 (63.1) 517 (59.3) Cavitary lesions 466 (33.0) 416 (33.8) 410 (34.1) 356 (32.6) 359 (32.8) 281 (30.7) 302 (34.3) 323 (37.0)

2004n (%)

2005n (%)

2006n (%)

2007n (%)

2008n (%)

2009n (%)

2010n (%)

2011n (%)

New TB cases 1056 1043 935 858 910 862 784 689

Sex Male 648 (61.4) 633 (60.7) 571 (61.1) 531 (61.9) 556 (61.1) 477 (55.3) 480 (61.2) 429 (62.3)

Age, years 0–14 59 (5.6) 70 (6.7) 55 (5.9) 40 (4.7) 80 (8.8) 49 (5.7) 57 (7.3) 46 (7.3) 15–24 170 (16.1) 148 (14.2) 112 (12.0) 112 (13.1) 107 (11.8) 102 (11.8) 73 (9.3) 67 (9.3) 25–44 404 (38.3) 386 (37.0) 344 (36.8) 325 (37.9) 339 (37.3) 320 (37.1) 290 (37.0) 245 (37.1) 45–64 205 (19.4) 187 (17.9) 221 (23.6) 189 (22.0) 190 (20.9) 200 (23.2) 177 (22.6) 165 (24.1) ⩾65 218 (20.6) 252 (24.2) 203 (21.7) 192 (22.4) 194 (21.3) 191 (22.2) 187 (23.9) 166 (24.1)

Site of TB Pulmonary 641 (60.7) 615 (59.0) 548 (58.6) 491 (57.2) 554 (60.9) 508 (58.9) 462 (58.9) 359 (52.1) Extra-pulmonary 316 (29.9) 322 (30.9) 317 (33.9) 292 (34.0) 291 (32.0) 263 (30.5) 248 (31.6) 259 (37.6) Both 71 (6.7) 84 (8.1) 69 (7.4) 75 (8.7) 65 (7.1) 91 (10.6) 74 (9.4) 71 (10.3)

Sputum bacteriology†

Positive AFB 353 (53.5) 350 (54.7) 297 (52.3) 286 (53.0) 315 (57.6) 305 (54.8) 275 (56.0) 224 (55.4) Positive culture 557 (84.4) 541 (84.5) 492 (86.6) 458 (84.8) 458 (83.7) 463 (83.1) 411 (83.7) 336 (83.2)

Chest X-ray‡

Normal 15 (2.1) 12 (1.7) 23 (3.7) 20 (3.5) 20 (3.2) 26 (4.3) 23 (4.3) 17 (4.0) Abnormal No cavitary lesions 420 (59.0) 440 (62.9) 405 (65.6) 344 (60.8) 393 (63.5) 378 (63.1) 346 (64.6) 268 (62.3) Cavitary lesions 275 (38.6) 247 (35.3) 188 (30.5) 201 (35.5) 205 (33.1) 192 (32.1) 165 (30.8) 144 (33.5)

* Some percentages do not add up to 100% due to missing data.† Adults aged ⩾15 years with pulmonary TB.‡ Chest X-ray in pulmonary TB patients.TB = tuberculosis; AFB = acid-fast bacilli.

140 The International Journal of Tuberculosis and Lung Disease

e xceeds the goals set by the ECDC and attained by other EU/EEA countries,14 as well as by Spain as a whole.16 However, many areas do not collect data on DST results against fi rst-line drugs, and in Galicia the percentage of MDR-TB cases is much lower than in other regions.8,21 The percentage of patients with TB-HIV co-infection shows a downward trend, at <10%. TB cases among drug users and in the immigrant population did not affect the epidemiology of TB in Galicia.

Cases treated in Galicia exceed WHO22 and EU23 percentages of satisfactory outcomes (cure/treatment completion), which is not the case for the EU as a whole,14 nor for neighbouring regions; this is indica-tive of the quality of the work of the TB surveillance and treatment team in Galicia.

In Galicia, a high percentage of contacts of smear-positive index cases are investigated, and a high pro-portion are recorded as having correctly completed treatment for LTBI, although in the latter case we cannot rule out underreporting, which continues to be a challenge for the GTPCP.10

CONCLUSION

The creation of the GTPCP has led to a reduction in TB incidence—which nevertheless remains higher than in neighbouring regions—and a fall in the average annual rate, which is again higher than the European rate. TB incidence by age group is similar to that of countries with effective TB control programmes, al-though the incident rate among children is still high. The long diagnostic delay possibly contributes to transmission of infection and the high incidence rate observed among children. Our study results high-light the need for effective TB programmes to control the disease.

AcknowledgementsThe authors thank all those who participate in the Galician Tuber-culosis Prevention and Control Programme, especially the teams from the seven tuberculosis prevention and control units and Gali-cian Mycobacterial Reference Laboratory.

Confl ict of interest: none declared.

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berculosis in New York City—turning the tide. N Eng J Med 1995; 333: 229–233.

3 Nahid P, Menzies D. Update in tuberculosis and non-tuberculous mycobacterial disease 2011. Am J Respir Crit Care Med 2012; 185: 1266–1270.

4 Dirección Xeral de Saúde Pública. Programa Galego de Pre-vención e Control da Tuberculose. Documentos Técnicos de Saúde Pública. Serie A, no. 13. Santiago de Compostela, Spain: Dirección Xeral de Saúde Pública, Consellería de Sanidade, Xunta de Galicia, 1995. [Galician]

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defi nitions for reporting communicable diseases to the Com-munity network under Decision No 2119/98/EC of the Euro-pean Parliament and of the Council (notifi ed under document number C (2008) 1589). 2008/426/EC. OJ L 159/46; 18.06. 2008. Brussels, Belgium: European Union Commission, 2008.

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Epidemiology of TB in Galicia i

C O N T E X T E : Galice, Espagne.

O B J E C T I F : Décrire l’évolution épidémiologique et les

caractéristiques de la tuberculose (TB) en Galice de

1996 à 2011.

S C H É M A : Etude descriptive rétrospective avec comme

source d’information le Système d’information sur la

TB. Le programme de lutte contre la TB de Galice est

basé dans 7 unités qui recueillent activement tous les cas

de TB et les suivent.

R É S U LTAT S : L’incidence de la TB est passée de 72,9

cas/100 000 habitants en 1996 à 24,6 en 2011 (respec-

tivement 40,5 et 14,2 pour les patients âgés <15 ans).

En 2011, 49,8% (n = 343) avaient de 25 à 54 ans et

62,3% (n = 429) étaient des hommes ; 52,1% (n = 359)

avaient uniquement une atteinte pulmonaire, dont 33,5%

(n = 144) avaient une forme cavitaire ; 50,7% (n = 218) avaient un examen de crachats positif et 80,5%

(n = 346 cas de TB pulmonaire) avaient une culture

positive. Le délai médian de diagnostic était de 56 jours ;

4,6% (n = 32) étaient séropositifs pour le VIH et 5,2%

(n = 36) étaient des immigrants. Le taux de réussite du

traitement était proche de 90%. Les sujets contacts ont

fait l’objet d’examens dans 86,7% des cas index à cra-

chats positifs.

C O N C L U S I O N : L’incidence de la TB en Galice décroit

progressivement, mais elle excède encore celle des ré-

gions voisines. Le délai de diagnostic est long, ce qui fa-

vorise l’incidence élevée constatée chez les enfants.

M A R C O D E R E F E R E N C I A : Galicia, España.

O B J E T I V O : Describir la evolución epidemiológica y las

características de la tuberculosis (TB) en Galicia, España,

en el período 1996–2011.

M E T O D O S : Estudio observacional descriptivo retrospec-

tivo. Fuente de información: Sistema de Información

de Tuberculosis. El Programa Gallego de Tuberculosis

(1994) se basa en siete Unidades de Tuberculosis, que

realizan una captación y seguimiento activo de todos los

casos de TB.

R E S U LTA D O S : La incidencia pasó de 72,9 casos por

100 000 habitantes en 1996 a 24,6 en 2011 (40,5 y 14,2

en habitantes <15 años de edad, respectivamente). En el

año 2011, el 49,8% (n = 343) tenían entre 25 y 54 años

y el 62,3% (n = 429) del total fueron hombres; el

52,1% (n = 359) tenían una localización exclusiva-

mente pulmonar y, de estos, el 33,5% (n = 144) tenían

una lesión cavitada; el 50,7% (218 casos pulmonares)

tenían una baciloscopia de esputo positiva y el 80,5%

(346 casos pulmonares) un cultivo positivo. La mediana

de retraso diagnóstico fue de 56 días; el 4,6% (n = 32)

eran virus de la inmunodeficiencia humana positivos y

el 5,2% (n = 36) inmigrantes; los porcentajes de cura-

ción son próximos al 90%. Se estudiaron contactos en

el 86,7% de los casos índice bacilíferos.

C O N C L U S I Ó N : La incidencia de la TB en Galicia dismi-

nuye de forma progresiva; sin embargo, todavía supera

a la de regiones vecinas. Se observa un elevado retraso

diagnóstico, que favorecería la alta incidencia observada

en niños.

R É S U M É

R E S U M E N