Tuber&
and Lung Disease (1992) 73, 2W202
HIV-related tuberculosis in England and Wales M. N&r*, M. Narulat, N. Beechingt, P. D. 0. Davies* *Tuberculosis Research Unit, Sefton General Hospital, Liverpool, UK, and tlnfectious Diseases Unit, Fazakerley Hospital, Liverpool, UK S UMMA R Y.
Numbers of tuberculosis notifications in England and Wales increased by 8% from 1987 to 1989. An analysis of notifications by age and sex has been undertaken to determine whether this increase has been due to an increase in young male adults, as has occurred in the USA, implying that HIV is largely responsible for the increase in notifications. Though notifications increased by 9.5% in younger males between 1987 and 1989 they also increased by over 10% amongst most age groups of females, and elderly males. These findings would suggest that there are a number of factors causing a rise in tuberculosis notifications, and that HIV is not yet directly implicated in England and Wales. R ES UMA
. Le nombre de notifications de tuberculose en Angleterre et au Pays de Galles a augment6 de 8% entre 1987 et 1989. Une analyse des notifications selon l’lge et le sexe du malade a Cte faite ailn de determiner si cette augmentation Ctait due a un accroissement d’hommes jeunes comme il a et6 trouve aux Etats Unis, ce qui suggere que le VIH est largement responsable de cette augmentation des notifications. Bien que le nombre de notifications ait augment6 de 93% chez les sujets masculine plus jeunes entre 1987 et 1989, il a aussi augment6 de plus de 10% dans la plupart des groupes d’ige de femmes, et chez les hommes fig&. Ces constatations suggerent qu’il y a plusieurs raisons 21cette augmentation de notifications de tuberculose, et que le VIH n’y est pas encore directement hnplique en Angleterre et au Pays de Galles.
R ES U M E N. El numero de notiilcaciones de tuberculosis en Inglatera y Gales aument6 en 8% entre 1987 y
1989. Se efectud un an&is de las notiilcaciones segun edad y sexo para determinar si este aumento era debido a una major incidencia en hombres jovenes adultos, come ha ocurrido en Estados Unidos, lo que implicaria que el VIH es ampliamente responsable de1 aumento de notiilcaciones. Aunque las notificaciones aumentaron en 93% en 10s hombres maisjovenes entre 1987 y 1989, tambien aumentaron en m8s de 10% en la mayoria de 10s grupos de edad de las mujeres, y en 10s hombres de mayor edad. Estos resultos sugieren que hay un cierto numero de factores que causan un aumento en las notificaciones de tuberculosis, y que el VIH no est4 aun directamente implicado en Inglaterra y Gales.
Notifications in England and Wales showed a similar arrest in decline in 1985 and 1986. An analysis of notifications by age and sex showed this to be due to a relative rise in notifications amongst the elderly, particularly older females.3 After a sharp drop in notifications from 1986 to 1987, numbers have again risen by about 4% per annum in 1988 and 1989 and fallen only slightly in 1990.4 We have again undertaken an analysis of notifications by age group for both sexes to determine whether this recent rise in notifications parallels the USA experience in terms of a sharp rise in younger males, implying a substantial HIV-related contribution to disease.
INTRODUCTION Since 1985 the USA has experienced a reversal in its previous decline of tuberculosis notifications. On analysing the notification data by age and sex it has been found that the overall reversal in tuberculosis decline is due to a large increase among males aged 25-44, amounting to 14% between 1985 and 1988, while all other age groups for both sexes showed a continuing decline.’ This has been attributed to a rise in HIV-related tuberculosis. More recently tuberculosis in certain centres of the USA has increased dramatically.2
Correspondence to: P. D. 0. Davies, Sefton General Hospital, Smithdown Lane, Liverpool L15 2HE, UK. 200
HIV-relatedtuberculosisin England and Wales 101
METHODS AND RESULTS
DISCUSSION
Data for tuberculosis notifications by age and sex have been extracted from the relevant Office of Population Censuses and Survey monitors for the years 1982-1989 (the most recent full years for which corrected results are available). The overall numbers of notifications for both sexes and all ages combined by year are shown in the Figure. Figures by age and sex are not yet available for 1990. The numbers by age and sex for 1987-1989 are shown in the Table and the percentage increase for each age group over the 2-year period is also shown. It can be seen that there has been an increase of nearly 8% in the total over the 2 years. However, though there has been a rise of nearly 10% among younger males, those most likely to be at risk for HIV, numbers amongst other groups and ages have also increased substantially:
Between 1984 and 1986 the slowing in the decline of tuberculosis appeared to be due to a very slow decline in disease in the elderly. This analysis of the arrest in decline of disease from 1987 to 1989 suggests that many groups, including young adults, are experiencing an increase in numbers. The fact that the increase is not confined to younger males suggests that the reasons for this arrest in decline of notifications are multifactorial and, more importantly, HIV is not yet implicated as contributing to tuberculosis in England and Wales as it is in the USA. Results are presented as numbers of notifications instead of rates, as given in an earlier publication,-’ to provide a more direct comparison with current data from the USA.’ It has been suggested that the rise in notifications in the very elderly might be due to increased longevity and a resurgence of disease from infection incurred during the War years.? It is probable that immigration has contributed to the increase in notification amongst younger adults, particularly younger females.5 Though it is speculative, the increasing numbers of people reported to be living rough in recent years may also have made a contribution to the increase in disease amongst younger adults. Recent evidence suggests a continuing failure to notify disease by health professionals involved in the management of tuberculosis.h It is possible, though unlikely, that the rise in numbers notified reflect an increase in awareness by doctors to notify and not a real rise in actual numbers with disease. The fact that tuberculosis decline appears to have arrested for 4 successive years emphasizes the importance of continuing the battle against the disease. Services in the diagnosis, case-finding. and management of patients with tuberculosis cannot yet be dismantled. The suggestion from this data that there may be several causes of this arrest in decline also underlines the importance of including details of ethnic origin” and possibly of religious allegiance as well.“’ when a further survey of tuberculosis notifications is carried out.
Females aged 15-24 by 16%. Females aged 2544 by 10%. Females aged 45-64 by 12%. Males aged 75 or more by 17%. Females aged 75 or more by 14%. The overall rise in notifications is therefore due to a rise in notifications in a number of groups and is not isolated to younger males as is the case in the USA.
6000
,
I
z
0 ._ c
m
References year
DiseasesCentre. Update:tuberculosis elimination MMWR 1990;39: 153-156. 2. CharatanF. Tuberculosis soars in New York. Br Med J 1991: 303: 1. Communicable - United States.
Figure-Total notifications of tuberculosis (all forms) by year, 1982-1990.
Table.
a
209.
O-75+
Total tuberculosis
notification 15-24 M
O-14 M
F
1987
217
222
279
1988
193
187
268
by sex and age in England and Wales
1987-1989
2544 M
F
45-64 M
331
822
670
797
487
416
352
837
821
789
478
451
F
F
65-74 M
> 75 M
F
226
372
236
407
F
Total M
Total F
Total
246
2903
2182
5085
260
2945
2234
5179
1989
198
231
286
385
900
738
799
547
447
240
435
280
3065
242
I
5486
% increase
-8.8%
4.1%
2.5%
16.3%
9.5%
20.1%
0.3%
12.3%
7.5%
6.2%
16.9%
13.8%
5.6%
I/.0%
7.9%
202
Tubercle and Lung Disease
3. Davies P D 0. The slowing of the decline in tuberculosis notifications and HIV infection. Resp Med 1989; 83: 321-322. 4. OPCS Quarterly Monitor Series MB2. 5. Gilbertson K, Stark D, Taw K, Gillon-Moore J. Use of community organisations to assess immigrant populations at risk of tuberculosis. Thorax 1991; 46: 311 (abstract). 6. King D, Cock H, Sheldon C D, Wilkinson P, Barnes N C. Notifications of tuberculosis: how many are never reported? Thorax 1992; 46: 742 (abstract). I. Medical Research Council Tuberculosis & Chest Diseases Unit. National survey of tuberculosis notifications in England
and Wales 1978-1979. Br Med J 1980; 281: 895-898. 8. Medical Research Council Tuberculosis & Chest Diseases Unit. National survey of tuberculosis notifications in England and Wales 1983. Br Med J 1985; 291: 658-661. 9. Nisar M, Williams C S D, Davies P D 0. Experience of tuberculosis in immigrants from South East Asia - implications of the imminent lease back of Hong Kong. Resp Med 1991; 85: 219-222. 10. Finch P J, Millard F J C, Maxwell J D. Risk of tuberculosis in immigrant Asians: culturally acquired immunodeficiency. Thorax 1991; 46: l-5.
and Lung Disease (1992) 73, 2W202
HIV-related tuberculosis in England and Wales M. N&r*, M. Narulat, N. Beechingt, P. D. 0. Davies* *Tuberculosis Research Unit, Sefton General Hospital, Liverpool, UK, and tlnfectious Diseases Unit, Fazakerley Hospital, Liverpool, UK S UMMA R Y.
Numbers of tuberculosis notifications in England and Wales increased by 8% from 1987 to 1989. An analysis of notifications by age and sex has been undertaken to determine whether this increase has been due to an increase in young male adults, as has occurred in the USA, implying that HIV is largely responsible for the increase in notifications. Though notifications increased by 9.5% in younger males between 1987 and 1989 they also increased by over 10% amongst most age groups of females, and elderly males. These findings would suggest that there are a number of factors causing a rise in tuberculosis notifications, and that HIV is not yet directly implicated in England and Wales. R ES UMA
. Le nombre de notifications de tuberculose en Angleterre et au Pays de Galles a augment6 de 8% entre 1987 et 1989. Une analyse des notifications selon l’lge et le sexe du malade a Cte faite ailn de determiner si cette augmentation Ctait due a un accroissement d’hommes jeunes comme il a et6 trouve aux Etats Unis, ce qui suggere que le VIH est largement responsable de cette augmentation des notifications. Bien que le nombre de notifications ait augment6 de 93% chez les sujets masculine plus jeunes entre 1987 et 1989, il a aussi augment6 de plus de 10% dans la plupart des groupes d’ige de femmes, et chez les hommes fig&. Ces constatations suggerent qu’il y a plusieurs raisons 21cette augmentation de notifications de tuberculose, et que le VIH n’y est pas encore directement hnplique en Angleterre et au Pays de Galles.
R ES U M E N. El numero de notiilcaciones de tuberculosis en Inglatera y Gales aument6 en 8% entre 1987 y
1989. Se efectud un an&is de las notiilcaciones segun edad y sexo para determinar si este aumento era debido a una major incidencia en hombres jovenes adultos, come ha ocurrido en Estados Unidos, lo que implicaria que el VIH es ampliamente responsable de1 aumento de notiilcaciones. Aunque las notificaciones aumentaron en 93% en 10s hombres maisjovenes entre 1987 y 1989, tambien aumentaron en m8s de 10% en la mayoria de 10s grupos de edad de las mujeres, y en 10s hombres de mayor edad. Estos resultos sugieren que hay un cierto numero de factores que causan un aumento en las notificaciones de tuberculosis, y que el VIH no est4 aun directamente implicado en Inglaterra y Gales.
Notifications in England and Wales showed a similar arrest in decline in 1985 and 1986. An analysis of notifications by age and sex showed this to be due to a relative rise in notifications amongst the elderly, particularly older females.3 After a sharp drop in notifications from 1986 to 1987, numbers have again risen by about 4% per annum in 1988 and 1989 and fallen only slightly in 1990.4 We have again undertaken an analysis of notifications by age group for both sexes to determine whether this recent rise in notifications parallels the USA experience in terms of a sharp rise in younger males, implying a substantial HIV-related contribution to disease.
INTRODUCTION Since 1985 the USA has experienced a reversal in its previous decline of tuberculosis notifications. On analysing the notification data by age and sex it has been found that the overall reversal in tuberculosis decline is due to a large increase among males aged 25-44, amounting to 14% between 1985 and 1988, while all other age groups for both sexes showed a continuing decline.’ This has been attributed to a rise in HIV-related tuberculosis. More recently tuberculosis in certain centres of the USA has increased dramatically.2
Correspondence to: P. D. 0. Davies, Sefton General Hospital, Smithdown Lane, Liverpool L15 2HE, UK. 200
HIV-relatedtuberculosisin England and Wales 101
METHODS AND RESULTS
DISCUSSION
Data for tuberculosis notifications by age and sex have been extracted from the relevant Office of Population Censuses and Survey monitors for the years 1982-1989 (the most recent full years for which corrected results are available). The overall numbers of notifications for both sexes and all ages combined by year are shown in the Figure. Figures by age and sex are not yet available for 1990. The numbers by age and sex for 1987-1989 are shown in the Table and the percentage increase for each age group over the 2-year period is also shown. It can be seen that there has been an increase of nearly 8% in the total over the 2 years. However, though there has been a rise of nearly 10% among younger males, those most likely to be at risk for HIV, numbers amongst other groups and ages have also increased substantially:
Between 1984 and 1986 the slowing in the decline of tuberculosis appeared to be due to a very slow decline in disease in the elderly. This analysis of the arrest in decline of disease from 1987 to 1989 suggests that many groups, including young adults, are experiencing an increase in numbers. The fact that the increase is not confined to younger males suggests that the reasons for this arrest in decline of notifications are multifactorial and, more importantly, HIV is not yet implicated as contributing to tuberculosis in England and Wales as it is in the USA. Results are presented as numbers of notifications instead of rates, as given in an earlier publication,-’ to provide a more direct comparison with current data from the USA.’ It has been suggested that the rise in notifications in the very elderly might be due to increased longevity and a resurgence of disease from infection incurred during the War years.? It is probable that immigration has contributed to the increase in notification amongst younger adults, particularly younger females.5 Though it is speculative, the increasing numbers of people reported to be living rough in recent years may also have made a contribution to the increase in disease amongst younger adults. Recent evidence suggests a continuing failure to notify disease by health professionals involved in the management of tuberculosis.h It is possible, though unlikely, that the rise in numbers notified reflect an increase in awareness by doctors to notify and not a real rise in actual numbers with disease. The fact that tuberculosis decline appears to have arrested for 4 successive years emphasizes the importance of continuing the battle against the disease. Services in the diagnosis, case-finding. and management of patients with tuberculosis cannot yet be dismantled. The suggestion from this data that there may be several causes of this arrest in decline also underlines the importance of including details of ethnic origin” and possibly of religious allegiance as well.“’ when a further survey of tuberculosis notifications is carried out.
Females aged 15-24 by 16%. Females aged 2544 by 10%. Females aged 45-64 by 12%. Males aged 75 or more by 17%. Females aged 75 or more by 14%. The overall rise in notifications is therefore due to a rise in notifications in a number of groups and is not isolated to younger males as is the case in the USA.
6000
,
I
z
0 ._ c
m
References year
DiseasesCentre. Update:tuberculosis elimination MMWR 1990;39: 153-156. 2. CharatanF. Tuberculosis soars in New York. Br Med J 1991: 303: 1. Communicable - United States.
Figure-Total notifications of tuberculosis (all forms) by year, 1982-1990.
Table.
a
209.
O-75+
Total tuberculosis
notification 15-24 M
O-14 M
F
1987
217
222
279
1988
193
187
268
by sex and age in England and Wales
1987-1989
2544 M
F
45-64 M
331
822
670
797
487
416
352
837
821
789
478
451
F
F
65-74 M
> 75 M
F
226
372
236
407
F
Total M
Total F
Total
246
2903
2182
5085
260
2945
2234
5179
1989
198
231
286
385
900
738
799
547
447
240
435
280
3065
242
I
5486
% increase
-8.8%
4.1%
2.5%
16.3%
9.5%
20.1%
0.3%
12.3%
7.5%
6.2%
16.9%
13.8%
5.6%
I/.0%
7.9%
202
Tubercle and Lung Disease
3. Davies P D 0. The slowing of the decline in tuberculosis notifications and HIV infection. Resp Med 1989; 83: 321-322. 4. OPCS Quarterly Monitor Series MB2. 5. Gilbertson K, Stark D, Taw K, Gillon-Moore J. Use of community organisations to assess immigrant populations at risk of tuberculosis. Thorax 1991; 46: 311 (abstract). 6. King D, Cock H, Sheldon C D, Wilkinson P, Barnes N C. Notifications of tuberculosis: how many are never reported? Thorax 1992; 46: 742 (abstract). I. Medical Research Council Tuberculosis & Chest Diseases Unit. National survey of tuberculosis notifications in England
and Wales 1978-1979. Br Med J 1980; 281: 895-898. 8. Medical Research Council Tuberculosis & Chest Diseases Unit. National survey of tuberculosis notifications in England and Wales 1983. Br Med J 1985; 291: 658-661. 9. Nisar M, Williams C S D, Davies P D 0. Experience of tuberculosis in immigrants from South East Asia - implications of the imminent lease back of Hong Kong. Resp Med 1991; 85: 219-222. 10. Finch P J, Millard F J C, Maxwell J D. Risk of tuberculosis in immigrant Asians: culturally acquired immunodeficiency. Thorax 1991; 46: l-5.
