Review

The new global map of human brucellosis

Georgios Pappas, Photini Papadimitriou, Nikolaos Akritidis, Leonidas Christou, Epameinondas V Tsianos

The epidemiology of human brucellosis, the commonest zoonotic infection worldwide, has drastically changed over Lancet Infect Dis 2006; 6: 91–99
the past decade because of various sanitary, socioeconomic, and political reasons, together with the evolution of GP, LC and EVT are at the First
international travel. Several areas traditionally considered to be endemic—eg, France, Israel, and most of Latin Division of Internal Medicine of
the Medical School at the
America—have achieved control of the disease. On the other hand, new foci of human brucellosis have emerged,
University of Ioannina, Greece;
particularly in central Asia, while the situation in certain countries of the near east (eg, Syria) is rapidly worsening. PP is at the Pediatrics
Furthermore, the disease is still present, in varying trends, both in European countries and in the USA. Awareness Department of the University
of this new global map of human brucellosis will allow for proper interventions from international public-health Hospital of Ioannina, Greece; and
NK is at the Internal Medicine
organisations.
Department of the General
Hospital “G Hatzikosta”,
Introduction USA Ioannina, Greece.
Brucellosis is an old disease with minimal mortality. Yet Until the 1960s, most human cases in the USA were Correspondence to:
human brucellosis remains the commonest zoonotic attributed to Brucella abortus, reaching a high of Dr Georgios Pappas, Internal
Medicine Department, University
disease worldwide with more than 500 000 new cases 6321 cases in 1947.27 A massive eradication campaign
Hospital of Ioannina, 45110,
annually,1–3 is associated with substantial residual resulted in the elimination of cattle brucellosis and a Greece. Tel: +30 26510 49453;
disability,4 and is an important cause of travel-associated substantial decline in the incidence of human disease. gpele@otenet.gr
morbidity.5 The global epidemiology of the disease has During the 1970s brucellosis was mainly attributed to
drastically evolved over the past decade. We focus on the Brucella suis, prevalent among abattoir workers.28
current global distribution of the disease and its According to annual reports from the Centers for
relocation during the past decade, and attempt to explain Disease Control and Prevention (Atlanta, GA),17
the rationale behind this evolution and its possible 2215 cases were reported in the period 1973–82, and
future projections. 1201 cases were reported between 1983 and 1992.
1056 cases were reported for the period 1993–2002,
Global status more than half deriving from Texas and California. The
Figure 1 depicts the incidence of human brucellosis 136 cases and incidence of 0·48 cases per million for
worldwide. Table 1 shows the countries with the highest 2001 represent respective peaks since 1985 and 1983. A
annual incidence of human brucellosis from 2000 small decline was noted in 2002. Table 2 shows the
onwards, as well as the incidence for selected other average annual incidence per state for 1993–2002, and
countries. figure 2 depicts the incidence distribution per state.

Annual incidence of brucellosis

per 1000 000 population
500
50–500 cases
10–50
2–10
2
Possibily endemic, no data
Non-endemic/no data

Figure 1: Worldwide incidence of human brucellosis

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 Review

Country and reference Incidence (annual cases per (continued)

million of population) Asia
Europe Afghanistan7 3·8
Albania6 63·6 Armenia16 31·3
Bosnia and Herzegovina7 20·8 Azerbaijan8 52·6
Denmark7 0·7 China19 8
France7 0·5 India No data available, possibly endemic
Former Yugoslav Republic of Macedonia8 148 Iraq7 278·4
Georgia7 27·6 Iran8 238·6
Germany7 0·3 Israel7 9·2
Greece9 20·9 Jordan20 23·4
Ireland7 1·3 Kazakhstan21 115·8
Italy10 9 Korea, South7 1
Netherlands7 0·5 Kuwait7 33·9
Norway7 0·7 Kyrgyzstan16 362·2
Portugal11 13·9 Lebanon22 49·5
Russia7 4·1 Mongolia23 605·9
Serbia and Montenegro7 8·4 Oman7 35·6
Spain12 15·1 Pakistan No data available, possibly endemic
Sweden7 0·3 Saudi Arabia24 214·4
Switzerland13 1·5 Syria7 1603·4
UK14 0·3 Tajikistan7 211·9
Africa Turkey7 262·2
Algeria8 84·3 Turkmenistan7 51·5
Cameroon7 Endemic, no specific data available United Arab Emirates25 41
Egypt15 2·95 Uzbekistan7 18
Eritrea16 5·48 Oceania
Ethiopia7 Endemic, no specific data available Australia26 0·9
Mali8 2
Namibia8 4·9 Table 1: Global incidence of human brucellosis
Tunisia7 35·4
Uganda7 0·9
North America
Canada7 0·09 the actual picture of brucellosis in the USA today is
USA17 0·4 represented: a disease caused by B melitensis, affecting
Mexico18 28·7 the Hispanic population, and localised in areas
Central and South America
neighbouring Mexico.29,30 A recent report from San
Argentina8 8·4
Chile7 0·6 Diego, California showed a limited area where B abortus
Colombia7 1·85 is prevalent.31 The disease is imported through the
Guatemala16 15·7 US/Mexican border by means of infected dairy products,
Panama7 10·1
particularly Mexican soft cheese.32–34 The increased
Peru7 34·9
(continues) incidence in Illinois remains of obscure aetiology.

Most of the US cases are attributed to Brucella
melitensis. 647 (79·4%) of the 815 patients for whom
ethnicity was documented were of Hispanic origin.
During 1993–2002, 46 states reported at least one case,
and 26 states reported at least one case in 2002. Illinois,
Florida, Texas, Arizona, Colorado, and California
reported at least one case annually, while Maine,
Vermont, Rhode Island, North Dakota, West Virginia,
and Nevada reported no cases at all. The annual
incidence is highest in Wyoming, although the small
number of cases precludes evaluation of the clinical
importance of this incidence. The average incidence is
increased in North Carolina and Arkansas due to
clusters of 27 cases in 1993 and nine cases in 2001,
respectively. Most cases in northern states probably
represent imported disease acquired through
international travel or infected food preparations
imported from endemic areas. This is not the case for
west south central, mountain, and Pacific states, where
Latin America
Mexico remains one of the most important reservoirs of
human brucellosis. Data from the Mexican Ministry of
Health’s epidemiology directorate18 for the years
1996–2003 show a decline until 2000, and a subsequent
increase in the annual number of cases reported; 3008
cases were reported in 2003. Whether this increase is
actual or related to improvements in notification
systems35 cannot be determined. The disease is localised
in two zones: the northern districts neighbouring the
USA—eg, Coahuila, Nuevo Leon, Sonora, and
Chihuahua (average annual incidence 186, 85, 57, and
54 cases per million respectively)—and northwestern
and west central districts—eg, Sinaloa, Zacatecas,
Durango, and Guanajuato (although the latter district
exhibits a continuous incidence decline). The most
important parameter of the epidemiology of human
brucellosis in Mexico is the effect the endemicity of the
northern districts exhibits on the epidemiology of the
disease in the USA. Even strict border control cannot

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contain a zoonosis; thus eradication cannot be achieved Area Number of Annual incidence
by means of national control programmes, especially in cases (cases per million)*
areas where immigration is common. A global, or at New England 11 0·08
least continental plan has to be undertaken to ensure Maine 0 0
eradication. New Hampshire 1 0·08
Vermont 0 0
Animal brucellosis exists throughout Central Massachusetts 8 0·13
America36 but human disease is not endemic. Guatemala Rhode Island 0 0
and Panama are exceptions, according to annual data Connecticut 2 0·06
from the World Organisation for Animal Health (OIE).7,8 Mid-Atlantic 27 0·07
New York 13 0·07
South America has been traditionally considered an New Jersey 3 0·04
endemic area of human brucellosis, B melitensis being Pennsylvania 11 0·09
prevalent in Peru and west Argentina, and B abortus in East north central 111 0·25
east Argentina37,38 and other South American countries. Ohio 12 0·11
Indiana 1 0·02
Data from the OIE imply that brucellosis is still Illinois 68 0·57
important in Peru and Argentina.8 There are no data Michigan 24 0·24
available for Brazil, which hosts the largest commercial Wisconsin 6 0·11
cattle population in the world, and is presumably at risk West north central 52 0·28
Minnesota 9 0·19
of increased prevalence of human B abortus disease. Iowa 22 0·77
Under-reporting may be an obstacle in evaluating the Missouri 15 0·27
true incidence in Brazil39 and neighbouring countries: North Dakota 0 0
South Dakota 1 0·13
brucellosis is not included in the notifiable diseases for
Nebraska 2 0·12
which surveillance is active (even in Peru). With the Kansas 3 0·11
exception of Peru and Argentina, South America should South Atlantic 126 0·26
be excluded from the highly endemic global zones of Delaware 2 0·27
Maryland 5 0·1
human brucellosis.
DC 1 0·19
Virginia 6 0·09
European Union/western Europe West Virginia 0 0
Brucellosis-free status has been granted by the European North Carolina 46 0·61
South Carolina 3 0·08
Union (EU) to Sweden, Denmark, Finland, Germany,
Georgia 18 0·23
the UK (excluding Northern Ireland), Austria, Florida 45 0·3
Netherlands, Belgium, and Luxembourg.40 Norway and East south central 23 0·14
Switzerland are also considered brucellosis-free Kentucky 4 0·1
Tennessee 7 0·13
countries. Most of these countries do report a small
Alabama 7 0·16
number of cases annually, mainly in travellers to Mississippi 5 0·18
endemic countries or immigrants from endemic West south central 310 1·03
areas.41,42 A B abortus epidemic has been evolving since Arkansas 24 0·95
Louisiana 8 0·18
1998 in Northern Ireland, with 89 cases in total. Re- Oklahoma 5 0·15
emergence of human brucellosis does not seem possible Texas 273 1·38
in western Europe, especially since adequate Mountain 91 0·54
surveillance systems exist. Eradication campaigns in Montana 1 0·11
Idaho 5 0·41
southern European member countries will probably Wyoming 7 1·46
prevent trafficking of the disease inside the EU. Colorado 18 0·45
The Mediterranean basin is an acknowledged endemic New Mexico 12 0·69
region of human brucellosis. The disease was initially Arizona 43 0·92
Utah 5 0·24
described in Malta, where sporadic cases are noted Nevada 0 0
nowadays. Pacific 305 0·7
France is an example of successful eradication. More Washington 10 0·17
than 800 cases of human brucellosis were reported in Oregon 8 0·24
California 272 0·83
1976, declining to 405 cases in 1983, 125 cases in 1990, Alaska 2 0·33
and 44 cases in 2000.43 According to OIE data for the Hawaii 13 1·09
following years, the annual number of cases reported Total 1056 0·39
remained low.7 Most of these cases are due to localised
*Average incidence for 1993–2002, derived from the annual summaries of notifiable
outbreaks in southern provinces, and are related to the disease of the Centers for Disease Control and Prevention.18 1998 population used in
consumption of dairy products imported from Spain. estimating incidence, as provided in the same source.

The evolution of eradication is also represented in Table 2: Reported cases and annual incidence of brucellosis in the USA,
regional distribution. Corsica reported most of the 1994–2003
national cases during 1990–95, yet no cases were

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 Review
Annual incidence of brucellosis
per 1000 000 population
1
0·5–1
0·1–0·5
0·1
No cases
Figure 2: Brucellosis incidence in the USA, 1993–2002
reported in the past 3 years. Small foci still exist in the
southeastern provinces of Savoie and Alpes Maritimes.
Although massive progress has been achieved in
minimising human disease in Spain, the country still has
one of the highest annual incidences in Europe. Data are
available for 1997–2003 from the National Centre of
Epidemiology.12 A substantial, consistent decline in
annual number of cases is evident, reaching an all-time
low of 642 cases in 2003. This decline is reflected in most
autonomous communities. However, the annual
incidence remains high in Andalusia, Castille-La Mancha,
Aragon, and Castille-Leon (70, 68, 60, and 56 cases per
million per year, respectively). The highest annual
incidence is noted in Extremadura, but the situation in
this region has been improving substantially throughout
this period. Although the consistent decline in the
incidence of human brucellosis in Spain underlines the
systematic national approach towards disease control,
Spain remains an endemic area. However, one can be
confident that the situation will change, approaching the
French situation, in the years to come.
Portugal has achieved pronounced progress in
minimising human brucellosis. Data from the
Portuguese Ministry of Health11 for 1999–2003 indicate a
steep decline in annual incidence, from 70 cases per
million in 1999 to less than 14 cases per million in 2003.
The progress is attributed to enhanced control in certain
endemic northern and central districts. However, the
situation has not improved substantially in southern
regions—eg, the district of Alentejo, where the annual
incidence remains high. This district neighbours the
endemic region of Extremadura in Spain; as already
discussed, the situation in Extremadura has improved in
recent years, and it will be interesting to observe the
dynamics of human disease trafficking, and particularly
whether persistence of the disease in the Portuguese
region will induce a resurgence in the Spanish region.
94
In Italy, a unique pattern in the epidemiology of
human brucellosis has been observed between 1994
and 2003, according to data derived from the Italian
Ministry of Health.10 A steady decline in the number of
annual cases has been consistently observed over the
past 30 years: in 1976, 3318 cases were reported in
total, and by 1986 the annual number of cases dropped
below 2000. A gradual, although inconsistent, decline
was subsequently observed. However, the annual
incidence of the disease has not dropped in a uniform
fashion across the country: of the 520 cases reported in
2003, 488 (93·2%) were reported from four southern
regions, compared with 63·7% in 1994. Sicily alone
reported 57·6% of the 2003 cases. The average annual
incidence for Sicily, Calabria, Puglia, and Campania
was 111, 48, 44, and 37 cases per million, respectively.
None of the northern and central regions reported
more than ten cases in 2003, and these cannot be
attributed to local epidemiological factors. In Italy,
human brucellosis has travelled to the south,
something explained by socioeconomic factors; the
schism of Italy to the rich north and the poor south is
nowhere more pronounced than in the incidence of
human brucellosis.
Greece remains in the list of the 25 countries with the
highest incidence worldwide. The annual incidence,
according to data from the Centre for Special Infections
Control9 is gradually declining. Concern exists that these
data may not represent the actual situation: the data is
generally inconsistent—eg, in 1995 only six cases were
officially reported. Under-reporting is also evident in the
regional distribution of cases, since the annual number
of cases reported for the northwestern region of Epirus
represents a gross underestimation according to our
personal experience and a recent epidemiological study
in this area.44 One reason for poor reporting, apart from
inadequate awareness from private sector practitioners,
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 Review

is that a percentage of new cases consists of patients

living in southern Albania, who commonly seek medical
advice in Greece. These patients are reported neither in
Greece nor in Albania. Even with official estimates, the
annual incidence in Epirus is high—over 70 cases per
million per year. Various parameters account for the Brucellosis status
Endemic
increased incidence in this region: illegal trafficking of Brucellosis free
herds or even dairy products through the Non-endemic
Greek/Albanian border, inadequate implementation of
control programmes,45 poor health literacy of both
general population and medical practitioners, fear of
economic losses through slaughtering of infected
livestock belonging to patients undergoing
epidemiological surveillance, and most importantly, the
overall socioeconomic status of the area. A measure of
the relation between brucellosis endemicity and
socioeconomic status can be drawn from the gross
domestic product (GDP) for certain endemic regions of
the EU, such as Epirus. Figure 3 shows the GDP values
of various EU regions: the endemic areas of Portugal
and Greece are characteristically the poorest areas of the
EU. The disease is also widespread on the Greek
mainland, with the average annual incidence for
Thessaly, northern Greece, and Peloponissos
approaching 120, 51, and 48 cases per million,
respectively. Figure 4 depicts the brucellosis free and
endemic regions of western and southern Europe.

The Balkan peninsula

Apart from Greece, two other countries in the Balkan
peninsula have the highest disease incidence in Europe.
In the Former Yugoslav Republic of Macedonia, human
brucellosis is almost an epidemic, although the annual
incidence is gradually decreasing.8 The incidence is also
high in Albania,6 where a substantial degree of under-
100
80
Incidence
Figure 4: Brucellosis status in Europe
reporting exists due to inadequate health networks and
patient migration to Greece. The effect such an endemic
site exerts on neighbouring countries has been already
discussed, but is further underlined by a recent increase
in the reported cases from Bosnia-Herzegovina,7 and in
the region of Kosovo, where, according to the data from
OIE,7 the annual incidence for 2004 approached 20 cases
per million.

60

40
20
0
40·0 60·0 80·0 100·0 120·0 140·0
GDP
Figure 3: Gross domestic product and endemicity of brucellosis for EU
regions and countries
Gross domestic product (GDP) according to official EU data.46 Data as follows (in
parentheses, endemicity in annual cases per million of population and GDP as
the percentage of median EU GDP before the expansion, respectively). Greece:
Thessaly (87·5/60·2), Epirus (31·4/54), northern Greece (24·6/65·2). Italy: Sicily
(60·4/65·3), Calabria (19·9/62·1), Campania (15·6/65·1), Puglia (14·7/65),
Piemonte (1·4/115·1), Lombardia (0·9/131·3), Toscana (0·6/111·1), Emilia
Romana (0·5/126·2), Veneto (0·2/115·8). Portugal: Alentejo (56·2/56·9),
central (27·5/56·9), north (8·4/56·9), Lisbon and Vale do Tejo (4·7/94·7). Spain:
Extremadura (54·1/53·5), Castille-La Mancha (51·6/67·1), Andalusia
(32·5/63·1), Castille-Leon (31/78), Catalonia (7·7/100·7), Madrid (5·2/112·4),
Basque country (1·4/105·1). Denmark: (2·6/115·3). Germany: (0·3/100·4).
France: (0·5/104·8). Ireland: (1·3/117·6). Sweden (0·3/106·1). UK: (0·3/105·4).
Eastern Europe
Brucellosis is not endemic in eastern Europe.
Characteristically in Poland, the disease is limited to
veterinarians or is imported from Mediterranean
countries.47 Brucellosis in Russia nowadays is mainly a
disease of the Caucasian districts—eg, Dagestan, where
the annual incidence exceeds 100 cases per million of
population48—and districts neighbouring republics of
the former Soviet Union with a high incidence of
brucellosis. However, substantial under-reporting may
also exist.
Asia
The middle east has traditionally been considered as an
endemic area. Indeed, five of the ten countries with the
highest incidence for human brucellosis are in this
area.

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 Review
Syria has the highest annual incidence worldwide,
reaching an alarming 1603 cases per million per year
according to data from OIE.7 The annual cases reported
are practically doubling each year, although this may be
attributed to enhanced surveillance.
An increase in the annual number of cases reported
has been also observed in Turkey, exceeding
15 000 cases in 2004.7 Brucellosis is particularly
endemic in the poor eastern regions. Numerous reports
have addressed the epidemiology of the disease in
isolated areas from this region,49 although a coordinated
national approach is still missing. The relation of poor
socioeconomic status and brucellosis incidence, as
outlined in the EU, probably applies here too:
numerous studies focusing on seroprevalence,
summarised by Cetinkaya and colleagues,50 show that
the proximity of a region either to Europe or to Ankara
is accompanied by lower seroprevalence rates, possibly
due to enhanced application of the Turkish Brucellosis
Challenge Project that has been running for the past 20
years.50
The situation in Iran is improving, according to data
from the National Commission on Communicable
Diseases Control. In 1989 the annual incidence exceeded
1000 cases per million;51 in 2003, the annual incidence
had fallen to 238·6 cases per million.8 Still, human
brucellosis remains a huge burden for this country.
Data from OIE were recently made available for the
incidence of human brucellosis in Iraq,7 underlining the
huge endemicity of the disease in this region, despite
ongoing attempts to control both animal and human
disease.52,53 Whether control can be achieved in a state
still plagued by war and famine is questionable;
moreover, the endemicity of the disease in this area may
raise concerns, since a purely endemic brucellosis case
in an international soldier stationed in Iraq might cause
alarm of a possible biowarfare incident. Similarly, the
endemicity of the disease in Afghanistan cannot be
disputed, although substantial data are lacking. The first
official report from the OIE from the region, in 2004,7
with an estimated incidence of 3·8 cases per million of
population, might be a gross underestimation of the
actual incidence.
Brucellosis is endemic in the southern region of
Oman, with an annual incidence exceeding 1000 cases
per million.7
Saudi Arabia is also a vast reservoir of human
brucellosis. Regional endemicity varies in Saudi Arabia,
partly according to climate factors: a rainy season in an
area would result in increased grass growth and thus
influx of shepherds and flocks.54 The increased
incidence of brucellosis in this country is also attributed
to massive importations of uncontrolled slaughter
animals and inadequate quarantine procedures.55 The
absence of health literacy, which could interrupt the
direct link between animal and human disease, is also
critical.56
96
In the United Arab Emirates, most cases are reported
from Dubai,25 a popular international travel destination,
underlining the importance of the disease in the field of
travel medicine.
Kuwait is a prime example of modification of the
epidemiology of human brucellosis by political factors:
20 years ago, the annual incidence exceeded 500 cases per
million, mainly due to widespread animal brucellosis.51
Massive loss of livestock during the 1991 Iraqi invasion
resulted in a substantial decrease in human cases in the
following years; however, this decrease was not sustained
over time,7 and the region is still endemic.
In Jordan, the estimated incidence of human
brucellosis exceeded 300 annual cases per million in the
recent past.57 Data from the Ministry of Health denotes
ongoing control of the disease between 1996 and 2003.20
Similar control has been achieved in Israel, a country
that can no longer be considered endemic.7 However, an
increased number of cases reported by Palestine in
recent years58 could endanger the continuing decline of
brucellosis prevalence in Israel.
Endemicity of the disease in Lebanon has been steady
over the past 10 years, especially in the Beqaa region,
according to data from the Ministry of Public Health.22
One distinct characteristic of the disease in this country
is that the most cases are noted in female patients, by
contrast with the rest of the world, possibly reflecting an
increased transmission as a foodborne disease (via milk
consumption) or increased participation of women in
procedures associated with brucellosis transmission (eg,
milking).
Seven republics of the former Soviet Union are
included in the 25 countries with the highest incidence
of the disease worldwide, while another country of this
region, Mongolia, is ranked second. The situation in
central and western Asia is dramatic: in Kyrgyzstan,
control of brucellosis has become a national priority,
since the already extremely high prevalence may
actually be tripling: more cases were reported in the
first half of 2003 than in the whole of 2002.59 In
Tajikistan and Kazakhstan the annual cases reported
are rapidly increasing, according to OIE data, when
compared with WHO data from 1993–98.60 A rapid
increase can be observed in Mongolia according to data
from the National Statistic Office for the period up to
2000.23 Data from the Ministry of Health of Azerbaijan
for the years up to 2000 show that the annual incidence
is declining.61 Data from OIE7,16 show a steady incidence
pattern for Armenia, Georgia, Uzbekistan, and
Turkmenistan.
These countries have emerged as the most important
loci of human brucellosis worldwide in recent years, and
the seemingly uncontrollable, constantly increasing
incidence poses a serious public-health problem,
especially in the context of inadequately developed
health-care networks. Moreover, since a substantial
percentage of the population in these countries relies on
http://infection.thelancet.com Vol 6 February 2006

livestock for their survival, the disease affects the
economic stability of these countries.
How did these new foci of brucellosis emerge? All of
these countries were part of the former Soviet Union, or
were Eastern bloc satellite states. The evolution from a
socialist state to free market economy resulted in the
loss of strict livestock control. Furthermore, the
transition of the health system during this period
precluded early recognition of the disease, or
intervention for the emerging trends in human beings
and animals.62 Economic instability precludes further
planning of such interventions, even if proven cost
effective.63 However, it is possible that the endemic was
already underway, but under-reporting took place
before political transition. Either way, central policy
directly influenced the natural history of human
brucellosis in these areas, and international
intervention is urgently needed. Interest and financial
and scientific support from international organisations
could be of huge benefit for these countries, but has not
yet emerged.
Most data available about the prevalence of
brucellosis in China are derived from the work of Deqiu
and colleagues.64 A massive vaccination programme of
the human population at risk of acquiring brucellosis
took place between 1964 and 1976. The annual number
of cases reported exhibited a gradual decline, reaching
an all-time low of almost 500 cases in 1994. Thereafter
annual number of cases increased, approaching
1500–3000, without a reciprocal increase in the
prevalence of animal brucellosis. This discrepancy may
be attributed to increased awareness and enhanced
laboratory diagnosis; however, others propose a relation
with climate factors such as the periodicity of the El
Niño phenomenon.64 A steep increase in the reported
cases of human brucellosis was noted during the first
half of 2004, with cases for this period reaching 5753,
according to the Chinese Ministry of Health.19
B melitensis is the commonest pathogen isolated,
although B abortus and B suis prevail in certain
provinces (Sichuan and Guangxi/Guangdong,
respectively). The geographic distribution has also
evolved, with the disease travelling south. Until 1980
the incidence was highest in the provinces of Inner
Mongolia, Jilin, and Helongiiang, in northeastern
China. However, in the past 15 years the prevalence is
highest in the eastern central provinces of Shanxi,
Hebei, and Henan. Tibet remains a region with
increased endemicity.
According to data from OIE,7 an increasing number of
human cases of brucellosis has been noted during
2003–04 in South Korea, the aetiology and significance
of which remains obscure.
The disease is endemic in India, with numerous
reports of cases from isolated areas in the literature,65
and an acknowledged prevalence of animal brucellosis,66
but official data of the incidence of human disease are
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Review
lacking. Animal disease exists also in Pakistan, but there
are no data for the incidence of human disease.
Australia
A limited number of cases of human brucellosis are
reported annually from Australia, according to the
National Notifiable Diseases Surveillance System,26
almost exclusively from the area of Queensland, one of
the poorest areas of the country.
Africa
North Africa has been traditionally considered endemic
for brucellosis. Data on the prevalence of the disease in
Egypt are scarce, with reports from national authorities
probably underestimating the true prevalence of the
disease, since they are derived from selected medical
institutions.16 There are also no official data for Morocco;
the disease may be endemic along the
Moroccan/Algerian border. Limited data exist about
Libya, while the incidence in Tunisia may be an
underestimate of the actual situation.7 Algeria has the
tenth highest annual incidence worldwide,8 but the
annual number of cases reported remained steady
during the last decade. Various WHO programmes have
focused on controlling brucellosis in these countries,51
although available data would support the urgent need
for such intervention only for Algeria and Tunisia.
Brucellosis exists throughout sub-Saharan Africa, but
essentially nothing is known about its prevalence. Most
African countries are of poor socioeconomic status, with
people living with and by their livestock, while health
networks and surveillance and vaccination programmes
are virtually non-existent. Moreover, there are far more
morbid endemic infectious diseases, particularly
malaria. Most febrile patients in these countries are
initially empirically diagnosed as suffering from
malaria, and only a small part of non-responders may be
further tested for brucellosis. Most of the data are
derived from small seroepidemiological studies of
patients with fever or high-risk populations.67 According
to data from OIE for 2004,7 Cameroon, Ethiopia, Kenya,
Nigeria, Tanzania, and Uganda reported the existence of
human cases of brucellosis, while in 2003 similar
reports8 existed for Burkina Faso, Republic of Congo,
Eritrea, Mali, Namibia, and Swaziland. Ghana, Togo,
and Chad are probably also endemic according to
seroepidemiological studies.67,68
Brucellosis cannot be considered an emergency for
Africa since there are other, more morbid, infectious
priorities. Moreover, control of animal disease might
incorporate the slaughtering of infected animals (since
mass vaccination campaigns demand funds and
adequate health-care networks), further compromising
the socioeconomic status of the susceptible population;
in Africa, one can assume, it is better to live with
brucellosis than try to eradicate it and then starve to
death.
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 Review
Search strategy and selection criteria
Data on the prevalence of human brucellosis for each country
from 1990 onwards were sought from health ministries or
other official national organisations, public-health
international organisations, and the medical literature.
Medical literature was searched through Medline (but also
general search engines), using “brucella” or “brucellosis” and
individual country and region names as keywords. PROMED-
mail was also used, searching with the keywords “brucellosis”
and individual country names. When available, official
national data were used, even if not in concordance with data
from international organisations. For countries without such
official data, data from international organisations were used.
Medical literature was used only when including
epidemiological information, or (in the case of
seroprevalence studies) in the absence of any other data
regarding disease status in a country. Serial data on incidence
were evaluated for the presence of epidemiological trends
correlating with sanitary, socioeconomic, and political
characteristics of individual countries. In calculating the
annual incidence, when this information was not provided in
the source references, population data derived from official
publications such as the CIA World Factbook71 were used.
Conclusions
The traditional perception of human brucellosis, as
reproduced in most reviews of the disease,69,70 is of a
zoonotic disease prevalent in countries of the
Mediterranean basin, the near east, South America, and
possibly sub-Saharan Africa. Yet, in the past 15 years, the
epidemiology of human brucellosis has evolved,
reflecting alterations in socioeconomic parameters,
improvements in recognition and notification systems,
outcomes of ongoing eradication programmes of animal
brucellosis, and the evolution of the “global village”
through international tourism. New endemic foci have
emerged, warranting eradication programmes that
escape national boundaries. Financial and scientific
support from international organisations should target
the new endemic areas and become a global health
priority. Enhanced surveillance of human brucellosis
may be responsible for the alteration in the endemicity
of the disease in certain countries, but this fact serves
only to underline the magnitude of the problem and the
possibility of it further inflating in the near future. The
fact that the continuing existence of human (and animal)
brucellosis extends beyond medical and veterinary
duties and encompasses political factors goes to show
that the eradication of the disease will not be an easy task
for the future.
Conflicts of interest
We declare that we have no conflicts of interest.
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