Guidance

Appendix 2: Supplementary evidence

Updated 9 October 2025

Applies to England

Additional evidence to support the development of the TB guidance.

2.1 TB in England in the prison setting

Transmission of TB to residents and staff is not uncommon in secure settings. During a UKHSA review of 6 TB outbreak summary reports in England and Wales between 2017 and 2024, 10% of the TB disease cases were amongst staff [1]. Staff may have prolonged close contact, for example, during hospital bed watch with variable use of personal protective equipment (PPE). Movement of residents with TB and their contacts within the prison estate (and to and from the community) can widen the settings affected. This can lead to TB outbreaks, large numbers of potential contacts and complex contact tracing exercises.

Recent biobehavioural surveys conducted in 8 prisons and 2 IRCs, commissioned by UKHSA between 2022 and 2024, found that 166 of the 2,209 (7.5%) individuals tested overall were IGRA positive, suggestive of current or previous infection with Mycobacterium tuberculosis. IGRA positivity rates varied considerably between the different secure settings included in the survey, with the highest seen in 2 IRCs (18%, 95% confidence interval (CI) 14.1 to 21.9%), then a foreign national men’s prison [2] (13.9%, 95% CI 9.6% to 18.2%) and the lowest rates seen in an adult mens’ category C prison, with 2% of individuals testing positive (95% CI 0.1% to 4%). IGRA positivity was significantly higher in those born in a country with medium TB incidence (between 40 and 150 cases per 100,000 per year) or high TB incidence (more than or equal to 150 cases per 100,000 per year) [3].

Data from a UKHSA review of 6 TB outbreak summary reports in England and Wales between 2017 and 2024 showed that 10% of the TB disease cases were among staff.

2.2 TB in other secure settings 

TB in children: TB is rare in children and young people in England, with 358 cases notified in people aged 0 to 19 years old in 2023. The population of the children and young people secure estate (CYPSE) was under 550 in 2024. In the event that a TB case did occur, it would be managed on an individual basis depending on the specific governance arrangements of the setting in which it occurred [4].

Forensic NHS hospitals: these have a small population size; TB incidence is low and these settings have close links to NHS services to facilitate referral pathways.

Police custody and courts: these settings are likely to have brief contact with affected individuals and opportunities to provide TB screening or care will be limited. TB cases or outbreaks in these settings would be managed on an individual basis by HPTs.

Mass accommodation sites, such as Manston in Kent for people arriving by small boats and contingency hotels for people seeking asylum, are subject to different guidance [5],[6].

2.3 Summary of community engagement work on TB in secure settings (December 2024 to February 2025)

Across 8 different focus groups, the UKHSA National Health & Justice team spoke with around 30  prisoners in prisons or residents of approved premises (APs) and around 40 staff working in these secure settings.

This included:

• 3 in-person focus groups with prisoners (17 males and 7 females in total), co-facilitated by EP:IC
• one in-person focus group with 9 members of secure staff in a male prison, co-facilitated by EP:IC
• one in-person focus group with 5 residents and 3 staff in an AP
• one online focus group with 7 regional AP staff across England
• 2 online focus groups with healthcare providers in prisons in North West and South West regions (approximately 20 participants)

General themes

Poor baseline understanding

Baseline understanding was very poor (“I know very little”), and there were common misconceptions, including the belief that TB is linked to being unhygienic or “dirty”. Some associated TB with people drying their clothes and in the moisture in prisons. 

Enthusiasm to learn more

There was a tremendous amount of enthusiasm and engagement in all focus groups from both staff and residents with a real appetite to learn more about TB.

Information for secure staff

Secure staff also wanted to be better informed to know how they could protect themselves from risk whilst at work: “…there’s stuff that prisoners have that we could really do with knowing so we know how to best look after them and protect ourselves…”

Reception screening

Many prisoners preferred screening to occur a few days after arrival rather than on the first night, reporting that the first night in prison is overwhelming and stressful, leading to lower prioritisation of health: “You’re drained… you just want to get settled into your room.”

Reporting symptoms

Prisoners often feel overlooked and dismissed when raising health concerns, reporting “people have to kick off to get anything done… otherwise you get ignored.” Additionally, some were reluctant to report symptoms due to fears of isolation and the stigmas associated with TB.

TB testing

Hospital visits were noted as a significant barrier to seeking care due to fears of being judged or stared at. Prisoners expressed a strong preference for in-reach X-ray services, which they believed would increase their likelihood of getting tested.

Medication

Prisoners often noted structural barriers which prevented them taking their medications such as prison lockdowns and sometimes this would be recorded as a “refusal to take medication” even if it was beyond their control. 

Isolation

Prisoners highlighted the need to consider the wider effects of isolation on mental health and also the need to minimise routine disruption wherever possible.

Continuity of care

Supporting prisoners on release to access healthcare and improve continuity of care of someone on TB treatment was highlighted as a priority area.

Awareness and knowledge

Engagement work during guidance development has highlighted the need to strengthen awareness and knowledge of TB which is often poor among staff and residents, leading to delays in diagnosis and onwards transmission in secure settings. There was a huge appetite to learn more when they understood how serious the infection can be and how it can be prevented and treated successfully with antibiotics. There are also notable exceptions where local TB ‘champions’ have successfully strengthened TB awareness and management and are exemplars of good practice.

References

1. OFFICIAL SENSITIVE Internal UKHSA analysis of 6 TB outbreak reports in prisons in England and Wales between 2017 and 2024.

2. Offender management statistics quarterly: April to June 2024

3. TB profile

4. TB in children: incidence, epidemiology and microbiology in England, 2021

5. Outbreak management in short term asylum seeker accommodation

6. Migrant health guide