East Midlands: tuberculosis in 2023
Published 4 September 2025
© Crown copyright 2025
This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gov.uk.
Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.
This publication is available at https://www.gov.uk/government/publications/tuberculosis-tb-regional-reports-2023/east-midlands-tuberculosis-in-2023
Incidence, treatment and prevention of tuberculosis (TB) in the East Midlands region using data up until the end of 2023
Executive summary
In 2023, there were 397 tuberculosis (TB) case notifications for individuals resident in the East Midlands, a rate of 8.0 cases per 100,000 population (95% confidence interval (CI) 7.2 to 8.8). There has been a year on year increase in TB notifications since 2020, with a 3% increase in TB cases between 2022 and 2023. The East Midlands TB rate remains lower than the TB rate in England as a whole (8.4 per 100,000, with a 95% CI 8.2 to 8.7).
Leicester local authority had the highest TB rate in the East Midlands in 2023, with 43.2 cases per 100,000. This is followed by Derby (12.4 per 100,000) and Nottingham (11.5 per 100,000). Increases in cases were observed between 2022 and 2023 in 5 out of the 10 local authorities in the East Midlands. Leicester local authority also had the highest average TB rate in England between 2021 and 2023.
The highest age and sex specific rates of TB in the East Midlands were recorded among men aged 20 to 29 years (17.1 per 100,000) and women aged 20 to 29 years (12.7 per 100,000).
In 2023, the majority of people with TB in the East Midlands were born outside the UK (78%). The number of cases born outside of the UK has increased by 2.3% between 2022 and 2023 (311 versus 304 in 2022) and has been increasing since 2020. The number of TB notifications in the East Midlands among UK-born individuals also saw an increase in 2023.
Among people with TB who were born outside of the UK, the highest proportion of cases occurred in those that had been in the UK for less than 2 years prior to their diagnosis (29.3%). This has seen an increase since 2022.
India continues to be the most common country of birth for people with TB in the East Midlands, accounting for just over one third of cases (36.3%). This was followed by the UK (21.7%) and Romania and Pakistan (both less than 10%). The number of cases from India increased between 2022 and 2023.
In 2023, 62.2% of TB cases diagnosed were pulmonary TB which is generally considered infectious. Of those, only 74.9% of pulmonary TB cases were confirmed by culture of a TB isolate, which is below the national target of 80%. Over one quarter of people with pulmonary TB in the East Midlands had a delay of more than 4 months from becoming unwell to starting treatment (29.4%). Contact tracing for pulmonary cases of TB found a median of only 3 contacts identified and screened per case.
In the East Midlands, 22.4% of TB cases reported having at least one of the named comorbidities, with diabetes being the most commonly reported (11.1%). HIV tests were offered to the majority of eligible people with TB in 2023 (97.4%), with nearly all of these receiving a test.
Treatment was completed within 12 months by 76.5% (247 out of 323) of people with non-multidrug-resistant (MDR) or non-rifampicin resistant (RR) TB diagnosed in 2022 whose expected treatment duration was less than 12 months, which is lower than completion rates in the previous 4 years in the East Midlands. The most common reason for not completing treatment was treatment being stopped (5.3%) and lost to follow up (5.0%).
Of the culture-confirmed TB cases in the East Midlands, 12.6% had first line drug resistance. This is a decrease compared to 2022 (17.1%), which was the highest proportion in recent years.
TB continued to be associated with deprivation, with higher TB case rates among residents in more deprived areas in the East Midlands. People with at least one recorded social risk factor for TB (including alcohol misuse, asylum seeker, drug misuse, homelessness, mental health needs, and prison), accounted for 16.8% of TB cases which is an increase from 2022 and the highest figure in recent years. In addition, 7.2% of TB cases had more than one social risk factor for TB recorded. Having a social risk factor was more common in male TB cases and those who were UK-born. In 2023, 38.8% of cases required enhanced case management.
In conclusion, the overall number of TB notifications has increased in the East Midlands, and renewed efforts are required to reverse this trend and achieve the World Health Organization’s (WHO) End TB Strategy target by 2035. TB needs to remain a health priority. Importantly, this report demonstrates how the burden of TB falls on more socio-economically challenged groups, and the high number of individuals with TB and social risk factors underlines the need for services to work collaboratively, across the range of health and social care issues. A continued effort is needed to support the early diagnosis of TB and deliver effective packages of TB care to maximise treatment completion and minimise transmission.
Data for all the graphs in this report can be found in the East Midlands TB supplementary data 2023 spreadsheet.
TB incidence and epidemiology
In 2023, 397 cases of tuberculosis (TB) were notified in residents in the East Midlands, a rate of 8.0 cases per 100,000 population (95% CI from 7.2 to 8.8) (Figure 1). This represents an increase of 11 cases from 2022. The rate of TB in the East Midlands remains lower than the overall rate for England (8.4 per 100,000, with a 95% CI from 8.2 to 8.7) (Figure 2) (1).
Case numbers had been gradually declining in the East Midlands since the early 2000s but have increased over the past few years, mirroring the national trend. There was a 3% increase in the East Midlands rate between 2022 and 2023 compared to a 9% increase in the number of people with TB in England over the same period (7.7 per 100,000 in 2022 versus 8.4 per 100,000 in 2023) (1).
The TB notification rate in the East Midlands is currently higher than the rate required to meet the WHO End TB 2035 goal of a 90% reduction in TB incidence (2). The required rate for 2023 is 4.9 per 100,000 (Figure 3).
Figure 1. Number of TB notifications per year, East Midlands, 2001 to 2023
Figure 2. TB notification rates per 100,000 population per year, East Midlands, 2001 to 2023 [note 1]
Note 1: error bars represent upper and lower 95% confidence intervals.
Figure 3. Observed TB notification rate compared with required TB notification rates to meet the WHO End TB 2035 goal of 90% reduction in incidence by 2035, East Midlands, 2015 to 2023 [note 2] [note 3]
Note 2: error bars represent upper and lower 95% confidence intervals.
Note 3: dashed line represents required TB notification rates to meet the WHO End TB 2035 goal of 90% reduction in incidence by 2035.
The local authority with the highest TB notification rate in 2023 was Leicester where the rate of TB was 43.2 per 100,000, followed by Derby (12.4 per 100,000) and Nottingham (11.5 per 100,000) (Figure 4, Figure 5). TB cases in Leicester accounted for 41.3% (164 out of 397) of all East Midlands TB cases in 2023. Leicester became the local authority with the highest average TB rate in England between 2021 and 2023 (1).
Case numbers decreased between 2022 and 2023 in 5 out of 10 local authorities, with the largest reduction in numbers observed in Nottingham (down 25.5%, 38 cases versus 51 in 2022). Another large reduction in cases was observed in Lincolnshire (down 14.3%, 30 cases versus 35 in 2022). An increase in cases was observed in 5 out of 10 local authorities between 2022 and 2023. The largest increases in cases were observed in Derbyshire (up 26.1%, 29 cases versus 23 in 2022), and Leicester (up 17.1%, 164 cases versus 140 in 2022).
Figure 4. TB notification rate by upper tier local authority of residence, East Midlands, 2001 to 2023 [note 4]
Note 4: the blue line represents the upper tier local authority noted and the grey lines represent the other upper tier local authorities in the region as a comparator.
Figure 5. TB notification rate by upper tier local authority of residence, East Midlands, 2023
In 2023, 61.7% (245 out of 397) of people with TB in the East Midlands were male, and the rate was higher among males than for females (Figure 6 and Figure 7). Using 10-year age groups, rates and absolute numbers were highest for those aged 20 to 29 years for both males (53 cases, 17.1 per 100,000) and females (38 cases, 12.7 per 100,000). There were more male cases than female cases in all age groups except the 0 to 9 years and 80 years and over age groups where 60% (3 out of 5) and 50% (6 out of 12) were female respectively.
Figure 6. Number of TB notifications by age and sex, East Midlands, 2023
Figure 7. TB notification rate by age and sex, East Midlands, 2023
The rates of TB among people born outside the UK should be interpreted in the context of changes to the pre-UK entry screening policies. In 2005 the UK piloted the pre-entry screening of long-term migrants to the UK for active pulmonary TB in 15 high TB incidence countries. In 2012 this pre-entry screening was extended to all countries with a high incidence of TB (more than 40 cases per 100,000 population) (3).
In 2023, 100% of TB cases had a recorded country of birth, and of these, over three-quarters (78%, 311 out of 397) were born outside the UK which is similar to the proportion nationally (80%) (Figure 8). In 2023, the number of TB notifications increased by 2.3% in people born outside of the UK (311 in 2023 versus 304 in 2022) and increased by 4.9% in those that are UK-born (86 in 2023 versus 82 in 2022).
Since 2020, there has been an increasing trend in the number of people in the East Midlands with TB that were born outside of the UK.
Figure 8. Number of TB notifications in non-UK-born and UK-born people by place of birth, East Midlands, 2001 to 2023
In 2023, the number of TB notifications in cases born outside of the UK were highest in the 15 to 44 years age group (194 cases). For UK-born cases, TB notifications were highest in those aged 45 to 64 years (30 cases) (Figure 9).
The age distribution of TB cases varied between patients born within and outside the UK. For the 0 to 14 years age group the proportions were broadly similar between the UK-born and non-UK-born cases (5.8% UK-born versus 1.6% non-UK-born). The proportion of cases 15 to 44 years old was much higher in non-U-born cases compared to UK-born cases (33.7% UK-born versus 62.4% non-UK-born). For the 45 to 64 years age group the proportion of cases was slightly higher in UK-born cases (34.9% UK-born versus 26.4% non-UK-born). The proportion of cases in the 65 years and over age group was much higher in UK-born cases compared to non-UK-born cases (25.6% UK-born versus 9.6% non-UK-born).
The number of non-UK-born cases aged 15 to 44 years has increased year-on-year since 2020. The numbers have remained relatively stable or decreased in the other age groupings.
Figure 9. Number of TB notifications in non-UK-born and UK-born people by place of birth and age group, East Midlands, 2001 to 2023
In cases notified in 2023, the year of entry to the UK was reported by 77.8% (242 out of 311) of TB patients born outside of the UK. Of those, the largest proportion (29.3%, 71 out of 242) had arrived in the UK less than 2 years prior to their TB diagnosis, this represents an increase in the number of TB cases that had arrived less than 2 years prior compared to recent years (Figure 10). The second largest proportion (27.7%, 67 out of 242) had arrived in the UK 11 or more years prior to their TB diagnosis, this suggests these cases could be reactivation of latent disease, although some could be new acquisitions.
Figure 10. Proportion of TB notifications by time since entry for people born outside the UK, East Midlands, 2001 to 2023
In 2023, as in previous years, the most common country of birth for all TB cases notified in the East Midlands was India (36.3%, 144 out of 397), and the median time since entry to the UK was 5 years (interquartile range (IQR) 1 to 11 years) (Table 1). The next most frequently reported countries of birth were:
- the United Kingdom (21.7%, 86 out of 397)
- Romania (5.5%, 22 out of 397)
- Pakistan (4.5%, 18 out of 397)
- Eritrea (3.5%, 14 out of 397)
The 5 most common countries of birth made up 71.5% of all cases (284 out of 397). There were less than 10 TB cases notified from all other countries of birth.
Table 1. Most common countries of birth for people with TB and time between entry to the UK and TB notification, East Midlands, 2023 [note 5]
| Country of birth | Number of people notified with TB | Proportion of people notified with TB (%) | Median time since entry to UK in years | IQR of time since entry to UK in years |
|---|---|---|---|---|
| India | 144 | 36.3 | 5.0 | 1.0 to 11.0 |
| United Kingdom | 86 | 21.7 | Not applicable | Not applicable |
| Romania | 22 | 5.5 | 6.5 | 3.0 to 8.0 |
| Pakistan | 18 | 4.5 | 6.0 | 1.0 to 26.0 |
| Eritrea | 14 | 3.5 | 4.5 | 1.0 to 9.5 |
| Nigeria | 9 | 2.3 | 0.0 | 0.0 to 0.8 |
| Zimbabwe | 9 | 2.3 | 1.0 | 0.5 to 1.5 |
| Poland | 8 | 2.0 | 9.0 | 8.0 to 9.0 |
| Bangladesh | 6 | 1.5 | 4.0 | 2.0 to 7.5 |
| Afghanistan | 5 | 1.3 | 0.0 | 0.0 to 0.5 |
| Lithuania | 5 | 1.3 | 10.0 | 8.5 to 10.5 |
| Philippines | 5 | 1.3 | 2.0 | 1.0 to 7.0 |
| Sudan | 5 | 1.3 | 15.5 | 10.0 to 18.2 |
| Tanzania, United Republic Of | 5 | 1.3 | 12.5 | 2.8 to 24.8 |
| Other | 56 | 14.1 | 6.5 | 1.0 to 22.2 |
| Total | 397 | 100.0 | Not applicable | Not applicable |
Note 5: other includes all countries with less than 5 people notified.
When removing the UK-born cases and only looking at TB patients born outside of the UK, the 6 most common countries of birth for TB patients in 2023, were:
- India (46.3%, 144 out of 311)
- Romania (7.1%, 22 out of 311)
- Pakistan (5.8%, 18 out of 311)
- Eritrea (4.5%, 14 out of 311)
- Nigeria (2.9%, 9 out of 311)
- Zimbabwe (2.9%, 9 out of 311)
See Figure 11 and Table 2. Numbers of TB cases born in Eritrea, India and Nigeria increased compared to the previous year, and the number of TB cases born in Pakistan, Romania and Zimbabwe decreased slightly compared to 2022.
The characteristics for people with TB from the most common non-UK countries of birth varied (Table 2). The median age for cases was highest in people with TB born in Pakistan (42.6 years) and lowest in people with TB born in Nigeria (28.6 years). The majority (over 50%) of the cases across each of the 6 most common countries of birth were male with the exception of Zimbabwe where only 22.2% were male. For cases born in India, Romania and Eritrea, the majority (over 50%) had pulmonary TB. In people with TB who entered the UK less than 2 years prior to their notification, the majority had pulmonary TB, with the exception of Pakistan and Zimbabwe where this was 0% and 40% respectively.
The 6 most common countries of birth outside of the UK make up 54.4% of all TB cases notified in 2023 in the East Midlands (216 out of 397).
Figure 11. Numbers of TB notifications for the most common countries of birth for people with TB born outside the UK, East Midlands, 2013 to 2023 [note 6]
Note 6: figure shows the top 6 countries in 2023.
Table 2. Characteristics of people with TB from the most common (non-UK) countries of birth, East Midlands, 2023
| Country of birth | Number of people notified with TB | Mean age (years) | Proportion male (%) | Proportion pulmonary (includes laryngeal and miliary) (%) | Proportion with UK entry less than 2 years (%) | Proportion pulmonary of those in the UK less than 2 years (%) |
|---|---|---|---|---|---|---|
| India | 144 | 40.8 | 56.2 | 54.2 | 25.7 | 65.5 |
| Romania | 22 | 36.8 | 54.5 | 90.9 | 25.0 | 100.0 |
| Pakistan | 18 | 42.6 | 72.2 | 22.2 | 33.3 | 0.0 |
| Eritrea | 14 | 32.6 | 92.9 | 71.4 | 33.3 | 100.0 |
| Nigeria | 9 | 28.6 | 66.7 | 44.4 | 100.0 | 50.0 |
| Zimbabwe | 9 | 42.4 | 22.2 | 33.3 | 71.4 | 40.0 |
In 2023, 99.2% (394 out of 397) of patients with TB had an ethnicity recorded, of which 10.7% (42 out of 394) were recorded as mixed or other. The highest number of TB notifications in the East Midlands were in patients with a recorded Indian ethnicity which accounted for 39.9% of cases (157 out of 394), followed by the White (27.2%, 107 out of 394) and Black African ethnic groups (15.2%, 60 out of 394) (Figure 12).
Collectively, patients with a recorded South Asian ethnicity made up 46.5% of cases (183 out of 394), of which 3.8% (7 out of 183) were UK-born (Figure 13). Patients of White ethnicity made up 27.2% of cases (107 out of 394), of whom the majority (63.6%, 68 out of 107) were UK-born. Patients of Black ethnicity made up 15.7% of cases (62 out of 394 cases), of whom 9.7% (6 out of 62) were UK-born.
All ethnic groups saw small increases in the number of TB cases between 2022 and 2023 (Figure 13). The greatest increases were in the South Asian ethnic group with an increase of 7 cases, and the Mixed or Other ethnic group with an increase of 3 cases.
Figure 12. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), East Midlands, 2023 [note 7]
Note 7: figure ordered by total number of notifications within each ethnicity irrespective of place of birth.
Figure 13. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), East Midlands, 2001 to 2023
In 2023, site of disease was recorded for all 397 cases. The majority (62.2%, 247 out of 397) of patients had pulmonary TB disease (with or without extra-pulmonary sites) which is a slight increase from 2022 (60.4%) (Figure 14). People with pulmonary TB have the potential to be infectious to others. 42.1% of TB cases had pulmonary TB disease only (167 out of 397) (Table 3). In 2023, 57.9% (230 out of 397) of TB cases had extra-pulmonary TB disease (with or without pulmonary sites) (Table 4). Lymph nodes were the next most common site of disease (32.4%, 129 out of 397), of which 39.5% (51 out of 129) were intra-thoracic and 60.5% were extra-thoracic (78 out of 129). Other extra-pulmonary sites of unknown origin also make up a large proportion of cases (27.7%, 110 out of 397).
Table 3. Number of pulmonary TB notifications by site of disease, East Midlands, 2023 [note 8] [note 9]
| Site of disease | Number of people notified with TB | Proportion of people notified with TB (%) |
|---|---|---|
| All pulmonary | 247 | 62.2 |
| Pulmonary only | 167 | 42.1 |
| Miliary only | 14 | 3.5 |
| Laryngeal only | 1 | 0.3 |
Note 8: percentages may not add up to 100 as people with TB may have more than one site of disease.
Note 9: ‘pulmonary only’ includes people notified with only pulmonary TB and therefore have not also been notified with miliary, laryngeal or extra-pulmonary TB.
Table 4. Number of extra-pulmonary TB notifications by site of disease, East Midlands, 2023 [note 10]
| Site of disease | Number of people notified with TB | Proportion of people notified with TB (%) |
|---|---|---|
| All extra-pulmonary | 230 | 57.9 |
| Other extra-pulmonary | 110 | 27.7 |
| Extra-thoracic lymph nodes | 78 | 19.6 |
| Intra-thoracic lymph nodes | 51 | 12.8 |
| Bone - spine | 27 | 6.8 |
| Pleural | 25 | 6.3 |
| Gastrointestinal | 18 | 4.5 |
| Central nervous system - other | 11 | 2.8 |
| Bone - not spine | 9 | 2.3 |
| Central nervous system - meningitis | 9 | 2.3 |
| Genitourinary | 5 | 1.3 |
| Cryptic disseminated | 4 | 1.0 |
Note 10: percentages may not add up to 100 as people with TB may have more than one site of disease.
Figure 14. Proportion of people notified with pulmonary TB, East Midlands, 2013 to 2023 [note 11]
Note 11: error bars represent upper and lower 95% confidence intervals.
Data for several comorbidities (diabetes, hepatitis B and C, chronic liver disease, chronic renal disease, and immunosuppression) is routinely collected as part of TB surveillance. In 2023, the numbers of TB cases reporting data for each of the named comorbidities varied (Table 5). Of all TB cases notified in 2023, 22.4% of TB cases reported having at least one of the named comorbidities (89 out of 397). The most commonly reported comorbidity was diabetes with 11.1% (40 out of 360) of TB cases reporting this, followed by immunosuppression (10.6%, 38 out of 357).
Table 5. Number and proportion of people with TB with comorbidities, East Midlands, 2023 [note 12]
| Comorbidity | Total with data reported | Number of people notified with TB with comorbidities | Proportion of people notified with TB with comorbidities (%) | Number of people notified with TB missing comorbidity data | Proportion of people notified with TB missing comorbidity data (%) |
|---|---|---|---|---|---|
| At least one of the named comorbidities | 397 | 89 | 22.4 | Not applicable | Not applicable |
| Chronic liver disease | 356 | 7 | 2.0 | 41 | 10.3 |
| Chronic renal disease | 359 | 9 | 2.5 | 38 | 9.6 |
| Diabetes | 360 | 40 | 11.1 | 37 | 9.3 |
| Hepatitis B | 337 | 5 | 1.5 | 60 | 15.1 |
| Hepatitis C | 341 | 3 | 0.9 | 56 | 14.1 |
| Immunosuppression | 357 | 38 | 10.6 | 40 | 10.1 |
Note 12: people with TB are reported as having at least one of the named comorbidities if any of the 6 comorbidities (chronic liver disease, chronic renal disease, diabetes, hepatitis B, hepatitis C or immunosuppression) had ‘yes’ recorded. As a result, the denominator is all notifications. This assumes that people for whom no data was recorded for individual comorbidities were a ‘no’ and may result in under-estimation.
For some patients who have TB, treatment can be more complicated because they also have HIV infection. However, both conditions can be successfully treated with a combination of antiretroviral therapy (ART) and appropriate TB antibiotic treatment (4). To optimise their outcome and reduce the risk of TB and HIV transmission to others, it is essential that all patients with TB undergo HIV testing to allow curative TB treatment and ART to be started as soon as possible.
In 2023, HIV testing status was recorded for 95.2% of TB cases (378 out of 397). HIV tests were offered or results were already known for 97.4% (368 out of 378) of these, whilst 10 cases were not offered a test (2.6%, 10 out of 378) (Figure 15). Of the cases that were offered a test, 1.4% (5 out of 368) did not receive the test. The proportion of people with TB that were offered a test was similar to previous years.
Figure 15. Proportion of people with TB offered an HIV test by year, East Midlands, 2018 to 2023 [note 13] [note 14]
Note 13: dashed line indicates target of 100% of people offered HIV test.
Note 14: error bars represent upper and lower 95% confidence intervals.
Data for social risk factors (alcohol misuse, asylum seeker status, drug misuse, homelessness, mental health needs, and prison) is routinely collected as part of TB surveillance. In 2023 in the East Midlands, 16.8% of TB cases aged 15 years or over reported at least one social risk factor (65 out of 387) and 7.2% of TB cases reported having more than one social risk factor (25 out of 347) (Table 6). The most common social risk factor reported was current alcohol misuse (6.8%, 23 out of 338), followed by current or previous drug misuse (6.1%, 20 out of 330), and having current asylum seeker status (6.0%, 21 out of 348).
The prevalence of social risk factors increased in 2023 (16.8%, 65 out of 387) compared to 2022 where 14.7% (55 out of 375) reported at least one social risk factor, this was also the highest proportion since 2013 (Figure 16 and Table 7).
Table 6. Number and proportion of people with TB aged 15 years or over with individual social risk factors, East Midlands, 2023 [note 15]
| Social risk factor | Total with data reported | Number of people notified with TB with social risk factors | Proportion of people notified with TB with social risk factors (%) | Number of people notified with TB and missing social risk factor data | Proportion of people notified with TB and missing social risk factor data (%) |
|---|---|---|---|---|---|
| At least one named social risk factor | 387 | 65 | 16.8 | Not applicable | Not applicable |
| More than one social risk factor | 347 | 25 | 7.2 | 40 | 10.3 |
| Alcohol misuse (current) | 338 | 23 | 6.8 | 49 | 12.7 |
| Asylum seeker (current) | 348 | 21 | 6.0 | 15 | 4.1 |
| Drug misuse (current or previous) | 330 | 20 | 6.1 | 57 | 14.7 |
| Homelessness (current or previous) | 330 | 18 | 5.5 | 57 | 14.7 |
| Mental health needs (current) | 324 | 11 | 3.4 | 63 | 16.3 |
| Prison (current or previous) | 322 | 14 | 4.3 | 65 | 16.8 |
Note 15: people with TB are reported as having ‘yes’ recorded for at least one of the named social risk factors if any of the 6 social risk factors, which are:
- current alcohol misuse
- current or a history of homelessness
- drug misuse
- imprisonment
- current asylum seeker status
- current mental health needs
As a result, the denominator is all notifications. This assumes that people for whom no data was recorded for individual social risk factors were a ‘no’ and may result in under-estimation. The denominators for more than one social risk factor and the individual risk factors only use notifications where data has been recorded.
Figure 16. Proportion of people with TB aged 15 years or over with at least one social risk factor (SRF), East Midlands, 2018 to 2023 [note 16] [note 17]
Note 16: error bars represent upper and lower 95% confidence intervals.
Note 17: not all social risk factors were captured before 2021.
Table 7. Number and proportion of people with TB aged 15 years or over reporting at least one social risk factor, East Midlands, 2013 to 2023 [note 18]
| Year | Number of people notified with TB with any social risk factor | Proportion of people notified with TB with any social risk factor (%) | Total notifications |
|---|---|---|---|
| 2013 | 30 | 7.6 | 394 |
| 2014 | 39 | 10.1 | 386 |
| 2015 | 34 | 9.9 | 345 |
| 2016 | 35 | 10.9 | 320 |
| 2017 | 52 | 15.7 | 332 |
| 2018 | 50 | 15.2 | 329 |
| 2019 | 49 | 14.3 | 343 |
| 2020 | 41 | 13.5 | 304 |
| 2021 | 37 | 10.7 | 346 |
| 2022 | 55 | 14.7 | 375 |
| 2023 | 65 | 16.8 | 387 |
Note 18: not all social risk factors were captured before 2021 and that this table includes people with no information recorded in the denominator.
In 2023, male TB cases were more likely to report all social risk factors compared to female TB cases (Table 8). In males having current asylum seeker status was most common (9.1%), and in females current alcohol misuse was most common (5.5%).
Experience of social risk factors varied by age group. Being an asylum seeker was the most common social risk factor reported by TB cases aged between 15 and 44 years (8.0%). For those aged between 45 and 64 years drug misuse was reported the most (8.2%), with mental health needs most common among those aged 65 years and older (2.6%).
UK-born TB cases were more likely to report all social risk factors compared to non-UK-born, with the exception of asylum seeker status. For TB cases born outside the UK the most commonly reported social risk factor was seeking asylum (7.2%), and for UK-born TB cases drug misuse was the most common (19.7%).
Table 8. Number and proportion of people with TB aged 15 years or over with a social risk factor (SRF) by demographic characteristics, East Midlands, 2023
| Demographic characteristics | Drug misuse (number) | Drug misuse (proportion) | Alcohol misuse (number) | Alcohol misuse (proportion) | Homelessness (number) | Homelessness (proportion) | Prison (number) | Prison (proportion) | Asylum seeker (number) | Asylum seeker (proportion) | Mental health needs (number) | Mental health needs (proportion) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Female | 4 | 3.2 | 7 | 5.5 | 2 | 1.6 | 1 | 0.8 | 0 | 0.0 | 3 | 2.6 |
| Male | 16 | 7.8 | 16 | 7.6 | 16 | 7.8 | 13 | 6.6 | 21 | 9.1 | 8 | 3.9 |
| Aged 15 to 44 | 12 | 6.2 | 14 | 7.1 | 12 | 6.2 | 8 | 4.3 | 17 | 8.0 | 6 | 3.1 |
| Aged 45 to 64 | 8 | 8.2 | 8 | 7.8 | 6 | 6.1 | 6 | 6.2 | 3 | 2.7 | 4 | 4.3 |
| Aged 65 or older | 0 | 0.0 | 1 | 2.5 | 0 | 0.0 | 0 | 0.0 | 1 | 2.0 | 1 | 2.6 |
| Non-UK-born | 7 | 2.7 | 10 | 3.7 | 14 | 5.3 | 4 | 1.6 | 21 | 7.2 | 3 | 1.2 |
| UK-born | 13 | 19.7 | 13 | 19.1 | 4 | 6.0 | 10 | 15.2 | 0 | 0.0 | 8 | 12.1 |
| Unemployed | 12 | 10.3 | 14 | 11.6 | 12 | 10.2 | 8 | 7.0 | 13 | 9.4 | 9 | 7.8 |
Based on the Index of Multiple Deprivation (IMD 2019) deciles assigned to geographical areas in the East Midlands, the deprivation decile with the highest rate of TB was decile 2 (18.6 per 100,000), followed by deciles 3 (15.6 per 100,000), 1 (13.5 per 100,000), and 4 (12.7 per 100,000) (Figure 17). As in previous years, generally there is a higher TB case rate among residents in more deprived areas in the East Midlands.
Figure 17. TB notification rate by deprivation decile, East Midlands, 2023 [note 19]
Note 19: error bars represent upper and lower 95% confidence intervals.
TB diagnosis, microbiology and drug resistance
In 2023, 66.0% (262 out of 397) of people with TB in the East Midlands had their diagnosis culture-confirmed. For pulmonary TB cases, 74.9% (185 out of 247) were confirmed by culture of a TB isolate which is slightly lower than the 80% target (Figure 18). This proportion is consistent with previous years though represents an increase from last year following a decrease in 2022, where 67.4% (157 out of 233) of pulmonary TB cases were culture-confirmed.
Figure 18. Proportion of people notified with pulmonary TB who were culture-confirmed, East Midlands, 2017 to 2023 [note 20] [note 21]
Note 20: dashed line indicates target of 80% culture-confirmation.
Note 21: error bars represent upper and lower 95% confidence.
There are several groups of TB antibiotics, and resistance to TB antibiotic drugs may occur to one or more of these drugs and in different combinations. A distinction is made between first, second and third line TB antibiotic drugs depending upon their clinical effectiveness (5). First line drugs include rifampicin, isoniazid, pyrazinamide and ethambutol. Second line drugs include injectable agents (for example, amikacin, capreomycin, kanamycin), fluoroquinolones (for example, moxifloxacin, ofloxacin, ciprofloxacin) and other oral bacteriostatic agents. Multi-drug resistant cases (MDR-TB) are initially resistant to at least isoniazid and rifampicin. Extensively drug-resistant TB cases (XDR-TB) are both MDR and resistant to at least one injectable agent, one of which must be a fluoroquinolone (6).
In 2023, of the TB patients confirmed by culture, 97.0% (254 out of 262) received first line drug results (Figure 19). This proportion is a decrease compared to previous years. Of the 262 culture-confirmed TB cases in the East Midlands, 12.6% (33 out of 262) had initial resistance to at least one first line drug (Figure 20). This is a decrease compared to last year where 17.1% (42 out of 245) of culture-confirmed TB cases had resistance to at least one first line drug, which was the highest proportion in recent years.
Figure 19. Proportion of people culture-confirmed with TB with first line drug results, East Midlands, 2017 to 2023 [note 22]
Note 22: error bars represent upper and lower 95% confidence intervals.
Figure 20. Proportion of people notified with culture-confirmed TB with initial resistance to any first line drug, East Midlands, 2017 to 2023 [note 23]
Note 23: error bars represent upper and lower 95% confidence intervals.
TB cases are assigned to whole genome sequencing (WGS) clusters when 2 or more individuals have isolates with less than 12 single nucleotide polymorphisms (SNP) difference. In 2023, 38.5% (101 out of 262) of culture-confirmed TB cases were identified in a cluster with more than one other person by WGS (Table 9). The number of TB cases identified as being part of a cluster has decreased slightly since 2020 where 42.6% (81 out of 190) of people with culture-confirmed TB were in a WGS cluster.
Table 9. Number of people notified, proportion with culture-confirmation and proportion of notifications identified in a WGS cluster, East Midlands, 2020 to 2023 [note 24] [note 25]
| Year | Total TB notifications | Number of notifications cultured | Proportion of notifications cultured | Number of culture-confirmed notifications identified in a cluster with more than one person | Proportion of culture-confirmed notifications identified in a cluster with more than one person (%) | 95% confidence interval |
|---|---|---|---|---|---|---|
| 2020 | 315 | 190 | 60.3 | 81 | 42.6 | 35.8 to 49.7 |
| 2021 | 350 | 231 | 66.0 | 85 | 36.8 | 30.8 to 43.2 |
| 2022 | 386 | 245 | 63.5 | 87 | 35.5 | 29.8 to 41.7 |
| 2023 | 397 | 262 | 66.0 | 101 | 38.5 | 32.9 to 44.6 |
| Total | 1,448 | 928 | 64.1 | 354 | 38.1 | 35.1 to 41.3 |
Note 24: a WGS cluster is defined as 2 or more individuals that have isolates with a less than 12 SNP difference.
Note 25: WGS cluster reporting has changed over time. These changes are likely to have affected the most recent year’s data.
TB in children: incidence, epidemiology and microbiology
In 2023 in the East Midlands, there were 10 cases of TB in children aged under 15 years, this represents a TB case rate of 1.2 per 100,000 in this age group (Figure 21 and Figure 22). The rate of TB in children aged under 15 years in the East Midlands has decreased overall between 2001 and 2023.
Figure 21. Number of TB notifications in children aged under 15 years, East Midlands, 2001 to 2023
Figure 22. TB notification rate in children aged under 15 years, East Midlands, 2001 to 2023 [note 26]
Note 26: error bars represent upper and lower 95% confidence intervals.
In 2023, 5 (50%, 5 out of 10) of the TB cases in children aged under 15 years were born in the UK. Between 2001 and 2023 there has been an overall decrease in the number of TB cases aged under 15 years that are born in the UK. There were also 5 (50%, 5 out of 10) TB cases in children under 15 years who were born outside of the UK. This was a similar number to previous years. The most common country of birth for children under 15 years with TB was the United Kingdom (50%, 5 out of 5), other countries of birth had less than 5 cases.
In 2023, 80% (8 out of 10) of children aged under 15 years with TB had pulmonary TB with or without extra-pulmonary sites, and 30% (3 out of 10) had severe TB. Severe TB includes cases with CNS, spinal, cryptic and miliary TB.
TB treatment
The Royal College of Nursing TB case management tool provides standardised recommendations for enhanced case management (ECM) in individuals receiving anti-TB treatment with clinical or social complexities.
In 2023, 38.8% of TB cases (154 out of 397) in the East Midlands received ECM (Table 10). There was a similar proportion of TB cases receiving each level of ECM with the highest proportion receiving level 2 ECM (13.6%, 54 out of 397). In 2023, the proportions of cases receiving each level of ECM were similar to 2022, however there was an increase compared to 2021 where 28.9% of TB cases (101 out of 350) received any ECM. Information on ECM was not recorded for 1 TB case.
Table 10. Number of people with TB receiving enhanced case management, East Midlands, 2021 to 2023 [note 31]
| Year | Total TB notifications | Any ECM (number) | Any ECM (proportion) | Level 1 (number) | Level 1 (proportion) | Level 2 (number) | Level 2 (proportion) | Level 3 (number) | Level 3 (proportion) | Unknown level (number) | Unknown level (proportion) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 2021 | 350 | 101 | 28.9 | 22 | 6.3 | 36 | 10.3 | 42 | 12.0 | 1 | 0.3 |
| 2022 | 386 | 150 | 38.9 | 52 | 13.5 | 51 | 13.2 | 46 | 11.9 | 1 | 0.3 |
| 2023 | 397 | 154 | 38.8 | 49 | 12.3 | 54 | 13.6 | 50 | 12.6 | 1 | 0.3 |
Note 31: total TB notifications includes all people notified with TB regardless of whether they are receiving ECM or not, or if this information is missing.
Treatment delay is defined as the time from symptom onset to treatment start. Information on delay was calculated for 84.4% (194 out of 230) of pulmonary TB cases who did not have a postmortem diagnosis. In 2023, 63.9% (124 out of 194) of pulmonary TB cases had a treatment delay of over 2 months (Figure 23).
Between 2018 and 2023 there has been an overall increase in the percentage of pulmonary TB patients starting treatment more than 2 months after symptom onset. In 2018, 57.6% (106 out of 184) of pulmonary TB cases started treatment over 2 months after symptom onset.
Figure 23. Proportion of people notified with pulmonary TB with a treatment delay over 2 months, East Midlands, 2018 to 2023 [note 32] [note 33]
Note 32: error bars represent upper and lower 95% confidence intervals.
Note 33: delay to treatment is defined by when treatment was started from symptom onset.
In 2023, 34.5% (67 out of 194) of pulmonary TB cases started treatment with a 2 to 4 month delay (61 to 121 days), and 29.4% (57 out of 194) started treatment more than 4 months (122 to 730 days) after symptom onset, indicating a prolonged period of infectiousness (Table 11). These proportions were similar to those seen the previous year. The time between symptom onset and treatment start was unknown or missing in 15.7% (36 out of 230) of pulmonary TB cases.
Table 11. Number and proportion of people notified with pulmonary TB with a treatment delay, time between symptom onset and treatment start, East Midlands, 2018 to 2023 [note 36]
| Year | 2 to 4 months delay (number) | 2 to 4 months delay (proportion) | Over 4 months delay (number) | Over 4 months delay (proportion) | Total | Missing (number) | Missing (proportion) | Total eligible |
|---|---|---|---|---|---|---|---|---|
| 2018 | 54 | 29.3 | 52 | 28.3 | 184 | 3 | 1.6 | 187 |
| 2019 | 53 | 29.8 | 49 | 27.5 | 178 | 1 | 0.6 | 179 |
| 2020 | 56 | 32.7 | 60 | 35.1 | 171 | 2 | 1.2 | 173 |
| 2021 | 60 | 35.9 | 55 | 32.9 | 167 | 15 | 8.2 | 182 |
| 2022 | 57 | 32.6 | 51 | 29.1 | 175 | 40 | 18.6 | 215 |
| 2023 | 67 | 34.5 | 57 | 29.4 | 194 | 36 | 15.7 | 230 |
Note 36: all people included in this table are people with pulmonary TB who did not have a postmortem diagnosis and it was known that they had started treatment. People included within the ‘Total’ includes these individuals and where the time from symptom onset to treatment start was also known. ‘Total eligible’ includes people in ‘Total’ plus those people where the time from symptom onset to treatment start was unknown/missing. Percentages for ‘2 to 4 month delay’ and ‘over 4 months’ delay were calculated using the ‘Total’ figure. The percentage for ‘Missing’ uses ‘Total eligible’. ‘2 to 4 month delay’ includes people with a delay of 61 to 121 days inclusive. An ‘over 4 month delay’ includes people with a delay between 122 and 730 days inclusive.
In 2023, the median treatment delay for pulmonary TB cases was 74 days (IQR 42 to 133) (Figure 24). This was a similar treatment delay compared to last year where the median treatment delay was 78 days for cases with pulmonary TB. This is above the target treatment delay of achieving a median of 56 days delay by 2027 (7).
Figure 24. Median treatment delays among people notified with pulmonary TB, East Midlands, 2018 to 2023 [note 37] [note 38] [note 39] [note 40]
Note 37: dashed line represents the target treatment delay of 56 days by 2027.
Note 38: ends of the whiskers represent the theoretical lower and upper limits for detecting outliers (lower or upper quartile negative or positive 1.5 times the interquartile range). Outliers falling outside of these limits have been removed.
Note 39: delay to treatment is defined by when treatment was started from symptom onset.
Note 40: all people included in this figure are people with pulmonary TB who did not have a postmortem diagnosis and it was known that they had started treatment. It excludes individuals with a delay over 730 days which was 12 cases in 2023. These were excluded as outliers but also may reflect incorrect dates entered.
TB treatment outcomes
For the purposes of TB outcome reporting, drug-sensitive cases are defined as sensitive to rifampicin. Under this definition, cases with resistance to isoniazid, ethambutol or pyrazinamide but sensitive to rifampicin are included in the drug-sensitive cohort. Drug-resistant strains are defined as those with resistance to rifampicin and cases with suspected rifampicin resistance (RR) (initial or acquired) including non-culture-confirmed patients treated for presumptive MDR-TB (6).
For the drug-sensitive cohort, patients with an expected duration of treatment less than 12 months, outcomes at 12 months are reported. This group excludes individuals with central nervous system (CNS) disease, spinal, cryptic disseminated or miliary disease where expected treatment durations are longer. Treatment outcomes for patients with CNS, spinal, cryptic disseminated or miliary disease are reported separately.
Among people notified in 2022, 76.5% (247 out of 323) of non-multidrug-resistant (MDR) or non-rifampicin resistant (RR) TB cases with an expected treatment duration of less than 12 months had completed treatment at 12 months (Table 12). This proportion is lower compared to previous years and remains below the target of 90% (Figure 25).
There were 76 TB cases who were recorded as not completing treatment at 12 months. The most common reason for not completing treatment at 12 months was treatment being stopped (5.3%, 17 out of 323), followed by lost to follow up (5.0%, 16 out of 323).
At the last recorded outcome, a further 20 cases had completed treatment, bringing completion to 82.7% (267 out of 323). An additional 2 cases (5.6%, 18 out of 323) were lost to follow up and 1 further case (5.6%, 18 out of 323) had stopped treatment.
Table 12. Treatment outcome at 12 months and last recorded outcome for people notified in 2022 with non-MDR or non-RR TB with expected treatment duration less than 12 months, East Midlands, 2022 [note 43] [note 44]
| Outcome | TB treatment outcome at 12 months (number) | TB treatment outcome at 12 months (proportion) | Last recorded treatment outcome (number) | Last recorded treatment outcome (proportion) |
|---|---|---|---|---|
| Treatment completed | 247 | 76.5 | 267 | 82.7 |
| Died | 11 | 3.4 | 11 | 3.4 |
| Lost to follow up | 16 | 5.0 | 18 | 5.6 |
| Still on treatment | 7 | 2.2 | 2 | 0.6 |
| Treatment stopped | 17 | 5.3 | 18 | 5.6 |
| Not evaluated | 25 | 7.7 | 7 | 2.2 |
| Total | 323 | 100.0 | 323 | 100.0 |
Note 43: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not still on treatment nor died.
Note 44: table does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a postmortem diagnosis of TB.
Figure 25. Proportion of people with non-severe TB treated for non-MDR or non-RR TB who completed treatment within 12 months compared with the target of 90%, East Midlands, 2018 to 2022 [note 44] [note 46] [note 47]
Note 44: chart does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a postmortem diagnosis of TB.
Note 46: dashed line indicates treatment target of 90%.
Note 47: error bars represent upper and lower 95% confidence intervals.
Among those notified in 2022, there were 44 non-MDR or non-RR TB cases without CNS disease with one or more social risk factors, and of these 75.0% (33 out of 44) had completed treatment at 12 months (Figure 26). This was a similar proportion compared to the last few years, however represents an overall increase since 2018 when 72.1% (31 out of 43) of cases with social risk factors had completed treatment at 12 months.
Figure 26. Proportion of people treated for non-MDR or non-RR TB without central nervous system (CNS) disease and with one or more social risk factors who completed treatment within 12 months, East Midlands, 2018 to 2022 [note 44] [note 45]
Note 44: chart does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a postmortem diagnosis of TB.
Note 45: error bars represent upper and lower 95% confidence intervals.
In the East Midlands, of those notified in 2022, 5.0% (16 out of 323) were lost to follow up at 12 months, this was an increase compared to 2021 (2.4%, 7 out of 296) (Figure 27).
The proportion that had stopped treatment at 12 months increased in 2022 (5.3%, 17 out of 323) compared to 2021 (2%, 6 out of 296).
In 2022, 3.4% (11 out of 323) of TB cases died before completing treatment, this was a small increase compared to the previous year (2.7%, 8 out of 296) (Figure 27).
In 2022, there were also 2.2% (7 out of 323) of cases still on treatment at 12 months which was a decrease compared to 2021 where 5.4% (16 out of 296) remained on treatment.
Figure 27. Outcomes of people evaluated who did not complete treatment by 12 months for people with non-MDR or non-RR TB and expected treatment duration of less than 12 months, East Midlands, 2013 to 2022
Table 13. TB outcome at 12 months for people with non-RR or MDR-TB with expected treatment duration of within 12 months, East Midlands, 2013 to 2022 [note 52]
| Year | Treatment completed (number) | Treatment completed with any social risk factor (number) | Died (number) | Lost to follow up (number) | Still on treatment (number) | Treatment stopped (number) | Not evaluated (number) | Total (number) |
|---|---|---|---|---|---|---|---|---|
| 2013 | 318 | 23 | 15 | 12 | 11 | 0 | 1 | 357 |
| 2014 | 280 | 25 | 11 | 18 | 17 | 3 | 0 | 329 |
| 2015 | 231 | 17 | 12 | 20 | 27 | 6 | 3 | 299 |
| 2016 | 230 | 20 | 19 | 14 | 25 | 4 | 8 | 300 |
| 2017 | 233 | 34 | 18 | 18 | 14 | 5 | 1 | 289 |
| 2018 | 251 | 31 | 15 | 14 | 14 | 6 | 4 | 304 |
| 2019 | 255 | 30 | 9 | 12 | 23 | 3 | 9 | 311 |
| 2020 | 230 | 29 | 14 | 7 | 11 | 4 | 4 | 270 |
| 2021 | 245 | 27 | 8 | 7 | 16 | 6 | 14 | 296 |
| 2022 | 247 | 33 | 11 | 16 | 7 | 17 | 25 | 323 |
Note 52: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not ‘still on treatment’ or ‘died’ within the timeframe of 12 months. Data includes all sites except cases with CNS, spinal, cryptic or miliary TB.
Table 14. Proportions of TB outcomes at 12 months for people with non-RR or MDR-TB with expected treatment duration of less than 12 months, East Midlands, 2013 to 2022 [note 53]
| Year | Treatment completed (proportion) | Treatment completed with any social risk factor (proportion) | Died (proportion) | Lost to follow up (proportion) | Still on treatment (proportion) | Treatment stopped (proportion) | Not evaluated (proportion) |
|---|---|---|---|---|---|---|---|
| 2013 | 89.1 | 6.4 | 4.2 | 3.4 | 3.1 | 0.0 | 0.3 |
| 2014 | 85.1 | 7.6 | 3.3 | 5.5 | 5.2 | 0.9 | 0.0 |
| 2015 | 77.3 | 5.7 | 4.0 | 6.7 | 9.0 | 2.0 | 1.0 |
| 2016 | 76.7 | 6.7 | 6.3 | 4.7 | 8.3 | 1.3 | 2.7 |
| 2017 | 80.6 | 11.8 | 6.2 | 6.2 | 4.8 | 1.7 | 0.3 |
| 2018 | 82.6 | 10.2 | 4.9 | 4.6 | 4.6 | 2.0 | 1.3 |
| 2019 | 82.0 | 9.6 | 2.9 | 3.9 | 7.4 | 1.0 | 2.9 |
| 2020 | 85.2 | 10.7 | 5.2 | 2.6 | 4.1 | 1.5 | 1.5 |
| 2021 | 82.8 | 9.1 | 2.7 | 2.4 | 5.4 | 2.0 | 4.7 |
| 2022 | 76.5 | 10.2 | 3.4 | 5.0 | 2.2 | 5.3 | 8.1 |
Note 53: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not ‘still on treatment’ or ‘died’ within the timeframe of 12 months. Data includes all sites except cases with CNS, spinal, cryptic or miliary TB.
There were 29 people notified in 2022 with CNS, miliary or cryptic disseminated TB, that was rifampicin sensitive. At 12 months, 34.5% (10 out of 29) had completed treatment, 13.8% (4 out of 29) had died, 3.4% (1 out of 29) were lost to follow up and 6.9% (2 out of 29) were still on treatment (Table 15). There were 41.4% (12 out of 29) of cases where the treatment outcome was not evaluated, not recorded or is unknown at 12 months. Treatment is expected to take longer than 12 months for people with these types of TB.
Table 15. Outcome at 12 months for people with rifampicin sensitive, CNS, miliary or cryptic disseminated diseases, East Midlands, 2022 [note 51]
| Outcome at 12 months | Number of TB notifications | Proportion of TB notifications |
|---|---|---|
| Treatment completed | 10 | 34.5 |
| Died | 4 | 13.8 |
| Lost to follow up | 1 | 3.4 |
| Still on treatment | 2 | 6.9 |
| Not evaluated | 12 | 41.4 |
| Total | 29 | 100.0 |
Note 51: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not still on treatment nor died.
For people with MDR and rifampicin-resistant TB, treatment outcome is measured at 24 months, so outcomes are presented for people notified up to 2021. In 2021 in the East Midlands there were 2 patients diagnosed with RR or MDR TB that did not have CNS, spinal, cryptic or miliary TB, this was a lower number compared to previous years. At 24 months, 50% (1 out of 2) had completed treatment and 50% (1 out of 2) were still on treatment.
TB prevention
In 2023 in the East Midlands, 77.6% (191 out of 246) of pulmonary TB cases had information about their contacts recorded (Table 16). In 2023, 15.4% (38 out of 246) of TB cases had 5 or more contacts identified and screened. The median number of contacts identified and screened for each pulmonary TB case was 3 (IQR 1 to 5), and this was similar for all demographic groups and disease characteristics. The proportion of people notified with at least 5 contacts identified and screened has been decreasing since 2020 (Figure 28).
Females were slightly more likely to have 5 or more contacts identified and screened than males (17.4% versus 14.3%).
TB cases born in the UK were more likely to have 5 or more contacts identified and screened than cases born outside the UK (20.0% versus 13.8%).
TB cases with social risk factors had a higher proportion of cases with 5 or more contacts identified and screened compared to those with no social risk factors (17.5% versus 14.8%).
Patients diagnosed with non-MDR or non-RR TB were more likely to have 5 or more contacts identified and screened than those diagnosed with MDR or RR TB (16.2% versus 0%). In the East Midlands no MDR or RR TB cases had 5 or more contacts identified and screened.
Adult TB cases were more likely to have 5 or more contacts identified and screened than child TB cases (15.6% versus 11.1%).
Table 16. Contact tracing information for people with pulmonary TB by demographic and disease characteristics, East Midlands, 2023 [note 56] [note 57]
| Category | Total | Contact information entered (number) | Contact information entered (proportion) | 5 or more contacts identified and screened (number) | 5 or more contacts identified and screened (proportion) | Median contacts identified and screened (median | IQR of contacts identified and screened |
|---|---|---|---|---|---|---|---|
| All people with pulmonary TB | 246 | 191 | 77.6 | 38 | 15.4 | 3 | 1.0 to 5.0 |
| Female | 92 | 73 | 79.3 | 16 | 17.4 | 3 | 1.0 to 5.0 |
| Male | 154 | 118 | 76.6 | 22 | 14.3 | 2 | 1.0 to 5.0 |
| Adults | 237 | 184 | 77.6 | 37 | 15.6 | 3 | 1.0 to 5.0 |
| Children (15 years or less) | 9 | 7 | 77.8 | 1 | 11.1 | 3 | 3.0 to 3.0 |
| Non-UK-born | 181 | 143 | 79.0 | 25 | 13.8 | 2 | 1.0 to 4.0 |
| UK-born | 65 | 48 | 73.8 | 13 | 20.0 | 3 | 1.0 to 6.0 |
| No social risk factor | 189 | 145 | 76.7 | 28 | 14.8 | 3 | 1.0 to 5.0 |
| At least 1 social risk factor | 57 | 46 | 80.7 | 10 | 17.5 | 2 | 0.0 to 5.0 |
| Non-MDR or RR TB | 235 | 182 | 77.4 | 38 | 16.2 | 3 | 1.0 to 5.0 |
| MDR or RR TB | 11 | 9 | 81.8 | 0 | 0.0 | 3 | 2.0 to 3.5 |
Note 56: routine contact tracing information is collected from close contacts only. Individuals identified as part of an incident are collected separately and not included in this table.
Note 57: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.
Figure 28. Proportion of people notified with pulmonary TB with at least 5 contacts identified and screened for active and latent TB by year, East Midlands, 2018 to 2023 [note 58] [note 59]
Note 58: error bars represent upper and lower 95% confidence intervals.
Note 59: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.
There were a total of 750 contacts of pulmonary TB cases identified in 2023 in the East Midlands (Table 17). Of these 61.7% (463 out of 750) were screened for active and latent TB, this was a decrease from 70% in 2022 (567 out of 810). As a result of this screening, 3.7% (17 out of 463) were diagnosed with active TB and 20.7% (96 out of 463) were diagnosed with latent TB. Of the contacts diagnosed with latent TB, 60.4% (58 out of 96) started treatment and 53.1% (51 out of 96) completed latent TB treatment.
The proportion of contacts that started and completed latent TB treatment was higher in child contacts (90%, 18 out of 20 started and 85%, 17 out of 20 completed) compared to adult contacts (52.6%, 40 out of 76 started and 44.7%, 34 out of 76 completed).
Table 17. Number of contacts identified, screened, screening results and treatment for contacts of people notified with pulmonary TB (index individuals), East Midlands, 2023 [note 60]
| Treatment and screening categories | All adult contacts (number) | All adult contacts (proportion) | All child contacts (number) | All child contacts (proportion) | Total contacts (number) | Total contacts (proportion) |
|---|---|---|---|---|---|---|
| Number of contacts identified | 612 | Not applicable | 138 | Not applicable | 750 | Not applicable |
| Number of contacts screened for active TB and latent TB | 378 | 61.8 | 85 | 61.6 | 463 | 61.7 |
| Number of contacts with active TB | 15 | 4 | 2 | 2.4 | 17 | 3.7 |
| Number of contacts with latent TB | 76 | 20.1 | 20 | 23.5 | 96 | 20.7 |
| Number of contacts who started treatment for latent TB | 40 | 52.6 | 18 | 90 | 58 | 60.4 |
| Number of contacts who completed treatment for latent tuberculosis | 34 | 44.7 | 17 | 85 | 51 | 53.1 |
Note 60: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.
BCG immunisation is recommended for people at higher risk of exposure to TB, particularly to protect against serious forms of disease in infants. Those eligible are:
- all infants (up to 12 months) with a parent or grandparent born in a country where incidence of TB is over 40 cases per 100,000 population per year
- all infants living in an area of the UK with an incidence above 40 per 100,000 population
The timing of the neonatal BCG immunisation was changed to a 28-day immunisation programme in September 2021. This change was prompted by the addition of screening for severe combined immunodeficiency (SCID) to the routine newborn screening test at 5 days of age (8).
In 2023 in the East Midlands, 47% (186 out of 397) of all TB cases had received the BCG vaccination. There was a higher BCG vaccination coverage in TB cases born outside of the UK (49%, 153 out of 311) compared to UK-born TB cases (38%, 33 out of 86). In 2023, 100% of children under 15 years old diagnosed with TB were vaccinated (10 out of 10).
Discussion
This report of TB in the East Midlands includes data up until the end of 2023 and provides the latest epidemiological picture of TB in the area.
For 2023, the East Midlands has seen a 3% increase in TB notifications compared to 2022 which is of concern if we are to meet the year-on-year decrease required by WHO to meet the WHO End TB 2035 goal of a 90% reduction in incidence. This will require monitoring and renewed efforts for this trend to be reversed.
Although the East Midlands figures remain below the TB rate for England as a whole, there remains variation in TB across the East Midlands. The highest rates of TB continue to be concentrated in the large urban areas of Leicester City, Nottingham City and Derby City. Leicester City local authority has also been highlighted as having the highest average incidence in England between 2021 and 2023. In the East Midlands 5 out of 10 UTLAs have experienced increases in TB incidence between 2022 and 2023, including Leicester City.
The number of TB cases in people who were born outside the UK continues to increase in the East Midlands with over three-quarters of TB cases born outside of the UK. A particular increase was noted in those aged 15 to 44 years for 2023. Although the number of cases in UK-born persons is substantially lower than those non-UK-born, this group has also seen an increase for 2023 which follows national trends. This indicates an ongoing issue with domestic transmission and a focus on also addressing TB rates in this group is important to reduce TB in the East Midlands.
In the East Midlands, there were more TB notifications in people born in India than those born in the UK, accounting for over one third of cases which was higher than the proportion for England overall. There has been an increasing trend in the number of TB cases in recent migrants, particularly in the proportion of TB cases in those that entered the UK less than 2 years prior to their diagnosis. This overtook the proportion of cases that had entered the UK 11 or more years ago for the first time in 2023. This increasing pattern of TB in recent migrants has also been seen nationally and is thought to reflect recent changes in migration patterns in England. A particular focus is required on this population group to optimise screening opportunities.
Over half of the TB cases in the East Midlands are pulmonary which is generally considered to be infectious. Although the proportion of pulmonary TB cases that were culture-confirmed increased in 2023, it remained below the national target. Culture-confirmation is important to ensure drug resistant infections can be identified, and effective treatment regimens put in place and to allow WGS cluster identification.
The time between symptom onset and starting treatment for pulmonary TB patients is of concern with over one quarter of cases having a treatment delay of over 4 months. This delay in treatment increases the opportunity for TB transmission to others and the risk of adverse outcomes for the patient. This highlights the need for continuing programmes of awareness raising and education surrounding TB amongst communities and healthcare professionals.
TB treatment completion for drug-sensitive patients within 12 months has continued to decrease and at 76% for those notified in 2022, is well below the 90% treatment target. Increases were seen in those lost to follow up but also where treatment had been stopped which needs to be further understood.
TB is known to be associated with deprivation and that is seen in the East Midlands, with higher TB rates amongst residents in more deprived areas. TB cases often have complex health and social needs. One fifth of cases reported at least one named comorbidity with diabetes being the most reported. There has been an increase in the proportion of cases reporting one or more social risk factors and at 16.8% is at the highest in recent years and a further area to focus screening. The most reported risk factor was alcohol misuse and having a social risk factor was more commonly reported in males and those that were UK-born. Enhanced case management was required by nearly 40% of cases in the East Midlands in 2023 reflecting the complexity of health and social needs and will have an impact on TB services workload.
The proportion of people notified with at least 5 contacts identified and screened has been decreasing since 2018 and the proportion of contacts screened for active and latent TB in the East Midlands is lower than the proportion nationally. Contact tracing is important for preventing further cases through identifying those at highest risk of exposure, finding people with disease earlier and also treating latent infection.
TB needs to remain a health priority for partners in the East Midlands. The increase in TB incidence in the East Midlands is of concern and renewed efforts are required to reverse this trend and move towards the WHO End TB Strategy pre-elimination goal by 2035. Certain risk groups continue to be more likely to be affected than others within the East Midlands. This underlines the need for services to work collaboratively, across the range of health and social care issues. A continued effort is needed to support the early diagnosis of TB and deliver effective packages of TB care to maximise treatment completion and minimise transmission.
Recommendations
To reverse the increasing trend in TB there are some important themes to focus on, which are summarised in the following recommendations linked to the 5 priority areas in the TB action plan Tuberculosis (TB): action plan for England, 2021 to 2026:
1. Recovery from COVID-19
Reestablish the East Midlands multi-agency TB Control Board, supporting implementation of the TB action plan and identify areas for regional collaborative working.
Reestablish and strengthen local TB clinical networks particularly where these were paused during the COVID-19 pandemic, focusing on areas with increasing TB rates.
UK Health Security Agency (UKHSA) teams should continue to monitor TB notifications and provide timely information, including more in-depth annual reports, to partners including local TB Networks and TB Control Board.
With Leicester having the highest TB incidence in England, partners should continue to work collaboratively in Leicester, Leicestershire and Rutland (LLR) to implement their local TB Strategy and share learning with other systems.
2. Prevent TB
Through multi agency working, identify opportunities to offer appropriate screening for high-risk groups such as those with social risk factors and consider integrating TB symptom screening to service specifications supporting inclusion health groups.
The increase in TB amongst recently arrived migrants suggest systems would benefit from increased focus on this population group. TB services and commissioners should identify missed opportunities for pre-entry and new migrant screening and consider best practice for screening new entrants.
Contact tracing is important in preventing further TB cases. Improve screening opportunities of contacts of pulmonary TB cases to increase the proportion that are screened for active and latent TB.
3. Detect TB
Partners and TB services should try to improve early detection of TB by investigating and understanding the components that contribute to treatment delays.
TB services should continue efforts to achieve the target of 80% of pulmonary TB cases being culture-confirmed to enable WGS and the identification of clusters and drug resistance.
4. Control TB
Partners and TB services should work to understand the reduction seen in current TB treatment completion rates, identify areas for collaboration and work with system partners such as drug support services and community outreach teams, with the aim of improving treatment completion rates for TB drug-sensitive cases and meeting the 90% target.
5. Workforce
TB services and commissioners should review the data provided by the NHSE commissioned Getting It Right First Time (GIRFT) TB review. Working with NHS Trust management, ICB commissioners should ensure that services are equipped to meet the needs of local communities.
Appendix
Methods
Full details of the data sources, methodologies and a glossary of the terms used in this reports are available in the Tuberculosis in England 2024 report.
Acknowledgements
We are grateful to all those who contribute information on people with tuberculosis in the East Midlands, including nurses, physicians, microbiologists, scientists, outreach and social care and administrative staff. We also acknowledge colleagues at the UKHSA National Mycobacterium Reference Service for information on culture-confirmation and drug susceptibility testing. Further thanks are due to the UKHSA National TB Unit for providing the cleaned matched data set, the East Midlands Health Protection Team and the Field Service (Midlands) team for their work supporting Enhanced Tuberculosis Surveillance.
References
- UKHSA (2024). ‘Tuberculosis in England, 2024 report’ (presenting data to end of 2023)
- WHO (2015). ‘The end TB strategy’
- UKHSA (2021). ‘UK pre-entry tuberculosis screening report 2020’
- WHO (2025). ‘WHO consolidated guidelines on tuberculosis. Module 4: treatment and care’
- Joint Formulary Committee. ‘British National Formulary 2018’ 3 October 2018
- WHO (2013). ‘Definitions and reporting framework for tuberculosis – 2013 revision’
- UKHSA (2021). ‘TB Action Plan for England, 2021 to 2026’
- UKHSA (2021). ‘BCG vaccination programme’