East of England: tuberculosis in 2023

Question 1

Executive summary

Accepted Answer

In 2023, there were 410 tuberculosis (TB) case reports to the UK Health Security Agency (UKHSA) National Tuberculosis Surveillance System (NTBS) for people resident in the East of England. The East of England has lower rates of TB than England as a whole. In 2023, the 410 cases equated to a rate of 6.1 cases per 100,000 population (95% confidence interval (CI) 5.5 to 6.7), compared to 8.4 per 100,000 in England overall. The Tuberculosis in England 2024 report showed that the rate of TB in the East of England in 2023 was significantly lower than London (18.7 per 100,000), and similar to other regions such as North East and Yorkshire (5.7 per 100,000) and South East (5.9 per 100,000).

In the East of England, both the number of cases and rate of TB increased in 2023 compared to 2022 (increase of 12.0% and 10.8% respectively). They were higher than the target rate required to meet the World Health Organization (WHO) End TB 2035 goal of 90% reduction in incidence. Provisional data published in the National quarterly report of TB in England shows a further 10.2% increase in the number of cases in the East of England in 2024 compared to 2023. The rate of TB increased in 2023 in most local authorities, particularly in Bedford (8.4 per 100,000, 21.7% increase), Luton (25.1, 29.4%), Norfolk (4.7, 27.0%), Peterborough (21.0, 27.3%) and Southend-on-Sea (8.8, 100%).

The highest age and sex specific rates of TB in the East of England in 2023 were recorded among males aged 20 to 29 years (13.1 per 100,000) and females aged 20 to 29 years (10.3 per 100,000). There were 7 cases among children aged less than 9 years.

Of people diagnosed with TB in the East of England in 2023, 81.0% were born outside the UK. Since 2020, there has been an increasing number of notifications among people born outside the UK, and a decreasing number among UK-born people. People with TB in 2023 who were born outside the UK were most frequently born in India, Pakistan, Romania, and Bangladesh. Over one-third of people had arrived in the UK 11 or more years prior to their TB diagnosis, but there was an increasing proportion of recent migrants, particularly for people born in Afghanistan. The majority of UK-born people with TB in 2023 were White (72.4%), and the majority of non-UK-born people with TB were Indian (21.4%) or Black African (21.4%).

As in previous years, over half (61.5%) of people had pulmonary TB. One quarter of people with TB had a comorbidity such as diabetes or immunosuppression. HIV tests were offered to 97.6% of people with TB. Among people with pulmonary TB, 73.8% were confirmed by culture, which is below the national target of 80%. Overall, 98.0% of culture confirmed TB were tested for antibiotic drug sensitivity, and initial drug resistance remained stable at 11.7% in 2023. Among culture-confirmed cases, 3.6% had rifampicin-resistant or multidrug-resistant TB (RR or MDR TB). Over the last 5 years, 0.8% have had pre extensively drug-resistant TB (pre-XDR TB), and 0.2% have had extensively drug-resistant TB (XDR TB). 41.3% of culture confirmed TB cases in 2023 were in a genetically related cluster with at least one other person.

The incidence of TB among children aged under 15 years varies each year, with 11 children notified in 2023, which equates to a rate of 0.9 cases per 100,000 population. 2023 was the first year in which there were more TB notification among non-UK-born children than UK-born children. The majority of children had pulmonary TB (72.7%) and only one child had severe TB (defined as central nervous system, spinal, cryptic or miliary TB).

In 2023, more than one-third of people with TB received enhanced case management (ECM), and more than 13% received the highest level of support (ECM level 3). Almost everyone (96.3%) notified with TB in 2023 started treatment. Among people with pulmonary TB, 62.3% did not start treatment within 2 months of symptom onset. In fact, one-third started treatment more than 4 months after symptom onset, consistent with a prolonged period of infectiousness. However, the average time to treatment has declined since 2021, indicating an overall improvement.

Treatment was completed within 12 months for 81.6% of people with rifampicin-sensitive TB reported in 2022 whose expected treatment duration was less than 12 months. Among those who did not complete treatment within 12 months, the most common last recorded outcome was death (4.1%). In recent years, a growing proportion of people have stopped treatment, but there was a reduction in people lost to follow-up. TB treatment completion was consistently lower among people with social risk factors (72.7% in 2022) or with RR or MDR TB (69.4% between 2017 and 2021).

Almost 20% of people with TB aged 15 years or older had at least one social risk factor, such as drug or alcohol misuse, homelessness, prison history, asylum seeker, or mental health needs. The rate of social risk factors among people with TB in the East of England has increased steadily since 2020 (12.0%). TB remains associated with deprivation, with 40.4% of people with TB in the East of England resident in the 3 most deprived decile areas based on the Index of Multiple Deprivation (IMD 2019).

In 2023, an average of 2 close contacts were screened for every person notified with pulmonary TB. Only 10% of people with pulmonary TB had 5 or more close contacts to screen, and the number of contacts were particularly high for children and for people with rifampicin-resistant TB. For people who were screened, 18.5% had latent TB, and 3.4% had active TB. Almost three-quarters of contacts with latent TB started treatment, among whom half have completed treatment.

To address the increasing TB trend in the East of England, we recommend:

strengthening early detection through targeted surveillance and improved diagnostics
enhancing culturally sensitive screening and support, particularly for non-UK-born populations
implementing strategies to improve timely treatment initiation and completion, particularly for vulnerable groups

Enhanced contact tracing, preventative therapy, and collaborative efforts across agencies to address social determinants of health are also crucial. Finally, continued monitoring and evaluation will be essential to measure the impact of these interventions.

Data for all the graphs in this report can be found in the East of England TB report 2023 supplementary data spreadsheet.

Question 2

TB incidence and epidemiology

Accepted Answer

Overall numbers, rates, and geographical distribution

In 2023, 410 cases of TB were notified in the East of England, with a crude rate of 6.1 per 100,000 population (95% confidence interval (CI) 5.5 to 6.7) as shown in Figure 1. This was an increase of 12.0% in the number of cases, and a 10.8% increase in the rate compared to 2022 (366 cases, rate: 5.5 per 100,000, 95% CI 4.9 to 6.1). The rate of TB in the East of England remains significantly lower than the overall rate for England (8.4 per 100,000) as shown in Figure 2.

The Tuberculosis in England 2024 report showed that the rate of TB in the East of England in 2023 was significantly lower than London (18.7 per 100,000). It was similar to other regions such as North East and Yorkshire (5.7 per 100,000) and South East (5.9 per 100,000). Case rates declined in the East of England from their peak in 2011 (9.2 per 100,000), but this trend has reversed and begun to show signs of increasing again. Provisional data published in the National quarterly report of TB in England shows a further 10.2% increase in the number of cases in the East of England in 2024 compared to 2023.

Figure 1. Number of TB notifications per year, East of England, 2001 to 2023

Figure 2. TB notification rates per 100,000 population per year, East of England, 2001 to 2023 [note 1]

Note 1: errors bars represent upper and lower 95% confidence intervals.

Since 2015, the overall trend in the rate of TB in the East of England has not declined in line with the WHO End TB 2035 goal of 90% reduction in incidence by 2035. In 2023, the difference between the observed rate (6.1 cases per 100,000 population) and the WHO regional target (3.9 cases per 100,000) increased (Figure 3). However, it is notable that the required rate for the East of England is lower than the rate required at a national level (4.2 cases per 100,000 in 2023) as quoted in the Tuberculosis in England 2024 report.

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 of England, 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 rates of TB increased in most upper tier local authorities in the East of England compared to 2022. The rate of TB in the following upper tier local authorities increased by over 20% in 2023:

Bedford (8.4 per 100,000 compared to 6.9 per 100,000 in 2022; 21.7%)
Luton (25.1 versus 19.4; 29.4%)
Norfolk (4.7 versus 3.7; 27.0%)
Peterborough (21.0 versus 16.5; 27.3%)
Southend-on-Sea (8.8 versus 4.4; 100%)

In general, rates were stable below 10 cases per 100,000 (low incidence) for most upper tier local authorities except for Luton and Peterborough. TB cases rates for upper tier local authorities are presented in Figure 4. The case rates for 2023 are also presented as a map in Figure 5 and full details are provided in the supplementary data tables.

Whilst rates consider the size of the population from which cases arise, the actual number of cases also need to be considered. Hertfordshire notified the largest number of cases in 2023 (71), while Central Bedfordshire reported the fewest (8). The largest increases in case numbers were seen in Luton (58 cases versus 44 in 2022; up 14), Norfolk (44 versus 34; up 10) and Peterborough (46 versus 36; up 10).

The number of TB notifications and rate is available by lower tier local authority and Integrated Care Board (ICB) in the supplementary tables.

Figure 4. TB notification rate by upper tier local authority of residence, East of England, 2001 to 2023 [note 4]

Note 4: grey lines represent the other upper tier local authorities in the region.

Figure 5. TB notification rate by upper tier local authority of residence, East of England, 2023

Demographic characteristics

Age and sex

The age sex distribution for people with TB in 2023 was similar to previous years, with more male (58.5%) than female cases, and the majority of cases aged 20 to 39 years (Figure 6). In 2023, there were 7 cases among children aged less than 9 years. Crude rates of TB were highest among males aged 20 to 29 years (13.1 per 100,000) and females aged 20 to 29 years (10.3 per 100,000).

Figure 6. Number of TB notifications and TB notification rate by age and sex, East of England, 2023

Place of birth and time since entry

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, which is described in the Tuberculosis in England 2024 report. 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) and has operated in 102 countries since 2014.

In 2023, 81.0% (332 out of 410) of people with TB were born outside the UK. Since 2020, the trend in TB notifications has diverged, with an increasing number of notifications among people born outside the UK (332 in 2023 versus 258 in 2020), and a decreasing number among UK-born people (78 versus 107) which reached its lowest point since 2001, as seen in Figure 7.

Figure 7. Number of TB notifications in non-UK-born and UK-born by place of birth, East of England, 2001 to 2023

Since the majority of people with TB in the East of England were born outside the UK, the age distribution of TB notifications from all places of birth reflects the distribution of people born outside the UK. The lowest number of notifications were consistently among non-UK-born children aged 0 to 14 years, and the highest among non-UK-born people aged 15 to 44 years. However, the number of notifications increased for all age groups of non-UK-born people between 2022 and 2023. The number of notifications for people born in the UK were comparatively stable for all age groups each year, as seen in Figure 8.

Figure 8. Number of TB notifications in non-UK-born and UK-born by place of birth and age group, East of England, 2001 to 2023

In 2023, the year of entry to the UK was reported for 75.6% (251 out of 332) of TB patients born outside the UK. Among those with a reported date of entry, 37.4% (94 out of 251) had arrived in the UK 11 or more years prior to their TB diagnosis. Since 2013, the majority of TB notifications have been among such settled migrants. However, in 2023, the proportion of notifications among recent migrants who arrived in the UK within the last 2 years increased and was similar to those who arrived 11 or more years ago (32.7%) (Figure 9).

Figure 9. Proportions of TB notifications by time since entry, for people born outside the UK, East of England, 2001 to 2023

The 10 most common countries of birth for TB patients born outside the UK and notified in 2023 were:

India (accounting for 16.8% of all TB patients in the East of England)
Pakistan (8.3%)
Romania (6.1%)
Bangladesh (5.1%)

Followed by:

Nigeria
Zimbabwe
Afghanistan
Philippines
Eritrea
Lithuania

Each accounting for less than 5.0% (Table 1).

It is notable that majority of Afghan people diagnosed with TB in 2023 had arrived in the UK in the last year, which aligns with the start of the Afghan Citizens Resettlement Scheme in the UK in January 2022 although not all of the individuals may have arrived under this scheme.

Table 1. Most common countries of birth for people with TB and time between entry to the UK and TB notification, East of England, 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
United Kingdom	78	19.0	Not applicable	Not applicable
India	69	16.8	3.0	1.0 to 15.0
Pakistan	34	8.3	19.0	7.0 to 35.0
Romania	25	6.1	3.0	2.0 to 7.0
Bangladesh	21	5.1	2.0	0.2 to 10.8
Nigeria	19	4.6	1.0	0.0 to 5.0
Zimbabwe	19	4.6	14.0	1.0 to 21.5
Afghanistan	15	3.7	0.0	0.0 to 1.0
Philippines	14	3.4	12.0	4.8 to 23.2
Eritrea	9	2.2	0.0	0.0 to 3.0
Lithuania	9	2.2	9.0	5.0 to 13.8
Other	98	23.9	8.0	1.0 to 20.2
Total	410	100.0	Not applicable	Not applicable

Note 5: other includes all countries with less than 9 people notified.

Among the 6 most common countries of birth for TB patients born outside the UK, there have been relatively stable numbers of notifications among people from:

India (69 in 2023)
Pakistan (34)
Romania (25)

Since 2021, the numbers of notifications have risen among people from Bangladesh (21), Nigeria (19) and Zimbabwe (19) as seen in Figure 10.

Figure 10. Numbers of TB notifications for the most common countries of birth for people with TB born outside the UK, East of England, 2013 to 2023 [note 6]

Note 6: figure shows the top 6 countries in 2023.

The average age of people with TB from the most common non-UK countries of birth was typically between 35 and 55 years. More than 60% of newly notified people with TB from India, Pakistan and Romania were male. However, only 31.6% of people with TB from Nigeria were male. The proportion of people with pulmonary TB from Romania (84.0%) and Zimbabwe (78.9%) was much higher than the East of England average for 2023 (61.5%), and notably low for people from India (37.7%). TB notifications were more common in the first 2 years after entry to the UK for people from Nigeria (58.8%, among cases with a recorded date of UK entry) and Bangladesh (44.4%). Among those small numbers of people from Pakistan, Romania and Zimbabwe who entered the UK less than 2 years prior to diagnosis, all had pulmonary TB (Table 2).

Table 2. Characteristics of people with TB from the most common (non-UK) countries of birth, East of England, 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	69	39.0	63.8	37.7	32.7	56.2
Pakistan	34	54.1	61.8	52.9	8.0	100.0
Romania	25	40.5	68.0	84.0	11.8	100.0
Bangladesh	21	39.6	47.6	47.6	44.4	25.0
Nigeria	19	34.9	31.6	42.1	58.8	50.0
Zimbabwe	19	45.6	42.1	78.9	33.3	100.0

Ethnicity

In 2023, 97.3% (399 out of 410) of people with TB reported their ethnicity. The majority of UK-born people with TB were White (72.4%, 55 out of 76), and the majority of non-UK-born people with TB were Indian (21.4%, 69 out of 323) or Black African (21.4%, 69 out of 323), and 15.5% (50 out of 323) were other Asian ethnicities as shown in Figure 11.

Figure 11. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), East of England, 2023 [note 7]

Note 7: figure ordered by total number of notifications within each ethnicity irrespective of place of birth.

Among non-UK-born people, the majority of TB notifications were among people of South Asian ethnicity. However, notifications have increased among non-UK-born Black and Mixed or other people since 2020. Among UK-born people, the number of TB notifications remain stable across all ethnic groups, with White ethnicity being most frequent. Overall, regardless of place of birth, between 2016 and 2021 people with TB most frequently reported White ethnicity, but this has now reversed, and there are more TB notifications among South Asian people again in 2023, as shown in Figure 12.

Figure 12. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), East of England, 2001 to 2023

Clinical characteristics

Site of disease

In 2023, 61.5% of patients (252 out of 410) had pulmonary TB disease (with or without extra-pulmonary sites) (Table 3). The next most common site of disease, as in 2018 and 2019, was extra-thoracic lymph nodes, present in 20.0% of cases (82 out of 410) (Table 4).

Table 3. Number of pulmonary TB notifications by site of disease, East of England, 2023 [note 8] [note 9]

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All pulmonary	252	61.5
Pulmonary only	177	43.2
Miliary only	17	4.1
Laryngeal only	2	0.5

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 of England, 2023 [note 10]

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All extra-pulmonary	233	56.8
Extra-thoracic lymph nodes	82	20.0
Other extra-pulmonary	65	15.9
Intra-thoracic lymph nodes	48	11.7
Pleural	28	6.8
Gastrointestinal	24	5.9
Bone - spine	11	2.7
Central nervous system - meningitis	8	2.0
Bone - not spine	4	1.0
Central nervous system - other	3	0.7
Genitourinary	3	0.7
Cryptic disseminated	2	0.5

Note 10: percentages may not add up to 100 as people with TB may have more than one site of disease.

The proportion of people notified with pulmonary TB each year was relatively stable, ranging from a low of 51.7% in 2013 (233 out of 451) up to 64.1% in 2018 (221 out of 345) as shown in Figure 13.

Figure 13. Proportion of people notified with pulmonary TB, East of England, 2013 to 2023 [note 11]

Note 11: error bars represent upper and lower 95% confidence intervals.

Comorbidities

As described in the Tuberculosis in England 2024 report, comorbidities with other infections or non-communicable diseases such as diabetes or chronic renal disease may affect TB susceptibility, treatment strategies and outcomes. In 2023, 20.5% of people notified with TB had at least one comorbidity. The most commonly recorded comorbidity was immunosuppression (11.0%), followed by diabetes (9.5%) as shown in Table 5.

Table 5. Number and proportion of people with TB with comorbidities, East of England, 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	410	84	20.5	Not applicable	Not applicable
Chronic liver disease	364	5	1.4	46	11.2
Chronic renal disease	365	12	3.3	45	11
Diabetes	369	35	9.5	41	10
Hepatitis B	334	10	3.0	76	18.5
Hepatitis C	333	4	1.2	77	18.8
Immunosuppression	365	40	11.0	45	11

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.

HIV testing

As discussed in the WHO consolidated guidelines on tuberculosis and comorbidities, TB complicating HIV infection is a well-recognised and particularly lethal clinical state but can be successfully treated with a combination of highly active antiretroviral therapy (HAART) and appropriate TB antibiotic treatment. For this reason, it is essential that all patients with TB should undergo HIV testing so that if they are diagnosed as having TB-HIV co-infection they have the opportunity to start curative TB treatment and HAART as soon as possible, and in so doing preserve their life expectancy and reduce the risk of TB and HIV transmission to others.

Of the 410 people diagnosed with TB in 2023, 381 had their HIV testing status recorded in NTBS. HIV tests were offered to 97.6% (372 out of 381) of people with TB (Figure 14). This includes where an HIV test was offered and done, offered but not done, offered but refused, or where an individual’s HIV status was already known. This represents a high and steadily increasing trend since 94.7% (343 out of 362) of people with TB were offered an HIV test in 2020. However, this remains below the target of 100% of people offered an HIV test.

Figure 14. Proportion of people with TB offered an HIV test by year, East of England, 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.

Social risk factors relevant to TB incidence include:

homelessness
drug and alcohol misuse
prison history
asylum seeker
mental health needs

In 2023, 16.5% of people with TB aged 15 years or over (66 out of 399) had at least one risk factor, and 9.2% had more than one risk factor (33 out of 360). The most common risk factor reported in 2023 was homelessness (7.7%, 27 out of 351) followed by asylum seeker status (7.4%, 27 out of 365), and imprisonment (6.1%, 21 out of 347) as shown in Table 6.

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	399	66	16.5	Not applicable	Not applicable
More than one social risk factor	360	33	9.2	39	9.8
Alcohol misuse (current)	350	14	4.0	49	12.3
Asylum seeker (current)	365	27	7.4	26	6.6
Drug misuse (current or previous)	344	14	4.1	55	13.8
Homelessness (current or previous)	351	27	7.7	48	12
Mental health needs (current)	343	13	3.8	56	14
Prison (current or previous)	347	21	6.1	52	13

Note 15: people with TB are reported as having at least one of the named social risk factors if any of the 6 social risk factors (current alcohol misuse, current or a history of homelessness, drug misuse, imprisonment, current asylum seeker status and current mental health needs) had ‘yes’ recorded. 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.

Overall, there has been an increasing proportion of people with TB aged 15 years or over who reported at least one social risk factor between 2020 (12.0%, 42 out of 351) and 2023 (16.5%, 66 out of 399) (Figure 15).

Note 16: error bars represent upper and lower 95% confidence intervals.
Note 17: please note: not all social risk factors were captured before 2021.

As shown below in Table 7, men with TB were more likely than women to report all social risk factors except mental health needs. When looking by age, the highest rates of homelessness (9.9%) and asylum seekers (12.0%) were reported by people with TB aged 15 to 44 years. Drug and alcohol misuse (9.7% and 4.8% respectively), prison (15.4%), and mental health needs (12.5%) were all reported more often by UK-born people with TB than those born outside the UK. However, UK-born and non-UK-born people with TB had similar rates of homelessness. Finally, people with TB who were unemployed at the time of diagnosis reported high rates of all social risk factors.

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	2.8	1	0.7	4	2.7	2	1.4	2	1.3	6	4.1
Male	10	5.0	13	6.3	23	11.3	19	9.5	25	11.4	7	3.6
Aged 15 to 44	8	4.0	6	2.9	20	9.9	13	6.4	26	12.0	6	3.0
Aged 45 to 64	5	5.0	7	7.0	7	6.7	6	5.9	0	0.0	6	5.9
Aged 65 or older	1	2.3	1	2.3	0	0.0	2	4.8	1	2.0	1	2.4
Non-UK-born	8	2.8	11	3.8	22	7.7	11	3.9	27	9.0	5	1.8
UK-born	6	9.7	3	4.8	5	7.6	10	15.4	0	0.0	8	12.5
Unemployed	11	9.6	10	8.7	18	15.3	15	13.2	18	14.3	10	9.0

Deprivation

Based on the Index of Multiple Deprivation (IMD 2019) rank assigned to different geographical areas in England in 2023, the rates of TB were highest in the most deprived areas (Figure 16). As in previous years, the rate of TB was statistically significantly lower in less deprived areas.

Figure 16. TB notification rate by deprivation decile, East of England, 2023 [note 18]

Note 18: error bars represent upper and lower 95% confidence intervals.

Question 3

TB diagnosis, microbiology and drug resistance

Accepted Answer

Culture confirmation

In 2023, 73.8% of people notified with pulmonary TB (186 out of 252) were confirmed by culture of a TB isolate. Culture confirmation of pulmonary TB has been consistently below the TB Action Plan for England target of 80% in the East of England apart from in 2022, when 82.8% were culture confirmed (Figure 17).

The proportion culture confirmed by ICB is available in supplementary tables of the Tuberculosis in England 2024 report, with Bedfordshire, Luton and Milton Keynes ICB (81.4%), Hertfordshire and West Essex ICB (82.8%) and Mid and South Essex ICB (80.0%) all achieving the above 80%. The remaining 3 ICBs in the East of England (Cambridgeshire and Peterborough ICB, Norfolk and Waveney ICB, and Suffolk and North East Essex ICB) all had culture confirmation rates between 60 and 70%.

Figure 17. Proportion of people notified with pulmonary TB who were culture confirmed, East of England, 2017 to 2023 [note 19] [note 20]

Note 19: dashed line indicates target of 80% culture confirmation.
Note 20: error bars represent upper and lower 95% confidence intervals.

Drug resistance

In 2023, among 248 people with culture confirmed TB (including both pulmonary and extra-pulmonary TB), 98.0% of isolates were tested for sensitivity to all 4 first line drugs (rifampicin, isoniazid, pyrazinamide and ethambutol). As shown in Figure 18, first line drug results between 2017 and 2023 were consistently reported for over 97% of culture confirmed TB.

Figure 18. Proportion of people culture confirmed with TB with first line drug results, East of England, 2017 to 2023 [note 21]

Note 21: error bars represent upper and lower 95% confidence intervals.

The proportion of culture confirmed TB with initial resistance to any first line drug remains relatively stable in the East of England, varying between 4.7% (10 out of 215) in 2020 and 11.7% (29 out of 248) in 2023 (Figure 19).

Several of the cases notified in 2023 were resistant to isoniazid but not rifampicin (4.4%, 11 out of 248), however 3.6% (9 out of 248) had rifampicin-resistant or multidrug-resistant TB (RR or MDR TB).

On average over the last 5 years, 2.3% of cases have had RR or MDR TB (27 out of 1,172), 0.8% have had pre extensively drug-resistant TB (pre-XDR TB, 9 out of 1,172), and 0.2% have had extensively drug-resistant TB (XDR TB, 2 out of 1,172). Since 2019, 10 cases were treated with a second line regimen for RR or MDR TB in the absence of drug-resistant test results.

Figure 19. Proportion of people notified with culture confirmed TB with initial resistance to any first line drug, East of England, 2017 to 2023 [note 22]

Note 22: error bars represent upper and lower 95% confidence intervals.

Clustering

Culture confirmed TB isolates can be analysed using whole genome sequencing (WGS) to determine how closely related 2 people’s TB infections are, which can identify likely transmission between people. Between 2020 and 2023, 60.5% (916 out of 1,515) of people with pulmonary or extra-pulmonary TB were culture confirmed (Table 8). Overall, 41.3% (378 out of 916) of these people had TB which was in a cluster with at least one other person (that is, in a cluster with less than 12 single nucleotide polymorphisms (SNP) between isolates). This proportion has remained relatively stable over time, ranging from 39.6% in 2022 to 43.1% in 2023.

Overall, 75.0% of people with TB between 2020 and 2023 (1,137 out of 1,515) were not known to be part of a WGS cluster. This was either because their TB wasn’t cultured, or the sources of their infection may be undiagnosed, not cultured, or overseas.

Table 8. Number of people notified, proportion with culture confirmation and proportion of notifications identified in a WGS cluster, East of England, 2020 to 2023 [note 23] [note 24]

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	371	215	58.0	86	40.0	33.7 to 46.7
2021	368	208	56.5	88	42.3	35.8 to 49.1
2022	366	245	66.9	97	39.6	33.7 to 45.8
2023	410	248	60.5	107	43.1	37.1 to 49.4
Total	1,515	916	60.5	378	41.3	38.1 to 44.5

Note 23: a WGS cluster is defined as 2 or more individuals that have isolates with a less than 12 SNP difference.
Note 24: WGS cluster reporting has changed over time. These changes are likely to have affected the most recent year’s data.

Question 4

TB in children: incidence, epidemiology and microbiology

Accepted Answer

Figure 20 shows the trend of TB notifications among children aged under 15 years in the East of England. Since 2018, there has been substantial variability, reaching a recent peak of 20 notifications in 2020, and 11 notifications in 2023. In every year apart from 2023, the number of TB notifications in UK-born children was larger than the number in non-UK-born children. The overall trend in notifications among UK-born children was very similar to all children in the East of England, with a recent peak in 2020 of 15 notifications, and 5 notifications in 2023. The overall trend in notifications among non-UK-born children was also similar, with a recent peak in 2020 of 7 notifications, and returning to a similar level in 2023 with 6 notifications. Full information on the number of notifications in UK-born and non-UK-born children is available in the supplementary data tables.

Figure 20. Number of TB notifications in children aged under 15 years, East of England, 2001 to 2023

The incidence rate of TB among children shows the same trend (Figure 21), reaching a recent high of 1.7 notifications per 100,000 children aged under 15 years in 2020, and 0.9 notifications per 100,000 in 2023, although this was not statistically significantly lower.

Figure 21. TB notification rate in children aged under 15 years, East of England, 2001 to 2023 [note 25]

Note 25: error bars represent upper and lower 95% confidence intervals.

The majority of children aged under 15 years notified in 2023 had pulmonary TB (72.7%, 8 out of 11), and almost half had extra-pulmonary sites of disease (45.5%, 5 out of 11) (Table 9). Only one child had severe TB (defined as central nervous system, spinal, cryptic or miliary TB).

Table 9. Site and severity of disease in children aged under 15 years with TB, East of England, 2023 [note 26]

Clinical characteristic	Number of notifications in children aged 0 to 4 years	Number of notifications in children aged 5 to 9 years	Number of notifications in children aged 10 to 14 years	Total
All disease sites	4	3	4	11
Pulmonary	3	2	3	8
Extra-pulmonary	1	1	3	5
Severe TB	0	0	1	1
Lymph nodes only	1	0	1	2
Other	0	0	0	0

Note 26: pulmonary also includes children with or without extra-pulmonary sites. Lymph nodes only includes intra- and extra-thoracic lymph nodes and no other site of disease including pulmonary or extra-pulmonary TB. Other includes gastrointestinal, genitourinary, or other extra-pulmonary.

Question 5

TB treatment

Accepted Answer

Enhanced case management

Enhanced case management (ECM) refers to the provision of additional expert clinical and psychosocial care by TB services for clinically and socially complex TB cases including vulnerable patients to support them through their diagnosis and treatment. ECM levels are set out by the Royal College of Nursing TB Case Management Tool and the National Institute of Health and Care Excellence (NICE) guidelines with increasing support provided for higher ECM levels.

In the East of England in 2023, more than one-third of people with TB (154 out of 410) received enhanced case management, and 13.2% (54 out of 410) received ECM level 3. This is an increasing trend since recording began in 2021 (Table 10).

Table 10. Number of people with TB receiving Enhanced Case Management, East of England, 2021 to 2023 [note 27]

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	368	114	31.0	40	10.9	34	9.2	39	10.6	1	0.3
2022	366	140	38.3	57	15.6	46	12.6	37	10.1	0	0.0
2023	410	154	37.6	61	14.9	38	9.3	54	13.2	1	0.2

Note 27: total TB notifications includes all people notified with TB regardless of whether they are receiving ECM or not, or if this information is missing.

Directly observed and video observed therapy

Directly observed therapy (DOT) is a strategy where a healthcare worker or designated individual watches a patient swallow every dose of their prescribed anti-TB medication. This ensures patients take their medicine correctly and helps improve adherence to treatment, a crucial factor in preventing drug resistance and ensuring successful treatment of tuberculosis. Video observed therapy (VOT) is a secure online alternative to DOT where treatment observation is conducted remotely by asking patients to submit video clips of themselves taking their treatment via smartphones.

In England, DOT or VOT is offered to individuals with TB who are at increased risk of treatment failure due to complex clinical or social issues, or those with specific conditions like drug-resistant TB or those requiring ECM level 3. DOT is also recommended for individuals in prisons or IRC (immigration removal centres) receiving TB treatment.

As described in supplementary data in the Tuberculosis in England 2024 report, 13.2% of people with TB in the East of England in 2023 were offered DOT or VOT (51 out of 387 where information on DOT or VOT was recorded in NTBS). Among those offered DOT or VOT, 64.7% received it (33 out of 51).

Treatment delay

Overall, 96.3% of people notified with TB in 2023 started treatment (395 out of 410). Among people with pulmonary TB who reported both date of symptom onset and date of treatment start, 62.4% (74 out of 123) did not start treatment within 2 months of symptom onset (Figure 22), a slight decrease from 2022 where 67.7% of people were not treated within 2 months.

The proportion of people with extra-pulmonary TB with a treatment delay over 2 months was consistently higher than people with pulmonary TB. Among those who reported both date of symptom onset and date of treatment start, in 2023 72.5% (46 out of 121) did not start treatment within 2 months of symptom onset, a slight decrease from 2021 where 76.1% of people with extra-pulmonary TB were not treated within 2 months.

Figure 22. Proportion of people notified with TB with a treatment delay over 2 months by site of disease, East of England, 2018 to 2023 [note 28] [note 29]

Note 28: error bars represent upper and lower 95% confidence intervals.
Note 29: delay to treatment is defined by the time between symptom onset and treatment start.

In 2023, approximately one-third of people with pulmonary TB started treatment more than 4 months (122 days) after symptom onset (32.7%, 65 out of 199), indicating a prolonged period of infectiousness. However, the proportion of people with a treatment delay this long has declined substantially since 2021 (42.4%, 75 out of 177) as shown in Table 11. The average proportion of people with pulmonary TB with a treatment delay of more than 4 months is available by upper tier local authority in supplementary tables of the Tuberculosis in England 2024 report.

Table 11. Number and proportion of people notified with pulmonary TB with a treatment delay, time between symptom onset and treatment start, East of England, 2018 to 2023 [note 30]

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	57	30.0	64	33.7	190	27	12.4	217
2019	59	26.3	76	33.9	224	29	11.5	253
2020	54	28.1	78	40.6	192	26	11.9	218
2021	49	27.7	75	42.4	177	23	11.5	200
2022	48	28.7	65	38.9	167	33	16.5	200
2023	59	29.6	65	32.7	199	42	17.4	241

Note 30: all people included in this table are people with pulmonary TB who did not have a post-mortem 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 or 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.

The median, upper quartile, and maximum treatment delays among people with pulmonary TB have all declined between 2021 and 2023 (excluding outliers) as shown in Figure 23. This indicates an overall improvement in the time from symptom onset to treatment start, but the majority of people were not treated within the TB Action Plan for England target time of 56 days.

Figure 23. Median treatment delays among people notified with pulmonary TB, East of England, 2018 to 2023 [note 31] [note 32] [note 33] [note 34]

Note 31: dashed line represents the target treatment delay of 56 days by 2027.
Note 32: ends of the whiskers represent the theoretical lower and upper limits for detecting outliers (lower/upper quartile negative/positive 1.5 times the interquartile range). Outliers falling outside of these limits have been removed.
Note 33: delay to treatment is defined by when treatment was started from symptom onset.
Note 34: all people included in this figure are people with pulmonary TB who did not have a post-mortem diagnosis and it was known that they had started treatment. It excludes individuals with a delay over 730 days.

Question 6

TB treatment outcomes

Accepted Answer

Treatment outcomes in the non-MDR or non-RR TB cohort (without CNS disease)

People with TB sites of disease that do not include the central nervous system (CNS), spinal, miliary or cryptic disseminated disease are usually expected to complete treatment within 12 months. 81.6% of people (261 out of 320) diagnosed in 2022 with rifampicin-sensitive TB and an expected treatment duration of less than 12 months completed treatment within 12 months (Table 12). A further 12 people completed treatment by the time their last treatment outcome was recorded. The next most common treatment outcome was death, among 4.1% (13 out of 320) people with TB, and 2.8% were lost to follow-up (9 out of 320).

Table 12. Treatment outcome at 12 months and last recorded outcome for people notified in 2022 with non-MDR or non-RR TB (without CNS disease), East of England, 2022 [note 35] [note 36]

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	261	81.6	273	85.3
Died	13	4.1	13	4.1
Lost to follow-up	9	2.8	10	3.1
Still on treatment	6	1.9	2	0.6
Treatment stopped	6	1.9	8	2.5
Not evaluated	25	7.8	14	4.4
Total	320	100.0	320	100.0

Note 35: 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 36: table does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a post-mortem diagnosis of TB.

The proportion of people with rifampicin-sensitive TB (without CNS, spinal, miliary or cryptic disseminated disease) completing treatment within 12 months remains stably below the TB Action Plan for England target of 90% each year (Figure 24).

Figure 24. Proportion of people with non-MDR or non-RR TB (without CNS disease) who completed treatment within 12 months compared with the target of 90% Region, East of England, 2018 to 2022 [note 37] [note 38]

Note 37: dashed line indicates treatment target of 90%.
Note 38: error bars represent upper and lower 95% confidence intervals.

Figure 25 shows the long-term trends in the proportion of people who did not complete treatment within 12 months. In recent years, a growing proportion of people have stopped treatment (0.8% in 2019 to 1.9% in 2022). It is encouraging that the proportion of people lost to follow-up has reduced (7.2% in 2018 to 2.8% in 2022). However, there was an ongoing risk of death, which increased from 1.6% in 2021 to 4.1% in 2022 but this was not a statistically significant change.

Figure 25. Outcomes of people evaluated who did not complete treatment by 12 months for people with non-MDR or non-RR TB (without CNS disease), East of England, 2013 to 2022

TB treatment completion was consistently lower among people with one or more social risk factors: 72.7%% (40 out of 55) among those notified in 2022 which was a reduction of 9.8% compared to those notified in 2021 (82.5%, 33 out of 40) (Figure 26).

Note 39: error bars represent upper and lower 95% confidence intervals.

TB treatment outcomes for the non-MDR or non-RR TB cohort with CNS disease

For people notified in 2022 with rifampicin-sensitive TB and possible CNS involvement, 43.5% (10 out of 23) had completed treatment within 12 months (Table 13). The majority of people who had not completed treatment in this time were either not evaluated at 12 months (30.4%, 7 out of 23) or still on treatment (13.0%, 3 out of 23).

Table 13. Outcome at 12 months for people with rifampicin-sensitive, CNS, miliary or cryptic disseminated diseases, East of England, 2022 [note 40]

Outcome at 12 months	Number of TB notifications	Proportion of TB notifications
Treatment completed	10	43.5
Died	2	8.7
Lost to follow-up	1	4.3
Still on treatment	3	13.0
Not evaluated	7	30.4
Total	23	100.0

Note 40: 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.

TB treatment outcomes in the drug resistance (RR or MDR TB) cohort

TB treatment outcomes for the cohort of people with RR or MDR TB are reported at 24 months, so the most recent complete data is for people notified in 2021. Between 2017 and 2021, there were 36 people treated for RR or MDR TB. TB treatment completion was consistently lower among people with RR or MDR TB, with 69.4% (25 out of 36) completed at the last recorded treatment outcome. The death rate was also typically higher among people with RR or MDR TB (11.1%, 4 out of 36), as well as the rate of loss to follow-up (5.6%, 2 out of 36). Treatment duration can be particularly prolonged for people with RR or MDR TB, and among those notified between 2017 and 2021, 8.3% (3 out of 36) were still on treatment at their last recorded outcome. The remaining 2 out of 36 people had stopped treatment (Table 14).

Table 14. Last recorded outcomes for people treated for rifampicin-resistant TB, East of England, 2017 to 2021 [note 41]

Last recorded outcome	Number of TB notifications	Proportion of TB notifications
Treatment completed	25	69.4
Died	4	11.1
Lost to follow-up	2	5.6
Still on treatment	3	8.3
Treatment stopped	2	5.6
Total	36	100.0

Note 41: 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.

Question 7

TB prevention

Accepted Answer

Contact tracing according to NICE guidelines aims to identify latent or active TB infection among people who have been exposed to TB through contact with a person with pulmonary TB. Among 251 people diagnosed with pulmonary TB in 2023, contact tracing information was reported for 65.7% (Table 15). People with pulmonary TB reported an average of 2 close contacts requiring screening, with 10.0% of people having 5 or more close contacts to screen. The average number of close contacts requiring screening was notably high for children with pulmonary TB (7 cases). The highest rate of contact identification was for people with pulmonary rifampicin-resistant TB although the overall number of notifications in this group was small. For the 10 people notified with drug-resistant pulmonary TB, they had an average of 4.5 close contacts requiring screening, and 20.0% identified 5 or more close contacts to screen.

Table 15. Contact tracing information for people with pulmonary TB by demographic and disease characteristics, East of England, 2023 [note 42] [note 43]

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	251	165	65.7	25	10.0	2.0	1.0 to 4.0
Female	98	70	71.4	8	8.2	2.0	1.0 to 4.0
Male	153	95	62.1	17	11.1	2.5	1.0 to 5.0
Adults	242	160	66.1	24	9.9	2.0	1.0 to 4.0
Children (15 years or less)	9	5	55.6	1	11.1	7.0	7.0 to 7.0
Non-UK-born	194	129	66.5	19	9.8	2.0	1.0 to 4.0
UK-born	57	36	63.2	6	10.5	3.0	1.0 to 5.5
No social risk factor	202	138	68.3	20	9.9	2.0	1.0 to 4.0
At least 1 social risk factor	49	27	55.1	5	10.2	3.0	1.5 to 8.0
Non-MDR or RR TB	241	158	65.6	23	9.5	2.0	1.0 to 4.0
MDR or RR TB	10	7	70.0	2	20.0	4.5	2.8 to 6.5

Note 42: 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 43: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

The TB Action Plan for England set a target that at least 5 close contacts be identified for 90% of people notified with pulmonary TB. There is an ongoing challenge in identifying this number of contacts for each person with pulmonary TB. A peak of 20.0% of people with pulmonary TB identified at least 5 contacts in 2022, however this dropped to 10.0% in 2023 (Figure 27). We anticipate an improvement in this proportion as case records are updated.

Figure 27. Proportion of people notified with pulmonary TB with at least 5 contacts identified and screened for active and latent TB by year, East of England, 2018 to 2023 [note 44] [note 45]

Note 44: error bars represent upper and lower 95% confidence intervals.
Note 45: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

Overall, for the 251 people notified with pulmonary TB in 2023, 735 close contacts were identified (Table 16). Among these, almost half were screened for TB infection (356 out of 735), which identified 12 contacts with active TB (3.4%, 12 out of 356) and 66 contacts with latent TB (18.5%, 66 out of 356). Active TB was more frequently diagnosed among adult contacts (3.7%, 10 out of 272), and latent TB was more common among child contacts (28.6%, 24 out of 84). Almost three-quarters of contacts identified with latent TB started treatment (72.7%, 48 out of 66), among whom 57.6% was recorded having finished latent treatment (38 out of 66). Latent treatment was notably high among child contacts (91.7%, 22 out of 24), 79.2% of whom finished latent treatment (19 out of 24). Contacts with active TB were notified to NTBS, and their treatment outcomes are reported in the year they were notified.

Table 16. Number of contacts identified, screened, screening results and treatment for contacts of people notified with pulmonary TB (index individuals), East of England, 2023 [note 46]

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	491	Not applicable	144	Not applicable	635	Not applicable
Number of contacts screened for active TB and latent TB	272	55.4	84	58.3	356	56.1
Number of contacts with active TB	10	3.7	2	2.4	12	3.4
Number of contacts with latent TB	42	15.4	24	28.6	66	18.5
Number of contacts who started treatment for latent TB	26	61.9	22	91.7	48	72.7
Number of contacts who completed treatment for latent tuberculosis	19	45.2	19	79.2	38	57.6

Note 46: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

LTBI testing and treatment programme for new entrants

As described in the Tuberculosis in England 2024 report, the national latent TB infection (LTBI) testing and treatment programme is commissioned by NHS England in 3 ICBs in the East of England. Individuals are eligible for testing if they migrated to England from a high TB incidence country (more than 150 cases per 100,000 population, or any country in sub-Saharan Africa) and have registered with a GP within 5 years of entering the UK and are aged 16 to 35 years. Other East of England areas have no formally commissioned protocols for new entrant screening.

In the East of England, there has been an increasing proportion of TB notifications among people who arrived in the UK within the last 5 years. This rose from a low of 31.7% in 2020 to 47.8% in 2023, which was the highest proportion since 2017. Figure 28 shows the growing proportion of TB notifications among people who may have been eligible for LTBI testing.

Figure 28. Proportion of TB notifications occurring within 5 years of entry to the UK for all countries of birth outside of the UK, East of England, 2017 to 2023 [note 47] [note 48]

Note 47: error bars represent upper and lower 95% confidence intervals.
Note 48: within 5 years refers to a time since entry of less than 1 year to 5 years inclusive.

Some regional and ICB-level detail on the LTBI testing and treatment programme is available in supplementary tables of the Tuberculosis in England 2024 report. In 2023, 2.9% of the 18,298 eligible new migrants in the East of England were tested within the programme. Among those tested, 23.0% were positive and 30.3% of those who were positive started treatment. 16.2% of those who started treatment also completed it. In Bedfordshire, Luton and Milton Keynes ICB, 0.4% of eligible new migrants were tested in 2023. Among those tested, 26.7% were positive and 50% of those started treatment. In Cambridgeshire and Peterborough ICB, 6.3% of new migrants were tested, with 30.3% positive, among whom 34.1% started treatment. In Hertfordshire and West Essex ICB, 6.9% of new migrants were tested, with 10.2% positive, none of whom started treatment.

BCG vaccination

The Bacillus Calmette-Guérin (BCG) vaccination programme is a risk-based programme recommended for individuals at higher risk of exposure to TB. This includes all infants (0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is over 40 notifications per 100,000 population per year. In addition to this, all infants living in an area of the UK with an incidence above 40 per 100,000 population should be offered the BCG vaccine.

In the East of England, between January and December 2023, 16,081 children up to 3 months old were eligible for BCG vaccination, among whom 81.1% were vaccinated. This was the highest coverage achieved by any region in England in 2023, which was reported in the Tuberculosis in England 2024 report. BCG vaccination coverage in other eligible age groups is not publicly available.

Among people of any age who were notified with TB in 2023, 42% had been vaccinated with BCG (Table 17). 73% of children with TB under 15 years were vaccinated, and among these, 75% of children under 5 years were vaccinated. Among all cases, non-UK-born vaccination rates were higher than UK-born vaccination rates (44% versus 36%) and was consistent with findings in previous years.

Table 17. BCG vaccination coverage among people with TB, East of England, 2023

Place of birth	Number of vaccinated people with TB under 5 years old	Total number of people with TB under 5 years old	Proportion of vaccinated people with TB under 5 years old	Number of vaccinated people with TB under 15 years old	Total number of people with TB under 15 years old	Proportion of vaccinated people with TB under 15 years old	Number of vaccinated people with TB (all ages)	Total number of people with TB (all ages)	Proportion of vaccinated people with TB (all ages)
Non-UK-born	0	0	0	5	6	83	146	332	44
UK-born	3	4	75	3	5	60	28	78	36
All cases	3	4	75	8	11	73	174	410	42

Question 8

Discussion

Accepted Answer

The overall trend in TB notification rates in the East of England has climbed and remains higher than the WHO End TB target required to eliminate TB. There was also a divergence between the increasing number among non-UK-born people (particularly those who arrived in the UK within the last 2 years), and the declining number among UK-born people. The increasing rate was particularly notable for Luton and Peterborough local authorities.

There has been a reduction in the average time between symptom onset and treatment start for people with pulmonary TB since 2021. However, treatment management has become more challenging, with an increasing proportion of people receiving enhanced case management.

In the East of England, TB services have not consistently met the TB Action Plan target for 80% culture confirmation each year. Among those TB cases who were culture confirmed, an average of 41.3% had TB which clusters with at least one other person. Rates of antibiotic drug resistance were low but persistent.

Rates of treatment completion were stagnant for people with rifampicin-sensitive TB (81.3%), with no sustained improvement in completion rates seen since 2018; struggling to reach the TB Action Plan target of 90%. And treatment completion rates were consistently lower among people with social risk factors (71.2%), or with rifampicin-resistant TB (69.4%).

TB remained a substantial problem for inclusion health groups, who represent an increasing proportion of cases in the East of England (almost 20% in 2023). They more commonly have pulmonary TB, poorer outcomes, and complex needs requiring additional case management support.

The proportion of people with pulmonary TB who identified at least 5 contacts was lower than the TB Action Plan target (10% compared to 90% target) and reducing. This limits the possibility of treating latent TB among people exposed to pulmonary TB, who may themselves go on to develop active disease.

Question 9

Recommendations

Accepted Answer

Based on the 2023 TB surveillance data for the East of England, the following recommendations are proposed to address the increasing trend of TB and improve control efforts:

1. Strengthen surveillance and early detection

Enhance efforts to identify TB cases earlier, particularly among individuals with pulmonary symptoms, to reduce the duration of infectiousness. This includes raising awareness among primary care physicians and improving diagnostic and treatment pathways within secondary care.
Monitor the increasing rates in specific local authorities (Bedford, Luton, Norfolk, Peterborough, Southend-on-Sea) with targeted investigations to understand local drivers and implement tailored interventions.
Improve culture confirmation rates for pulmonary TB to meet the national target of 80%, ensuring timely and accurate drug susceptibility testing.

2. Address TB in non-U-born populations

Develop and implement culturally sensitive and accessible TB screening programs for newly arrived migrants, particularly from high incidence countries like Afghanistan, India, Pakistan, Romania, and Bangladesh.
Provide targeted health education and awareness campaigns about TB to communities with a high proportion of non-UK-born residents, addressing potential barriers to accessing healthcare.

3. Improve treatment initiation and completion

Implement strategies to reduce delays in treatment initiation for pulmonary TB, aiming for treatment within 2 months of symptom onset for a higher proportion of patients. This should involve streamlining referral pathways and improving communication between primary care, diagnostic services and TB service providers.
Develop targeted interventions to improve treatment completion rates among individuals with social risk factors and drug-resistant TB, including enhanced support, directly or video observed therapy (DOT or VOT), and addressing social determinants of health.

4. Enhance contact tracing and preventative therapy

Increase the average number of close contacts screened per pulmonary TB case, particularly for high-risk individuals.
Improve the uptake and completion rates of latent TB infection (LTBI) treatment among identified contacts through effective education, counselling, and support programs.

Strengthen collaborative work with local authorities and other agencies to address the social determinants of TB, particularly in areas with high deprivation and among individuals with social risk factors. This should involve integrated support for housing, mental health, substance misuse, and immigration issues.

6. Paediatric TB

Conduct further investigation into the increasing proportion of TB cases among non-UK-born children to understand the epidemiological trends and implement appropriate prevention and control measures.
Ensure timely diagnosis and management of TB in children, including prompt investigation of contacts of adult cases.

7. Drug resistance monitoring and management

Maintain high rates of drug susceptibility testing for culture confirmed TB and ensure appropriate management of drug-resistant cases, including access to specialised expertise and treatment regimens.
Monitor trends in drug resistance and work with the national TB team to implement strategies to prevent its emergence and transmission.

8. Strengthen interagency collaboration

Enhance communication and collaboration between UKHSA, NHS England and the Department of Health and Social Care, TB diagnostic and treatment providers, local authorities, social care services, and voluntary organisations to ensure a coordinated and comprehensive approach to TB prevention, detection, treatment, and care.

By implementing these recommendations, the East of England can work towards reversing the recent increase in TB incidence and progress towards the WHO End TB targets, ultimately improving the health outcomes of its residents. Regular monitoring of surveillance data and evaluation of implemented interventions will be crucial to assess their effectiveness.

Question 10

Appendix

Accepted Answer

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 of England, 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
UKHSA Regions Data Science for developing an R package for the data analysis
the East of England Health Protection Team
the Field Service East of England team for their work supporting Tuberculosis Surveillance

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