London: 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/london-tuberculosis-in-2023
Incidence, treatment and prevention of tuberculosis (TB) in London using data up until the end of 2023.
Executive summary
London remains the area of highest tuberculosis (TB) incidence in England, accounting for 1 in 3 people with TB in England in 2023. After a sustained decline from 2011, case numbers have continued to increase year-on-year since 2020. In 2023, 1,662 people in London were notified with TB, a rate of 18.6 per 100,000 of the population. This was a 5% increase from 2022, but still less than half from the peak in 2005 (45.9 per 100,000).
The London boroughs of Newham, Brent, Harrow, and Ealing had a rate above 30 per 100,000. Over half of London boroughs saw an increase in TB rates.
The majority (86%) of people with TB in London were born outside the UK, and since 2020 there has been an increasing trend in the number of people in London with TB that were born abroad.
While almost half of the people with TB who were born elsewhere had been in the UK more than 10 years before their TB notification, there has been an increasing proportion (since 2017) of cases among more recent migrants, those diagnosed less than 2 years after entering the UK.
India was the most common country of birth people with TB in London in 2023, with 1 in 4 cases from there. Total numbers of cases of TB in people born in India has been increasing in London since 2020. Those from India had a shorter time between entering the UK and being diagnosed (a median time of 3 years, with 35% diagnosed less than 2 years after entering the UK).
Just over half of all people with TB had pulmonary disease, which is potentially infectious. Around a quarter of people with pulmonary TB in London had a delay of more than 4 months from becoming unwell to starting treatment. Extra-thoracic lymph node was the next most common site.
Almost 1 in 4 people had a key co-morbidity (diabetes, hepatitis B, hepatitis C, chronic renal disease, chronic liver disease or immunosuppression), most commonly diabetes, which 12% of people with TB had in 2023. Almost all people with TB in London were tested for HIV. Contact tracing was leading to a median of only 2 contacts identified and screened per person with pulmonary TB.
TB remains associated with deprivation, with increasing rates seen in the more deprived areas of London. The proportion of adults with TB that had a social risk factor, defined as homelessness, prison history, asylum seeker status, mental health, or drug or alcohol misuse, was higher than the previous decade at 18% in 2023. Experience of one or more social risk factors was more common among men and people born in the UK. Over half of all people with TB in 2023 received Enhanced Case Management by TB services, which may be due to clinical or social complexities.
Of those people with TB notified in 2022 that would be expected to receive 6 months standard treatment, (excluding those with rifampicin-resistance, CNS, spinal, miliary or cryptic disseminated disease) 83% had completed treatment at 12 months, while 4% died before completing treatment. Just 73% of those with a social risk factor had completed treatment. Only 46% of those with CNS, miliary or cryptic disseminated TB, that was rifampicin-sensitive, had completed treatment at 12 months, and 10% died before completing treatment.
Recommendations from this report include to continue to monitor trends in new cases, with opportunities for prevention, and also work towards more effective case management and contact tracing efforts, both through local cohort reviews and networks and the London Control Board and Clinical Leadership Group.
As part of this, all TB services should review the data provided by the NHSE Getting it right first time (GIRFT) review, and work with integrated care boards (ICBs) and wider stakeholders to help ensure that services are equipped to meet needs of local communities.
In conclusion, increasing rates are concerning and warrant renewed effort from partners across London. Work must continue to find, treat and prevent cases of TB occurring in the known higher-risk communities in London. A continued emphasis on early diagnosis and support through treatment must remain a priority for London, and in particular focused work to reduce the inequities associated with TB.
Data for all the graphs in this report can be found in the London TB supplementary data 2023 spreadsheet.
TB incidence and epidemiology
In 2023, there were 1,662 cases of tuberculosis (TB) notified in London residents, a rate of 18.6 per 100,000 of the population (Figure 1 and Figure 2). This was the highest rate of TB in London since 2019, and represents a 24% increase in rate from 2020, where the rate was at its lowest (15.7 per 100,000). However, the rate in 2023 was 58% lower than 2005, when rates in London peaked.
Figure 1. Number of TB notifications per year, London, 2001 to 2023
An increase in the number of people with TB was also observed nationally from 2022 to 2023. The 5% increase in London between 2022 and 2023 was smaller than the 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). The rate of TB in London in 2023 is over twice as high as the rate for England (19.5 per 100,000 versus 8.4 per 100,000) and accounts for 1 in 3 cases in England (34% of the 4,855 cases in 2023).
Between 2016 and 2022, the TB notification rates for London were in line to meet the World Health Organization (WHO) ‘End TB 2035’ goal of a 90% reduction in the incidence of TB (Figure 3). The increase in rates in 2023, however, means London is at risk of not meeting this goal.
Figure 2: TB notification rates per 100,000 population per year, London, 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, London, 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 London Borough of Newham had the highest rate of TB (38.9 per 100,000, 141 cases), followed by Brent (37.2 per 100,000, 128 cases), Harrow (35.3 per 100,000, 93 cases) and Ealing (31.7 per 100,000, 119 cases) (Figure 4). These were the only boroughs with rates over 30 per 100,000.
Rates in Newham, Brent and Ealing fell compared to 2022, but in Harrow increased by 22% (from 76 cases, 29.0 per 100,000 in 2022), despite large decreases in previous years (75.9 per 100,000 in 2013 to 24.4 per 100,000 in 2018).
The largest increase in TB rates was in Kingston upon Thames, although it was due to very small numbers (7 cases, 4.1 per 100,000, in 2022 to 18 cases, 10.6 per 100,000, in 2023).
Notable increases were also seen in:
- Bexley (15 cases, 6.1 per 100,000, in 2022 to 33 cases, 13.1 per 100,000, in 2023)
- Barking and Dagenham (33 cases, 15.0 per 100,000, in 2022 to 62 cases, 27.9 per 100,000, in 2023)
- Hammersmith and Fulham (22 cases, 11.9 per 100,000, in 2022 to 34 cases, 18.3 per 100,000, in 2023)
Rates declined in 15 boroughs, with the largest declines in:
- Westminster (32 cases, 15.2 per 100,000, in 2022 to 24 cases, 11.3 per 100,000, in 2023)
- Southwark (48 cases, 15.4 per 100,000, in 2022 to 38 cases, 12.0 per 100,000, in 2023)
- Camden (36 cases, 16.6 per 100,000, in 2022 to 29 cases, 13.1 per 100,000, in 2023)
Year on year changes in rates in low-incidence boroughs should be treated with caution due to small numbers.
Figure 4. TB notification rate by upper-tier local authority of residence, London, 2023 [note 4]
Note 4: City of London and Hackney boroughs have been combined due to data suppression regulations.
In 2023, 61% (1,018) of people with TB in London were male, and the rate was higher among males than for females (Figure 5 and Figure 6). Rates and absolute numbers were highest for those aged 20 to 29 years for both males (267 cases, 38.1 per 100,000) and females (165 cases, 22.2 per 100,000).
Rates in men aged 20 to 69 years old were above 20 per 100,000, while rates in women were under 15 per 100,000, apart from women aged 20 to 39 years. There were 28 cases in children under 10 years old. This was the only group with more females (17 cases, 3.3 per 100,000) than males (11 cases, 2.1 per 100,000).
Figure 5. Number of TB notifications by age and sex, London, 2023
Figure 6. TB notification rate by age and sex, London, 2023
In 2023, country of birth was missing for 3 people with TB in London. Overall, 86% of all people with TB in London were born abroad (1,426 cases). This is higher than the proportion nationally (80%) but the same as London in 2022 (86%) (Figure 7). The number of people with TB born abroad was over 6 times greater than the number of people with TB born in the UK.
Since 2020, there has been an increasing trend in the number of people in London with TB that were born abroad.
Figure 7. Number of TB notifications in non-UK-born and UK-born by place of birth, London, 2001 to 2023
There were 10 local authorities in London where the proportion of those with TB born abroad was over 90% (Lewisham, Hounslow, Barnet, Brent, Sutton, Hillingdon, Redbridge, Harrow, Merton, and Greenwich). Havering and Bexley had the lowest proportion of people with TB that were born abroad (58% and 70% respectively).
In those born outside of the UK, the highest number of cases in 2023 was among people aged 15 to 44 years, accounting for 62% of non-UK-born cases (Figure 8). Children aged 0 to 14 years were the only age group that was more often UK-born.
The number of non-UK-born cases aged 15 to 44 years declined from 2011 until 2020, but has increased year-on-year since then. The numbers have remained relatively stable or decreased in the other age groupings.
Figure 8. Number of TB notifications in non-UK-born and UK-born by place of birth and age group, London, 2001 to 2023
In 2023, information on time between entry to the UK and notification of TB was available for 97% of people born abroad (1,377 out of 1,426). The median time since entry to the UK was 8 years (IQR: 2 to 19).
Almost half of people born abroad had entered the UK over 10 years prior to notification (43%, 596 out of 1,377), although this proportion had decreased since 2020, although it was similar in 2023 to 2022.
Notably, there has been an increasing proportion since 2017 of people with TB born abroad who had entered the UK within the last 2 years, with the highest proportion (24%) in 2023 since 2007. Decreases were seen in the proportion of people with TB who had entered the UK in the previous 2 to 10 years (Figure 9).
Figure 9. Proportions of TB notifications by time since entry into the UK, for people born outside the UK, London, 2001 to 2023
In 2023, the country of birth was unknown for 3 people with TB in London. As in previous years, the most common country of birth was India (26%, 432 out of 1,659), and the median time since entry was 3 years (IQR 1 to 14 years) (Table 1). The UK was the next most frequently reported country of birth, accounting for 14% of people with TB. For those born in Pakistan, the second most common country of birth outside of the UK (7%), the median time since entry was 10 years (IQR 1 to 21 years).
Table 1. Most common countries of birth for people with TB and time between entry to the UK and TB notification, London, 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 | 432 | 26.0 | 3.0 | 1.0 to 14.0 |
| United Kingdom | 233 | 14.0 | Not applicable | Not applicable |
| Pakistan | 113 | 6.8 | 10.0 | 1.0 to 21.0 |
| Bangladesh | 79 | 4.8 | 14.0 | 2.5 to 27.5 |
| Somalia | 64 | 3.9 | 10.0 | 2.0 to 21.0 |
| Afghanistan | 59 | 3.6 | 3.0 | 0.0 to 11.0 |
| Romania | 55 | 3.3 | 6.0 | 4.0 to 9.0 |
| Nigeria | 50 | 3.0 | 9.0 | 1.0 to 21.8 |
| Nepal | 41 | 2.5 | 3.0 | 1.0 to 14.0 |
| Eritrea | 40 | 2.4 | 4.0 | 1.0 to 6.2 |
| Philippines | 40 | 2.4 | 14.0 | 8.0 to 20.0 |
| Other | 453 | 27.3 | 12.5 | 4.0 to 23.0 |
| Total | 1,659 | 100.0 | Not applicable | Not applicable |
In the 5 most common countries of birth (outside the UK), there was an increase in people diagnosed with TB in 2023 compared to 2022 (Figure 10). The greatest proportional increase in 2023 was in those born in Afghanistan (55% increase) but the greatest overall increase in numbers was of people with TB born in India, which has been increasing since 2020.
People with TB born in Bangladesh were least likely to have entered the UK in the 2 years before diagnosis (13%) (Table 2).
Those born in Afghanistan had the lowest median age of 36 years, the highest proportion of males (80%), the highest proportion of pulmonary TB (58%) and the highest proportion of recent entrants in the last 2 years (44%). Of those born in Afghanistan and diagnosed with TB within 2 years since entry, 80% had pulmonary TB.
Figure 10. Numbers of TB notifications for the 5 most common countries of birth for people with TB born outside the UK, London, 2013 to 2023 [note 6]
Note 6: figure shows the top 5 countries in 2023.
Table 2. Characteristics of people with TB from the most 5 common (non-UK) countries of birth, London, 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 | 432 | 38.2 | 62.3 | 45.1 | 34.8 | 40.1 |
| Pakistan | 113 | 43.5 | 63.7 | 43.4 | 26.6 | 44.8 |
| Bangladesh | 79 | 47.0 | 58.2 | 38.0 | 13.3 | 50.0 |
| Somalia | 64 | 37.3 | 57.8 | 32.8 | 23.0 | 35.7 |
| Afghanistan | 59 | 35.5 | 79.7 | 57.6 | 43.9 | 80.0 |
In 2023, the most common ethnic group of people with TB in London was Indian. This was also the most common ethnic group for non-UK-born people with TB, followed by Black African and then Asian-Other. For UK-born people with TB, White was the most common ethnic group, followed by Black African and Black-Caribbean (Figure 11).
Figure 11. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), London, 2023 [note 7]
Note 7: figure ordered by total number of notifications within each ethnicity irrespective of place of birth.
Just over half (52%, 868 of 1,662) of those notified with TB in 2023 had pulmonary disease (Table 3). The most common site for extra-pulmonary TB (1,062 cases) was extra-thoracic lymph nodes (396, 24%) and intra-thoracic lymph nodes (276, 17%).
This was similar to 2022 (53%) but slightly higher than the proportions reported since 2013 (Figure 12). People with pulmonary disease were more often male (66%), born abroad (82%) and aged 25 to 34 years (24%).
Table 3. Number of TB notifications by site of disease, London, 2023 [note 8] [note 9]
| Type | Site of disease | Number of people notified with TB | Proportion of people notified with TB (%) |
|---|---|---|---|
| Pulmonary | |||
| All pulmonary | 868 | 52.2 | |
| Pulmonary only | 600 | 36.1 | |
| Miliary only | 46 | 2.8 | |
| Laryngeal only | 3 | 0.2 | |
| Extra-pulmonary | |||
| All extra-pulmonary | 1,062 | 63.9 | |
| Extra-thoracic lymph nodes | 396 | 23.8 | |
| Intra-thoracic lymph nodes | 276 | 16.6 | |
| Other extra-pulmonary | 257 | 15.5 | |
| Pleural | 173 | 10.4 | |
| Gastrointestinal | 99 | 6.0 | |
| Bone - spine | 67 | 4.0 | |
| Central nervous system - meningitis | 41 | 2.5 | |
| Bone - not spine | 28 | 1.7 | |
| Cryptic disseminated | 23 | 1.4 | |
| Genitourinary | 23 | 1.4 | |
| Central nervous system - other | 18 | 1.1 |
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 and/or extra-pulmonary TB.
Figure 12. Proportion of people notified with pulmonary TB, London, 2013 to 2023 [note 10]
Note 10: 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. Just over 1 in 5 (21%, 363 out of 1,662) people with TB had at least one of these comorbidities. The most common was diabetes (12%) (Table 4).
Table 4. Number and proportion of people with TB with comorbidities, London, 2023 [note 11]
| 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 | 1,662 | 363 | 21.8 | Not applicable | Not applicable |
| Chronic liver disease | 1,620 | 30 | 1.9 | 42 | 2.5 |
| Chronic renal disease | 1,624 | 49 | 3.0 | 38 | 2.3 |
| Diabetes | 1,632 | 191 | 11.7 | 30 | 1.8 |
| Hepatitis B | 1,591 | 33 | 2.1 | 71 | 4.3 |
| Hepatitis C | 1,592 | 23 | 1.4 | 70 | 4.2 |
| Immunosuppression | 1,618 | 118 | 7.3 | 44 | 2.6 |
Note 11: 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 information was recorded for 99% (1,649 out of 1,662) of cases. HIV tests were offered or result already known for 99% (1,628 out of 1,649) of these, similar to previous years (99% in 2022 and 2021) (Figure 13). Of those offered, 8 did not receive the test. The proportion not offered testing was 1.3% (21). Of those not offered 11 (52%) were female, 15 (71%) were non-UK-born and 8 (38%) were children under the age of 15 years.
Figure 13. Proportion of people with TB offered an HIV test by year, London, 2018 to 2023 [note 12] [note 13]
Note 12: dashed line indicates target of 100% of people offered HIV test.
Note 13: error bars represent upper and lower 95% confidence intervals.
Data for several social risk factors (alcohol misuse, asylum seeker, drug misuse, homelessness, mental health needs and prison) is routinely collected as part of TB surveillance. The proportion of people with TB, aged over 15 years, with at least one social risk factor was 18% in 2023 (Table 5). More than one social risk factor was recorded for 108 (6.8%) individuals with TB.
The most common social risk factor was current or previous homelessness (6.6%, 104 out of 1,573 individuals with information). This was followed by current asylum seeker status (5.6%) and current alcohol misuse (5.2%). The prevalence of social risk factors increased in 2023 to the highest proportion since 2013 (Table 6). However, since 2019, the proportion has remained relatively stable between 17 and 18%.
Table 5. Number and proportion of people with TB aged 15 years or over with individual social risk factors, London, 2023 [note 14]
| 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 | 1,614 | 291 | 18.0 | Not applicable | Not applicable |
| More than one social risk factor | 1,591 | 108 | 6.8 | 23 | 1.4 |
| Alcohol misuse (current) | 1,564 | 81 | 5.2 | 50 | 3.1 |
| Asylum seeker (current) | 1,578 | 88 | 5.6 | 8 | 0.5 |
| Drug misuse (current or previous) | 1,572 | 66 | 4.2 | 42 | 2.6 |
| Homelessness (current or previous) | 1,573 | 104 | 6.6 | 41 | 2.5 |
| Mental health needs (current) | 1,562 | 75 | 4.8 | 52 | 3.2 |
| Prison (current or previous) | 1,555 | 41 | 2.6 | 59 | 3.7 |
Note 14: 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.
Table 6. Number and proportion of people with TB aged 15 years or over reporting at least one social risk factor, London, 2013 to 2023 [note 15]
| 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 | 279 | 9.7 | 2,867 |
| 2014 | 243 | 9.9 | 2,444 |
| 2015 | 234 | 10.6 | 2,198 |
| 2016 | 219 | 10.3 | 2,119 |
| 2017 | 216 | 11.7 | 1,854 |
| 2018 | 272 | 16.5 | 1,648 |
| 2019 | 285 | 17.6 | 1,622 |
| 2020 | 246 | 17.3 | 1,425 |
| 2021 | 272 | 17.7 | 1,533 |
| 2022 | 266 | 17.3 | 1,534 |
| 2023 | 291 | 18.0 | 1,614 |
Note 15: not all social risk factors were captured before 2021 and this table includes people with no information recorded in the denominator.
In 2023, males with TB were more likely to report experience of each social risk factor (Table 7). Homelessness was the most common in both females (4%) and males (8%).
Experience of social risk factors varied by age group. Being a person seeking asylum was the most common social risk factor reported by those aged 15 to 44 years (8%). For those aged 45 to 64 years, alcohol misuse was reported the most (10%), with mental health needs most common among those aged 65 or older (5%).
For people with TB born outside the UK, experience of homelessness (7%) and seeking asylum (6%) were the most commonly reported social risk factors. This differed to UK-born where experience of drug misuse (13%) and mental health needs (13%) were most commonly reported.
Table 7: Number and proportion (%) of people with TB aged 15 years or over with a social risk factor by demographic characteristics, London, 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 | 7 | 1.2 | 11 | 1.8 | 24 | 3.9 | 1 | 0.2 | 19 | 3.1 | 22 | 3.6 |
| Male | 59 | 6.1 | 70 | 7.3 | 80 | 8.3 | 40 | 4.2 | 69 | 7.0 | 53 | 5.5 |
| Aged 15 to 44 | 41 | 4.2 | 37 | 3.8 | 65 | 6.7 | 21 | 2.2 | 83 | 8.4 | 35 | 3.6 |
| Aged 45 to 64 | 23 | 5.7 | 41 | 10.1 | 36 | 8.7 | 18 | 4.5 | 4 | 1.0 | 30 | 7.4 |
| Aged 65 or older | 2 | 1.0 | 3 | 1.6 | 3 | 1.6 | 2 | 1.0 | 1 | 0.5 | 10 | 5.2 |
| Non-UK-born | 40 | 2.9 | 61 | 4.5 | 89 | 6.5 | 27 | 2.0 | 88 | 6.3 | 49 | 3.6 |
| UK-born | 26 | 13.3 | 20 | 10.4 | 15 | 7.7 | 14 | 7.3 | 0 | 0.0 | 26 | 13.3 |
| Unemployed | 43 | 7.9 | 46 | 8.5 | 77 | 14.1 | 29 | 5.4 | 57 | 10.1 | 53 | 9.9 |
Deprivation was assessed using the 2019 Index of Multiple Deprivation. In 2023, 62% of all people with TB were resident in the 4 most deprived deciles of London (1,038 out of 1,662) (Figure 14). Rates were the highest in decile 2 and 3 (25 per 100,000 in both deciles). Excluding decile 1, the rate progressively decreased along with decreasing deprivation, reaching 6.2 per 100,000 in the least deprived quintile.
Figure 14. TB notification rate by deprivation decile, London, 2023 [note 16]
Note 16: error bars represent upper and lower 95% confidence intervals.
TB diagnosis, microbiology and drug resistance
In 2023, 1,065 of 1662 people with TB in London had their diagnosis culture confirmed, 64%. The proportion of people with pulmonary TB that were culture confirmed was 78% (679 out of 868), slightly lower than the 80% target (Figure 15).
Figure 15. Proportion of people notified with pulmonary TB who were culture confirmed, London, 2017 to 2023 [note 17] [note 18]
Note 17: dashed line indicates target of 80% culture confirmation.
Note 18: error bars represent upper and lower 95% confidence.
Of the 1,065 people with culture confirmed TB in 2023, 99.3% (1, 058) had first line drug results. 140 people (13%) with culture confirmed TB had initial resistance to at least one first line drug. This is the highest proportion of initial resistance to first line drugs and resistance has been increasing since 2021 (Figure 16). There was 25 patients with TB diagnosed by culture or treated for multidrug-resistant tuberculosis (MDR) or rifampicin-resistant (RR) TB in 2023.
Figure 16. Proportion of people notified with culture confirmed TB with initial resistance to any first line drug, London, 2017 to 2023 [note 19]
Individuals are assigned to a whole genome sequencing (WGS) cluster if their isolate is within 12 single nucleotide polymorphisms (SNPs) of an isolate from another person in the database.
Of the 1,065 people with culture confirmed TB in London in 2023, 340 (32%) were less than 12 SNPs from another person with TB in England (Table 8).
The number of people with TB identified as being in a cluster has decreased slightly since 2020 where 39% of people with culture confirmation were in a WGS cluster.
Table 8. Number of people notified with TB, proportion with culture confirmation and proportion of notifications identified in a WGS cluster, London, 2020 to 2023 [note 20] [note 21]
| 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 | 1,463 | 935 | 63.9 | 362 | 38.7 | 35.6 to 41.9 |
| 2021 | 1,569 | 993 | 63.3 | 351 | 35.3 | 32.4 to 38.4 |
| 2022 | 1,570 | 1,024 | 65.2 | 324 | 31.6 | 28.9 to 34.6 |
| 2023 | 1,662 | 1,065 | 64.1 | 340 | 31.9 | 29.2 to 34.8 |
| Total | 6,264 | 4,017 | 64.1 | 1,377 | 34.3 | 32.8 to 35.8 |
Note 20: a WGS cluster is defined as 2 or more individuals that have isolates with a less than 12 SNP difference.
Note 21: 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, there were 48 cases of TB notified in children under the age of 15 years old, resident in London (Figure 17). This was a rate of 3.0 per 100,000 of the population. After many years of declining rates since a peak in 2005, this was a 34% increase from 2021, where the rate was at its lowest (2.3 per 100,000) (Figure 18).
This increase was in both children born in the UK, and those born outside the UK (Figure 18 and Figure 19). In 2023, 63% of children aged under 15 years with TB in London were born in the UK (30 cases).
For children aged under 15 years, 54% had pulmonary TB (with or without other extra-pulmonary disease as well). Pulmonary sites of disease were more common in younger age groups. Eight children had severe TB, defined as cases with CNS, spinal, cryptic or miliary TB; of whom 3 were aged less than 5 years old.
Figure 17. Number of TB notifications in children aged under 15 years, London, 2001 to 2023
Figure 18. TB notification rate in children aged under 15 years, London, 2001 to 2023 [note 22]
Note 22: error bars represent upper and lower 95% confidence intervals.
Figure 19. Number of TB notifications in UK-born children aged under 15 years, London, 2001 to 2023
Figure 20. Number of TB notifications in non-UK-born children aged under 15 years, London, 2001 to 2023
TB treatment
The Royal College of Nursing TB case management tool Case Management TB Publications, Royal College of Nursing provides standardised recommendations for enhanced case management (ECM) in individuals receiving anti-TB treatment with clinical and/or social complexities.
The ECM levels are:
- ECM level 1: people with clinical or social issues which may impact on treatment, for example, children with TB, or those taking antiretrovirals
- ECM level 2: people with complex clinical or social issues which are likely to impact on treatment, for example, complex side effects or single drug resistance, which may necessitate weekly visits
- ECM level 3: people with very complex clinical or social issues which highly impact on treatment, for example, social risk factors or MDR or RR TB which necessitates directly observed therapy (DOT) or virtually observed therapy (VOT)
In 2023, information on ECM was not recorded for 7 people with TB. Over half (54%) of all people with TB in London received ECM (896 out of 1,662) (Table 9). The proportion of people receiving ECM at each level increased year on year from 2021. One in 5 people with TB in London received level 3 ECM (22%, 365 cases), suggesting a high level of support required.
Table 9. Number of people with TB receiving Enhanced Case Management, London, 2021 to 2023 [note 23]
| 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 | 1,569 | 801 | 51.1 | 200 | 12.7 | 170 | 10.8 | 307 | 19.6 | 124 | 7.9 |
| 2022 | 1,570 | 809 | 51.5 | 254 | 16.2 | 216 | 13.8 | 335 | 21.3 | 4 | 0.3 |
| 2023 | 1,662 | 896 | 53.9 | 294 | 17.7 | 234 | 14.1 | 365 | 22.0 | 3 | 0.2 |
Note 23: 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. Overall delay includes time from symptom onset to first presentation to healthcare and from the first presentation to diagnosis and start of TB treatment. Information on delay was calculated for 89% of people (745 out of 840) with pulmonary TB in 2023 who did not have a postmortem diagnosis.
The proportion of people notified with pulmonary TB with a treatment delay over 2 months in London in 2023 was 56%, similar to previous years (Figure 21).
Figure 21. Proportion of people notified with pulmonary TB with a treatment delay over 2 months, London, 2018 to 2023 [note 24] [note 25]
Note 24: error bars represent upper and lower 95% confidence intervals.
Note 25: delay to treatment is defined by when treatment was started from symptom onset.
In 2023, around 1 in 3 people with pulmonary TB experienced a delay of 2 to 4 months, similar to recent years (between 28 and 34% from 2018 to 2022). A delay of over 4 months was observed for 24% of people with pulmonary TB, the lowest proportion since 2019 (Table 10). Median time from symptom onset to start of treatment was 67 days (IQR 36 to 119) (Figure 22).
Table 10. Number and proportion of people with pulmonary TB with a treatment delay, time between symptom onset and treatment start, London, 2018 to 2023 [note 26]
| 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 | 269 | 33.8 | 188 | 23.6 | 796 | 74 | 8.5 | 870 |
| 2019 | 228 | 30.8 | 191 | 25.8 | 741 | 79 | 9.6 | 820 |
| 2020 | 202 | 29.4 | 192 | 27.9 | 687 | 45 | 6.1 | 732 |
| 2021 | 191 | 27.5 | 198 | 28.5 | 695 | 69 | 9.0 | 764 |
| 2022 | 242 | 33.0 | 190 | 25.9 | 734 | 77 | 9.5 | 811 |
| 2023 | 238 | 31.9 | 177 | 23.8 | 745 | 95 | 11.3 | 840 |
Note 26: 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 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.
Figure 22. Median treatment delays among people notified with pulmonary TB, London, 2018 to 2023 [note 27] [note 28] [note 29] [note 30]
Note 27: dashed line represents the target treatment delay of 56 days by 2027.
Note 28: 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 29: delay to treatment is defined by when treatment was started from symptom onset.
Note 30: 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.
TB treatment outcomes
Among people notified in 2022, 83% (1,122 out of 1,349) of those with expected treatment durations of less than 12 months, had completed treatment by 12 months. This excluded people who had MDR and RR TB, as well as those with CNS, spinal, miliary or cryptic disseminated disease where expected treatment durations are longer.
The most common reasons for not completing at 12 months were still being on treatment (5%, 72 out of 1,349) and death (4%, 59 out of 1,349), followed by loss to follow up (3%, 46 out of 1,349). At the last recorded treatment outcome, a further 50 people completed treatment, bringing completion to 87%. An additional 3 people were lost to follow up (4%, 49 out of 1,349) and a further 1 person had treatment stopped (Table 11).
Table 11. 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, London, 2022 [note 31] [note 32]
| 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 | 1,122 | 83.2 | 1,172 | 86.9 |
| Died | 59 | 4.4 | 59 | 4.4 |
| Lost to follow up | 46 | 3.4 | 49 | 3.6 |
| Still on treatment | 72 | 5.3 | 31 | 2.3 |
| Treatment stopped | 11 | 0.8 | 12 | 0.9 |
| Not evaluated | 39 | 2.9 | 26 | 1.9 |
| Total | 1,349 | 100.0 | 1,349 | 100.0 |
Note 31: 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 32: table does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a postmortem diagnosis of TB.
Compared to 2018 to 2021, the completion at 12 months decreased by 3% from 86% and does not meet the national treatment target of 90% completion (Figure 23).
Figure 23. 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% Region, London, 2018 to 2022 [note 33] [note 34] [note 35]
Note 33: dashed line indicates treatment target of 90%.
Note 34: error bars represent upper and lower 95% confidence intervals.
Note 35: figure does not include people notified with CNS, spinal, cryptic and/or miliary TB or people notified with a postmortem diagnosis of TB.
For people with one or more social risk factor, just 74% had completed treatment at 12 months. This was the lowest since 2018 (range: 76% to 80%) (Figure 24).
Figure 24. Proportion of people with non-severe TB, with one or more social risk factors, treated for non-MDR or non-RR TB who completed treatment within 12 months, London, 2018 to 2022 [note 36] [note 37]
Note 35: error bars represent upper and lower 95% confidence intervals.
Note 37: figure does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a postmortem diagnosis of TB.
The proportion of people who died before completing treatment was 4.4% (59 cases), an increase from 3.7% in 2021 (Figure 25 ).
Loss to follow up was at its lowest proportion since 2013, at 3.4% (46 cases) in 2022 and has been decreasing year on year since 2017.
The proportion of people still on TB treatment (5.3%, 72 cases), however, was the highest since 2017, having decreased year on year prior to then.
The proportion with treatment stopped halved in 2022 (0.8%, 11 cases) compared to 2021 (1.6%, 22 cases) (Figure 25, Table 12 and Table 13).
Figure 25. Outcomes of people evaluated who did not complete treatment by 12 months for people with non-severe, non-MDR or non-RR TB and expected treatment duration, London, 2013 to 2022 [note 38]
Note 38: figure does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a postmortem diagnosis of TB.
Table 12. TB outcome at 12 months for people with non-RR or non-MDR-TB with expected treatment duration of within 12 months, London, 2013 to 2022 [note 39]
| 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 | 2,255 | 186 | 70 | 105 | 140 | 24 | 5 | 2,599 |
| 2014 | 1,950 | 169 | 53 | 84 | 114 | 17 | 7 | 2,225 |
| 2015 | 1,705 | 153 | 67 | 72 | 105 | 10 | 9 | 1,968 |
| 2016 | 1,645 | 144 | 59 | 81 | 111 | 12 | 8 | 1,916 |
| 2017 | 1,435 | 141 | 53 | 80 | 92 | 13 | 6 | 1,679 |
| 2018 | 1,278 | 177 | 42 | 71 | 78 | 8 | 12 | 1,489 |
| 2019 | 1,256 | 194 | 53 | 69 | 67 | 12 | 8 | 1,465 |
| 2020 | 1,090 | 158 | 56 | 47 | 56 | 14 | 8 | 1,271 |
| 2021 | 1,187 | 187 | 51 | 48 | 57 | 22 | 17 | 1,382 |
| 2022 | 1,122 | 173 | 59 | 46 | 72 | 11 | 39 | 1,349 |
Note 39: 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 13. Proportions of TB outcomes at 12 months for people with non-RR or non-MDR-TB with expected treatment duration of less than 12 months, London, 2013 to 2022 [note 40]
| 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 | 86.8 | 7.2 | 2.7 | 4.0 | 5.4 | 0.9 | 0.2 |
| 2014 | 87.6 | 7.6 | 2.4 | 3.8 | 5.1 | 0.8 | 0.3 |
| 2015 | 86.6 | 7.8 | 3.4 | 3.7 | 5.3 | 0.5 | 0.5 |
| 2016 | 85.9 | 7.5 | 3.1 | 4.2 | 5.8 | 0.6 | 0.4 |
| 2017 | 85.5 | 8.4 | 3.2 | 4.8 | 5.5 | 0.8 | 0.4 |
| 2018 | 85.8 | 11.9 | 2.8 | 4.8 | 5.2 | 0.5 | 0.8 |
| 2019 | 85.7 | 13.2 | 3.6 | 4.7 | 4.6 | 0.8 | 0.5 |
| 2020 | 85.8 | 12.4 | 4.4 | 3.7 | 4.4 | 1.1 | 0.6 |
| 2021 | 85.9 | 13.5 | 3.7 | 3.5 | 4.1 | 1.6 | 1.2 |
| 2022 | 83.2 | 12.8 | 4.4 | 3.4 | 5.3 | 0.8 | 2.9 |
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’ or ‘died’ within the timeframe of 12 months. Data includes all sites except cases with CNS, spinal, cryptic or miliary TB.
There were 106 people notified in 2022 with CNS, miliary or cryptic disseminated TB, that was rifampicin-sensitive. At 12 months, 46% (49 out of 106) completed treatment. Of the 57 that had not completed treatment, 29 were still on treatment (27%),13 were not evaluated (12%), 11 had died (10%), 3 were lost to follow up (3%) and 1 had treatment stopped (1%). Treatment is expected to take longer than 12 months for people with these types of TB.
For people with MDR and RR TB, treatment outcome is measured at 24 months, so outcomes are presented for people notified up to 2021. Among those notified in 2021 with MDR and rifampicin-resistant TB, 82.4% (14 out of 17) had completed treatment at 24 months. For the 3 who had not completed, 2 were lost to follow up and 1 was still on treatment.
Compared to previous years, treatment completion by 24 months has improved for people with MDR and rifampicin-resistant TB. This also improved for people with MDR and RR TB with social risk factors.
Table 14. Number and proportions of TB outcomes at 24 months for people treated for RR or MDR drug resistant TB, London, 2013 to 2021 [note 41]
| Year | Treatment completed (number) | Treatment completed (proportion) | Treatment completed with any social risk factor (number) | Treatment completed with any social risk factor (proportion) | Total (number) | Total with social risk factor (number) |
|---|---|---|---|---|---|---|
| 2013 | 28 | 73.7 | 8 | 21.1 | 38 | 11 |
| 2014 | 11 | 52.4 | 2 | 9.5 | 21 | 4 |
| 2015 | 9 | 52.9 | 0 | 0.0 | 17 | 3 |
| 2016 | 10 | 76.9 | 3 | 23.1 | 13 | 5 |
| 2017 | 10 | 66.7 | 1 | 6.7 | 15 | 3 |
| 2018 | 11 | 73.3 | 1 | 6.7 | 15 | 2 |
| 2019 | 17 | 89.5 | 4 | 21.1 | 19 | 5 |
| 2020 | 12 | 75.0 | 4 | 25.0 | 16 | 6 |
| 2021 | 14 | 82.4 | 4 | 23.5 | 17 | 5 |
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’ or ‘died’ within the timeframe of 24 months. Data includes all sites except cases with CNS, spinal, cryptic or miliary TB.
TB prevention
Contact information is presented for people with pulmonary TB. The proportion of people with pulmonary TB with at least 5 contacts has been decreasing year-on-year since 2018 (30%) to 2023 (17%) (Figure 26).
Figure 26. Proportion of people notified with pulmonary TB with at least 5 contacts identified and screened for active and latent TB by year, London, 2018 to 2023 [note 42] [note 43]
Note 42: error bars represent upper and lower 95% confidence intervals.
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 median number of contacts identified for all pulmonary TB cases was just 2 (IQR 1 to 4). Females were more likely to have 5 or more contacts identified and screened (22% for females versus 15% for males).
Non-UK-born people with TB were slightly more likely to have 5 or more contacts identified (18%) than UK-born (16%).
People with TB and at least 1 social risk factor were less likely to have 5 or more contacts identified and screened (16%) than people with TB and no social risk factors (18%).
The median number of contacts identified was higher than the median for all people with pulmonary TB for females, people with no social risk factors and MDR/RR TB (median of 3 for each) (Table 15).
Table 15. Contact tracing information for people with pulmonary TB by demographic and disease characteristics, London, 2023 [note 44] [note 45]
| 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 | 868 | 788 | 90.8 | 151 | 17.4 | 2 | 1.0 to 4.0 |
| Female | 291 | 269 | 92.4 | 65 | 22.3 | 3 | 1.0 to 5.0 |
| Male | 577 | 519 | 89.9 | 86 | 14.9 | 2 | 1.0 to 4.0 |
| Adults | 840 | 763 | 90.8 | 146 | 17.4 | 2 | 1.0 to 4.0 |
| Children (15 years or less) | 28 | 25 | 89.3 | 5 | 17.9 | 2 | 0.0 to 4.5 |
| Non-UK-born | 713 | 648 | 90.9 | 127 | 17.8 | 2 | 1.0 to 4.0 |
| UK-born | 154 | 140 | 90.9 | 24 | 15.6 | 2 | 0.0 to 4.0 |
| No social risk factor | 659 | 600 | 91.0 | 119 | 18.1 | 3 | 1.0 to 4.0 |
| At least 1 social risk factor | 209 | 188 | 90.0 | 32 | 15.3 | 2 | 0.0 to 4.0 |
| Non-MDR or RR TB | 852 | 773 | 90.7 | 146 | 17.1 | 2 | 1.0 to 4.0 |
| MDR or RR TB | 16 | 15 | 93.8 | 5 | 31.2 | 3 | 1.0 to 5.5 |
Note 44: 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 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.
A total of 2,744 contacts were identified from 868 people with pulmonary TB. Of these, 2,033 (74%) were adults and 711 (26%) were child contacts. The proportion of all contacts diagnosed with active TB was 3% which was consistent across adult and child contacts. Latent TB infection was found in 19% of contacts; this was more common among children (21%) than adults (18%).
Among those with latent TB infection, 77% started treatment (91% for children versus 71% for adults), with 60% completing treatment (79% for children verses 52% for adults) (Table 16).
Table 16. Number of contacts identified, screened, screening results and treatment for contacts of people notified with pulmonary TB (index individuals), London, 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 | 2,033 | Not applicable | 711 | Not applicable | 2,744 | Not applicable |
| Number of contacts screened for active TB and latent TB | 1,521 | 74.8 | 551 | 77.5 | 2,072 | 75.5 |
| Number of contacts with active TB | 47 | 3.1 | 19 | 3.4 | 66 | 3.2 |
| Number of contacts with latent TB | 270 | 17.8 | 113 | 20.5 | 383 | 18.5 |
| Number of contacts who started treatment for latent TB | 192 | 71.1 | 103 | 91.2 | 295 | 77 |
| Number of contacts who completed treatment for latent tuberculosis | 139 | 51.5 | 89 | 78.8 | 228 | 59.5 |
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.
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.
Coverage data for BCG is available from the Cover of vaccination evaluated rapidly (COVER) programme Coverage Statistics 2022 to 2023: NHS England Digital. Coverage is assessed at 3 months, with overall coverage for London 70.1% of the eligible population in 2022 to 2023. Coverage varied by local authority, from 31% in Camden to 89% in Hounslow.
Of all London residents notified with TB in 2023, 50% (837) had received BCG. Consistent with previous years, a higher proportion of non-UK-born cases had received BCG.
Of the 20 children aged less than 5 years old with TB, 11 (55%) had a BCG. Of the 9 not vaccinated, 8 were UK-born (50% of UK-born cases) and 1 was non-UK-born (25% of non-UK-born cases) (Table 17). Over half (5 cases) had pulmonary disease and 6 completed treatment at 12 months.
Table 17. BCG vaccination coverage among people with TB, London, 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 | 3 | 4 | 75 | 10 | 18 | 56 | 745 | 1,426 | 52 |
| UK-born | 8 | 16 | 50 | 15 | 30 | 50 | 92 | 233 | 39 |
| All cases | 11 | 20 | 55 | 25 | 48 | 52 | 837 | 1,662 | 50 |
Discussion
London remains the region with the highest incidence of TB in England, and accounts for 1 in 3 cases of TB in the country. Following a decline since 2011, TB rates in London began to rise again from 2020, increasing over 24% from then to 2023, with a 5% increase from 2022 to 2023. The increased TB incidence in London in 2023, means that for the first time the city has not met the year-on-year decrease required by WHO, and is therefore not on track to meet the WHO End TB 2035 goal of a 90% reduction in incidence.
A small number of London boroughs still have a significant burden of disease, with rates over 30 per 100,000. While many other boroughs have low rates, some have seen notable increases which, although small numbers, can be difficult for services to accommodate.
Rates remain highest among men, young adults aged 15 to 44, and those born outside the UK (nearly 9 in 10 London cases occurred in people born outside the UK). Since 2020, there has been a marked increase in numbers of cases occurring in people aged 15 to 44 who were born outside the UK, after a sustained decline in this group from 2011 to 2020. Meanwhile, numbers have remained stable among those born abroad but aged under 15 or over 44 years. There has also been a shift with an increase in cases in people who are recent entrants to the UK, after significant declines among this group since 2012 (and the introduction of pre-entry and post-entry screening for migrants from certain high incidence countries). Half of the cases of TB that occur in those born abroad are, however, diagnosed more than 10 years after entering the UK.
India was the most common country of birth, accounting for 1 in 4 people notified with TB in London. While increases were seen in people from several countries of birth since 2020, the largest numbers have been in people born in India. In 2023, 35% of the people with TB who were born in India, had entered the UK less than 2 years before their TB diagnosis (of whom 40% had pulmonary TB).
Although numbers overall remain small, in 2023 we observed an increase in the number of children aged under 15 years with TB, particularly among those born in the UK. This is concerning, and an indication of the risk of TB exposure here in London.
TB is recognised to be associated with deprivation, and in London higher rates are found in the more deprived communities. People with TB frequently have complex medical and social needs. Just over a fifth of people with TB in London in 2023 had at least one of the main comorbidities collected (with diabetes most common, affecting 12% of those with TB in London). Almost a fifth had at least one social risk factor, with current or previous experience of homelessness the most reported, although multiple issues were common. This was reflected in the use of enhanced case management by TB services, with over half of all people with TB requiring enhanced support, and 1 in 5 needing the highest level of support to complete their treatment. Despite enhanced support, however, only 73% of people with a social risk factor completed treatment, meaning 1 in 4 did not.
Overall treatment completion rates have reduced in recent years, with just 83% of those notified in 2022 completing treatment within 12 months (excluding those who would be expected to be on treatment for longer). Lower levels of loss to follow up are encouraging, but increased numbers still on treatment among those with expected regimens of less than 12 months may need further investigation, although usually associated with disease severity.
Culture confirmation levels are high for people with pulmonary disease, although just below the 80% target. The slight increase in resistance to first line drugs should be carefully monitored and supports the need to obtain culture confirmation where possible.
Contact tracing is important for identifying those at highest risk of exposure, finding people with disease earlier and also treating latent infection, therefore preventing further cases. Whilst contact information was entered for most TB patients, the majority had fewer than 5 contacts identified and screened for TB. This proportion of people with 5 or more contacts identified and screened has been decreasing since 2019. Where screened, 1 in 5 contacts had latent TB and 3% active disease: close contacts with recent exposure remain at elevated risk of developing TB.
Increasing rates are concerning and warrant renewed effort from partners across London. Further work to understand the reason for the increase will help identify solutions, but work must also continue to find, treat and prevent cases of TB occurring in the known higher risk communities in London. A continued emphasis on early diagnosis and support through treatment must remain a priority for London, and in particular focused work to reduce the inequities associated with TB.
Recommendations
The recommendations below link to the 5 priority areas in TB action plan Tuberculosis (TB): action plan for England, 2021 to 2026:
1. Recovery from COVID-19
UK Health Security Agency (UKHSA) London teams should continue to monitor TB notifications: reports will be shared with partners quarterly (for timely information) and more in-depth analysis annually, to be reviewed at the London Control Board, Clinical Leadership Group, and network meetings across London.
2. Prevent TB
The increase in TB among recently arrived migrants suggests there may need to be improvements in this area. Missed opportunities for both pre-entry and new migrant screening should be identified at local cohort reviews and raised via the London TB Control Board to national UKHSA TB team.
Local latent tuberculosis infection (LTBI) programmes should review local epidemiology, alongside their uptake and testing results, to evaluate their efforts.
London TB service providers should work with local authorities, ICBs and others to identify opportunities to offer appropriate screening for high risk groups (including people experiencing homelessness, those in contact with the criminal justice system, people seeking asylum, but also those starting biological therapies).
Contact tracing efforts should continue to be monitored through local cohort reviews, as well as in routine TB surveillance reporting (such as the London quarterly report).
3. Detect TB
Improving early detection of TB is a priority for the London TB Control Board (TBCB). Oversight of, and understanding of reasons for, delays should remain a core part of TB cohort review. Surveillance reports should continue to include indicators on delays, to monitor trends over time.
TB services should try to improve culture confirmation rates for all people with TB (to above 80% for pulmonary), and ensure PCR use for all people with potentially pulmonary/ infectious TB.
4. Control TB disease
Work to improve current TB completion rates, aiming for target of 90% treatment completion rates for TB drug sensitive cases by 2026. This will include specific monitoring of treatment completion among people with social risk factors as a priority group. Oversight will be done by the London TBCB.
Ensure effective management of cases of multi-drug resistant (MDR-TB) in association with the British Thoracic Society (BTS) MDR-TB Clinical Advice Service (CAS). In London, the MDR TB cohort review should continue to review all MDR cases and provide learning and educational opportunities to TB services.
5. Workforce
London TB services should continue to make use of the various London TB for a including the Workforce group for shared learning and development, as well as multidisciplinary peer support and strengthening relationships across disciplines.
All TB services should review the data provided by the NHSE Getting it right first time (GIRFT) review, and over the coming year work with ICBs and wider stakeholders to help ensure that services are equipped to meet needs of local communities. This will be a priority area of work for TBCB and TB services as it is an opportunity to look at capacity and other recommendations also address the priority areas above.
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.
Figure 27. TB notification rate by upper tier local authority of residence, London, 2001 to 2023 [note 47]
Note 44: grey lines represent the other upper tier local authorities in the region.
Acknowledgements
We are grateful to all those who contribute information on people with tuberculosis in London, 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 dataset, London Health Protection Teams and the Field Service team for their work supporting TB surveillance.