North West: 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/north-west-tuberculosis-in-2023
Incidence, treatment and prevention of tuberculosis (TB) in North West region using data up until the end of 2023
Executive summary
The number of tuberculosis (TB) cases reported in England increased by 11% in 2023, to an incidence of 8.5 per 100,000 population. TB incidence in the North West of England increased by 19% to 7.7 per 100,000 population, moving the region further away from achieving the World Health Organization’s ‘End TB’ goal of a 90% reduction in new TB notifications by 2035. The highest incidence area in the region in 2023 was Manchester.
Most TB cases were born outside the UK (76%) and a third of these (34%) were new entrants (notified within 2 years of entering the UK). Longer-term residents also comprised a significant proportion of these cases, with 30% notified to TB surveillance 11 or more years after entering the UK. The most common country of birth among TB cases born outside the UK was Pakistan.
TB rates were generally highest in the most socio-economically deprived populations: the rate was 15.6 per 100,000 population in the most deprived decile compared with 4.2 per 100,000 population in the least deprived decile. In 2023, 16% of cases aged 15 or over had at least one recorded social risk factor (SRF), such as substance misuse, prison history and homelessness.
Pulmonary TB comprised 52% of North West cases in 2023, and two-thirds of these cases (66%) started treatment within 4 months of symptom onset.
Culture confirmation remained similar to previous years at 58% for all TB cases, both pulmonary and extra-pulmonary. Over three-quarters (77%) of pulmonary cases were culture-confirmed, lower than the National Action Plan target of 80%.
The proportion of cases with resistance to at least one first line drug remained stable at 12%. Isoniazid resistance was 9% in 2023, higher than in 2022 but at a similar level to previous years. Resistance to rifampicin and ethambutol remained low.
Whole-genome sequencing (WGS) was carried out on all culture-confirmed TB cases, detecting that 33% of North West cases were clustered with at least one other TB case. In the non-severe TB cohort (cases without central nervous system disease and not identified as having multidrug-resistant or rifampicin-resistant TB), 86% of those notified in 2022 completed treatment within 12 months, similar to the previous year. Treatment completion in cases with central nervous system disease was 81% (at the last recorded outcome). In the drug-resistant cohort, 91% of cases had completed treatment at 24 months.
Contact tracing for pulmonary cases identified active TB in 4% of the total contacts screened. Latent TB was found in 16% of all contacts, while a fifth (21%) of child contacts were found to have latent TB.
Data for all the graphs in this report can be found in the North West TB report 2023 supplementary data spreadsheet.
TB incidence and epidemiology
Overall numbers, rates and geographical distribution
In 2023, 586 TB cases were reported among North West residents (Figure 1), a rate of 7.7 per 100,000 population. Case numbers increased by 18.6% compared to 2022 (494 cases; rate of 6.6 per 100,000 population).
Figure 1. Number of TB notifications per year, North West, 2001 to 2023
Figure 1 is a line chart showing counts of TB cases in the North West from 2001 to 2023. There was a general increase in case numbers from 2001 to 2011, then a decreasing trend from 2011 to 2020, with a subsequent increase from 2020 to 2023.
The North West TB rate remained below the England rate of 8.5 per 100,000 (Figure 2), and the North West rate was the fourth highest of the 9 UK Health Security Agency (UKHSA) regions in England (1). Overall, TB incidence in the North West has decreased since 2011; however, there has been a gradual increase since 2020.
Figure 2. TB notification rates per 100,000 population per year, North West, 2001 to 2023 [note 1]
Note 1: error bars represent upper and lower 95% confidence intervals.
Figure 2 is a line chart showing rates of TB in the North West and England from 2001 to 2023. Both trend lines are parallel, showing a general increase in incidence from 2001 to 2011, then a decreasing trend from 2011 to 2020, with a subsequent increase from 2020 to 2023. North West TB incidence is consistently lower than in England.
The recent increase in TB incidence has moved the North West further away from achieving the goal of a 90% reduction in new TB notifications by 2035 (Figure 3). This goal was set out by the World Health Organization (WHO) in the ‘End TB Strategy’ (2) in 2015. The rate in England has also been on an upward trajectory away from the 90% reduction goal.
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, North West, 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.
Figure 3 is a line chart showing TB notification rate in the North West from 2015 to 2023, compared with the rate required to meet the WHO End TB 2035 goal of 90% reduction. The North West rate has increased since 2020, moving further away from the reduction goal.
Among North West upper tier local authorities, the highest rates were in Manchester at 26.6, Oldham at 16.7 and Blackburn with Darwen at 15.2 per 100,000 population (Figure 4). The most significant increase in incidence occurred in Manchester, where incidence increased from 20.8 per 100,000 population in 2022 to 26.6 per 100,000 population in 2023 (from 118 to 154 cases). In Blackpool, the rate decreased from 16.9 per 100,000 population in 2022 to 7.0 per 100,000 population in 2023 (from 24 to 10 cases).
Figure 4. TB notification rate by upper tier local authority of residence, North West, 2023
Figure 4 is a choropleth map showing rates of TB by North West upper tier local authority of residence in 2023. Highest rates are shown in Manchester, Oldham and Blackburn with Darwen.
Age and sex
In 2023, 58.7% (344 out of 586) of North West TB cases were male. The number of males with TB was greater than the number of females across most age groups (Figure 5), with the exception of those aged 0 to 9 years and 80 years and over. A quarter (25.3%, 148 out of 586) of all North West TB cases reported in 2023 occurred in males aged 20 to 39 years. There were 22 cases of TB reported in children aged 0 to 14 years, less than in the previous year (33 cases reported in 2022).
Figure 5. Number of TB notifications by age and sex, North West, 2023
Description of Figure 5: a two-sided horizontal bar chart with bars showing counts of TB cases in the North West in 2023, split by sex and age group. The number of males was greater than the number of females in most age groups, with males aged 30 to 39 years comprising the largest group.
Place of birth and time since entry to the UK
In 2023, 24.1% (141 out of 584) of TB cases in the North West were born in the UK. Overall, the proportion of non-UK-born TB cases has gradually increased from 64.5% in 2018 to 75.9% in 2023. A proportional increase in non-UK-born cases was also reported nationally (1).
In general, the number of UK-born TB cases has decreased since 2010 (Figure 6), although cases increased from 115 in 2022 to 141 in 2023 (a 22.6% increase). There was a general decrease in non-UK-born cases from 2011 to 2018; however, numbers increased by 17.5% between 2022 and 2023 (from 377 to 443 cases), reflecting an overall increase of 39.3% (from 318 to 443 cases) among the non-UK-born since 2020.
Figure 6. Number of TB notifications in non-UK-born and UK-born cases by place of birth, North West, 2001 to 2023
Figure 6 is a line chart, with separate lines showing counts of TB in UK-born and non-UK-born cases from 2001 to 2023. Numbers were consistently higher for non-UK-born cases than for the UK-born. Case numbers increased for the UK-born between 2022 and 2023; and for the non-UK-born between 2020 and 2023.
Highest numbers of TB cases occurred in those aged 15 to 44 years for patients born in the UK (34.8%, 49 out of 141) as well as for those born outside the UK (63.0%, 279 out of 443). There has been a gradual increase in this age group among the non-UK-born since 2020 (Figure 7), and notifications increased by 34.1% (from 208 to 279 cases) between 2022 and 2023. Between 2020 and 2023, the number of non-UK-born TB cases aged 15 to 44 years increased by 53.3% (from 182 to 279 cases).
Figure 7. Number of TB notifications in non-UK-born and UK-born cases by place of birth and age group, North West, 2001 to 2023
Figure 7 is a series of line charts showing the number of North West TB notifications from 2001 to 2023, with separate lines showing trends for each age group. One chart shows all cases, one shows non-UK-born cases, and one shows UK-born cases only. The 15 to 44 years age group has the highest numbers overall in each chart, with significantly higher numbers among the non-UK-born (and in cases overall).
In 2023, 33.8% (123 out of 364) of non-UK-born cases had a notification within 2 years of UK entry and 25.5% (93 out of 364) had a notification 2 to 5 years after entry (Figure 8). This means that, overall, 59.3% (216 out of 364) had a notification within 5 years of entering the UK. The number of TB cases notified within 2 years of UK entry increased by 66.2% between 2022 and 2023 (from 74 to 123 cases). An increase in this group was also reported nationally (1).
A significant proportion (29.7%, 108 out of 364) of non-UK-born cases were notified to TB surveillance 11 or more years after entering the UK. This group comprised the highest proportion of non-UK-born cases in the North West between 2011 and 2022. However, the highest proportion in 2023 (33.8%, 123 out of 364) was in new entrants (notified within 2 years of UK entry).
Figure 8. Proportions of TB notifications by time since entry for people born outside the UK, North West, 2001 to 2023
Figure 8 is a line chart showing North West TB notifications from 2001 to 2023 for cases born outside the UK. Separate lines show trends for the number of years between a patient entering the UK and a TB notification being made. Cases notified 11 or more years after UK entry comprised the highest proportion between 2011 and 2022, but the highest proportion in 2023 was for cases notified within 2 years of UK entry.
Over half of cases (59.3%, 216 out of 364) born outside the UK were notified to TB surveillance within 5 years of entering the UK and this proportion has gradually increased since 2020 (Figure 9).
Figure 9. Proportion of TB notifications occurring within 5 years of entry to the UK for all countries of birth outside of the UK, North West, 2017 to 2023 [note 4] [note 5]
Note 4: error bars represent upper and lower 95% confidence intervals.
Note 5: within 5 years refers to a time since entry of less than 1 year to 5 years inclusive.
Figure 9 is a line chart with error bars showing the proportion of non-UK-born North West TB cases notified between 2017 and 2023 which occurred within 5 years of UK entry. The proportion increased between 2020 and 2023.
Approximately one quarter (25.2%, 147 out of 584) of TB cases reported in the North West in 2023 were born in Pakistan (Table 1), while just under a quarter (24.1%, 141 out of 584) were born in the UK. Those born in Zimbabwe had the longest median time between entry to the UK and TB notification (18 years, IQR 4.5 to 19 years).
Table 1. Most common countries of birth for people with TB and time between entry to the UK and TB notification, North West, 2023 [note 6]
| 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 |
|---|---|---|---|---|
| Pakistan | 147 | 25.2 | 5.0 | 2.0 to 16.0 |
| United Kingdom | 141 | 24.1 | Not applicable | Not applicable |
| India | 64 | 11.0 | 2.0 | 1.0 to 6.0 |
| Eritrea | 33 | 5.7 | 3.0 | 1.0 to 5.5 |
| Nigeria | 27 | 4.6 | 1.0 | 0.0 to 3.0 |
| Afghanistan | 16 | 2.7 | 1.0 | 0.0 to 6.5 |
| Zimbabwe | 13 | 2.2 | 18.0 | 4.5 to 19.0 |
| Romania | 12 | 2.1 | 4.0 | 3.5 to 6.5 |
| Somalia | 12 | 2.1 | 9.0 | 3.8 to 17.0 |
| Sudan | 11 | 1.9 | 1.0 | 0.0 to 4.0 |
| Other | 108 | 18.5 | 4.0 | 1.0 to 15.8 |
| Total | 584 | 100.0 | Not applicable | Not applicable |
Note 6: other includes all countries with less than 11 people notified.
Among North West TB cases born outside the UK, Pakistan has consistently been the most common country of birth, followed by India (Figure 10). Overall, numbers of cases from these countries decreased between 2013 and 2018, but subsequently increased to 2023.
Figure 10. Numbers of TB notifications for the most common countries of birth for people with TB born outside the UK, North West, 2013 to 2023 [note 7]
Note 7: figure shows the top 5 countries in 2023.
Figure 10 is a line chart showing North West TB notifications from 2013 to 2023 for cases born outside the UK. Separate lines show trends for the number of notifications born in specified countries outside the UK. Consistently, most non-UK-born TB cases in the North West were born in Pakistan. Notifications in non-UK-born TB cases from the 5 most common countries of birth increased between 2020 and 2023.
Approximately two-thirds of North West TB cases born in Nigeria (65.4%,17 out of 26) and Afghanistan (66.7%, 10 out of 15) were notified within 2 years of entry to the UK (Table 2). Most of these new entrants were diagnosed with pulmonary TB (64.7%, 11 out of 17 cases, from Nigeria; 70.0%, 7 out of 10 cases, from Afghanistan). Cases born in Pakistan had a median age of 45.1 years and approximately one quarter (24.6%, 29 out of 118) were notified within 2 years of UK entry.
Table 2. Characteristics of people with TB from the most common (non-UK) countries of birth, North West, 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 (%) |
|---|---|---|---|---|---|---|
| Pakistan | 147 | 45.1 | 55.8 | 44.2 | 24.6 | 41.4 |
| India | 64 | 38.5 | 56.2 | 40.6 | 41.2 | 38.1 |
| Eritrea | 33 | 29.6 | 72.7 | 48.5 | 43.3 | 53.8 |
| Nigeria | 27 | 42.2 | 55.6 | 40.7 | 65.4 | 64.7 |
| Afghanistan | 16 | 27.4 | 68.8 | 62.5 | 66.7 | 70.0 |
Ethnic group
In 2023, the most common among all TB cases in the North West were the Pakistani, White and Black African ethnic groups. Most Pakistani (86.9%, 153 out of 176) and Black African cases (97.6%, 123 out of 126) were born outside the UK; while most White cases (78.8%, 104 out of 132) were UK-born (Figure 11).
Figure 11. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), North West, 2023 [note 8]
Note 8: figure ordered by total number of notifications within each ethnicity irrespective of place of birth.
Figure 11 is a horizontal bar chart with bars showing counts of TB cases in the North West in 2023, separated by ethnic group and subdivided into UK and non-UK-born. The number of UK-born cases was highest among White and Pakistani ethnic groups; most non-UK-born cases were from Pakistani and Black African ethnic groups.
In the North West, the highest numbers of cases have historically been among South Asian ethnic groups. Overall numbers decreased between 2012 and 2018, then gradually increased to 2023, and this trend was reflected in those born outside the UK (Figure 12). There was a general decline in all cases of White ethnicity from 2012 to 2022, with a subsequent increase of 37.5% in 2023 (from 96 to 132 cases). This increase was driven by cases among UK-born individuals, which increased by 52.9% (from 68 to 104 cases). Cases of Black ethnicity also increased in 2023, particularly in those born outside the UK, which increased by 50.0% (from 88 to 132 cases).
Figure 12. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), North West, 2001 to 2023
Figure 12 is a series of line charts showing the number of North West TB notifications from 2001 to 2023, with separate lines showing trends for overall ethnic groupings. One chart shows all cases, one shows non-UK-born cases, and one shows UK-born cases only. Highest numbers overall for this time period were South Asian, followed by White, although cases of Black ethnicity increased in 2023 to a similar level to those of White ethnicity.
Site of disease
In 2023, 51.7% (303 out of 586) of TB cases in North West England had pulmonary disease (Table 3), similar to than the national level of 55.0% (1).
Table 3. Number of pulmonary TB notifications by site of disease, North West, 2023 [note 9] [note 10]
| Site of disease | Number of people notified with TB | Proportion of people notified with TB (%) |
|---|---|---|
| All pulmonary | 303 | 51.7 |
| Pulmonary only | 186 | 31.7 |
| Miliary only | 18 | 3.1 |
| Laryngeal only | 3 | 0.5 |
Note 9: percentages may not add up to 100 as people with TB may have more than one site of disease.
Note 10: ‘pulmonary only’ includes people notified with only pulmonary TB and therefore have not also been notified with miliary, laryngeal and/or extra-pulmonary TB.
Over two-thirds of TB cases (68.3%, 400 out of 586 cases) were diagnosed with extra-pulmonary disease, with or without pulmonary TB (Table 4).
Table 4. Number of extra-pulmonary TB notifications by site of disease, North West, 2023 [note 11]
| Site of disease | Number of people notified with TB | Proportion of people notified with TB (%) |
|---|---|---|
| All extra-pulmonary | 400 | 68.3 |
| Other extra-pulmonary | 188 | 32.1 |
| Extra-thoracic lymph nodes | 116 | 19.8 |
| Intra-thoracic lymph nodes | 110 | 18.8 |
| Pleural | 43 | 7.3 |
| Bone - spine | 24 | 4.1 |
| Gastrointestinal | 19 | 3.2 |
| Central nervous system - meningitis | 15 | 2.6 |
| Bone - not spine | 13 | 2.2 |
| Genitourinary | 8 | 1.4 |
| Central nervous system - other | 6 | 1.0 |
| Cryptic disseminated | 4 | 0.7 |
Note 11: percentages may not add up to 100 as people with TB may have more than one site of disease, including pulmonary.
The proportion of pulmonary TB cases in the North West has remained consistent, comprising 51.3% of cases on average between 2013 and 2023 (Figure 13).
Figure 13. Proportion of people notified with pulmonary TB, North West, 2013 to 2023 [note 12]
Note 12: error bars represent upper and lower 95% confidence intervals.
Figure 13 is a line chart with error bars showing the proportion of cases of pulmonary TB in the North West between 2013 and 2023. The proportion was consistently around 50.0% (range 46.3% to 57.4%) for this time period, with minor fluctuations.
Comorbidities
In 2023, 25.6% (150 out of 586) of North West TB cases were reported to have at least one co-morbidity (Table 5), similar to the national level of 25.9% (1).
Table 5. Number and proportion of TB cases with comorbidities, North West, 2023 [note 13]
| Comorbidity | Number with comorbidities reported | Proportion with comorbidities reported (%) | Number with missing data (comorbidity status unknown) | Proportion with missing data (comorbidity status not known) (%) | Total with data reported |
|---|---|---|---|---|---|
| At least one of the named comorbidities | 150 | 25.6 | Not applicable | Not applicable | 586 |
| Chronic liver disease | 8 | 1.6 | 75 | 12.8 | 511 |
| Chronic renal disease | 15 | 2.9 | 70 | 11.9 | 516 |
| Diabetes | 65 | 12.5 | 65 | 11.1 | 521 |
| Hepatitis B | 13 | 2.7 | 98 | 16.7 | 488 |
| Hepatitis C | 11 | 2.2 | 94 | 16 | 492 |
| Immunosuppression | 70 | 13.5 | 69 | 11.8 | 517 |
Note 13: 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
In 2023, 98.0% (553 out of 564) of TB cases with unknown HIV (human immunodeficiency virus) status were offered an HIV test (Figure 14), consistent with the previous year (98.1%, 475 out of 484, in 2022).
Figure 14. Proportion of people with TB offered an HIV test by year, North West, 2018 to 2023 [note 14] [note 15]
Note 14: dashed line indicates target of 100% of people offered HIV test.
Note 15: error bars represent upper and lower 95% confidence intervals.
Figure 14 is a line chart with error bars showing the proportion of North West TB cases between 2018 and 2023 which were offered and HIV test. The proportion improved between 2018 and 2020 but has decreased slightly between 2020 and 2023.
Social risk factors
In 2023, 15.8% (89 out of 564) of North West TB cases aged 15 years or over had at least one specified social risk factor (SRF) recorded (Table 6). Among the most common SRFs were homelessness (8.6%, 40 out of 467), being an asylum seeker (6.9%, 34 out of 496) and imprisonment (6.5%, 30 out of 464), and 8.2% (40 out of 488) of cases had more than one SRF.
Table 6. Number and proportion of people with TB aged 15 years or over with individual social risk factors, North West, 2023 [note 16]
| 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 | 564 | 89 | 15.8 | Not applicable | Not applicable |
| More than one social risk factor | 488 | 40 | 8.2 | 76 | 13.5 |
| Alcohol misuse (current) | 473 | 18 | 3.8 | 91 | 16.1 |
| Asylum seeker (current) | 496 | 34 | 6.9 | 40 | 7.5 |
| Drug misuse (current or previous) | 466 | 23 | 4.9 | 98 | 17.4 |
| Homelessness (current or previous) | 467 | 40 | 8.6 | 97 | 17.2 |
| Mental health needs (current) | 459 | 9 | 2.0 | 105 | 18.6 |
| Prison (current or previous) | 464 | 30 | 6.5 | 100 | 17.7 |
Note 16: 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.
The proportion of cases with at least one SRF has increased since 2021 (Table 7). However, this could be due to improved data completion.
Table 7. Number and proportion of people with TB aged 15 years or over reporting at least one social risk factor, North West, 2013 to 2023 [note 17]
| 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 | 57 | 8.3 | 690 |
| 2014 | 59 | 9.6 | 612 |
| 2015 | 67 | 12.3 | 545 |
| 2016 | 59 | 10.7 | 553 |
| 2017 | 45 | 9.0 | 500 |
| 2018 | 51 | 11.4 | 446 |
| 2019 | 55 | 11.1 | 494 |
| 2020 | 47 | 10.9 | 431 |
| 2021 | 59 | 12.7 | 465 |
| 2022 | 72 | 15.6 | 461 |
| 2023 | 89 | 15.8 | 564 |
Note 17: not all social risk factors were captured before 2021 and that this table includes people with no information recorded in the denominator.
Most cases with at least one SRF were male (83.1%, 74 out of 89) and over two-thirds (69.7%, 62 out of 89) were in the 15 to 44 years age group. The majority of UK-born cases with at least one SRF were in the white ethnic group (97.0%, 32 out of 33). Of non-UK-born cases with at least one SRF, the highest proportion occurred in the Black African ethnic group (60.7%, 34 out of 56). Most cases with at least one SRF had pulmonary disease (75.3%, 67 out of 89).
A greater proportion of UK-born TB cases recorded SRFs (not including asylum seeker status) than cases born outside the UK (Table 8).
Table 8. Number and proportion of people with TB aged 15 years or over with a social risk factor (SRF) by demographic characteristics, North West, 2023
| Demographic characteristics | Drug misuse (number) | Drug misuse (proportion) | Alcohol misuse (number) | Alcohol misuse (proportion) | Homelessness (number) | Homelessness (proportion) | Prison (number) | Prison (proportion) | Asylum seeker (number) | Asylum seeker (proportion) | Mental health needs (number) | Mental health needs (proportion) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Female | 4 | 2.1 | 5 | 2.6 | 7 | 3.6 | 3 | 1.6 | 4 | 1.9 | 1 | 0.5 |
| Male | 19 | 6.9 | 13 | 4.7 | 33 | 12.0 | 27 | 9.9 | 30 | 9.6 | 8 | 2.9 |
| Aged 15 to 44 | 14 | 5.0 | 6 | 2.1 | 27 | 9.7 | 22 | 7.9 | 32 | 10.5 | 3 | 1.1 |
| Aged 45 to 64 | 9 | 7.6 | 10 | 8.3 | 13 | 10.7 | 8 | 6.8 | 2 | 1.4 | 4 | 3.4 |
| Aged 65 or older | 0 | 0.0 | 2 | 2.9 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 2 | 3.0 |
| Non-UK-born | 5 | 1.4 | 3 | 0.8 | 29 | 8.0 | 16 | 4.4 | 34 | 8.7 | 4 | 1.1 |
| UK-born | 18 | 17.6 | 15 | 14.4 | 11 | 10.7 | 14 | 13.7 | 0 | 0.0 | 5 | 5.1 |
| Unemployed | 15 | 8.4 | 12 | 6.6 | 30 | 16.8 | 21 | 11.9 | 27 | 13.4 | 9 | 5.2 |
TB and deprivation
In 2023, the incidence of TB was 15.6 per 100,000 in the 10% of the population living in the most deprived areas of the North West, compared to 4.2 per 100,000 in the 10% of the population living in the least deprived areas (Figure 15). A greater proportion of non-UK-born cases resided in the most deprived areas (79.5%, 210 out of 264, in the most deprived decile).
Figure 15. TB notification rate by deprivation decile, North West, 2023 [note 18]
Note 18: error bars represent upper and lower 95% confidence intervals.
Figure 15 is a bar chart with error bars, with columns showing the TB notification rate in each deprivation decile in the North West in 2023. A clear trend is shown of higher incidence in the most deprived deciles compared with the least deprived deciles.
TB diagnosis, microbiology and drug resistance
Culture confirmation
In 2023, 57.8% (339 out of 586) of all TB cases, both pulmonary and extra-pulmonary, were confirmed by culture in the North West. Of the 303 pulmonary cases, 76.6% (232 out of 303) were culture-confirmed, compared with 75.1% nationally (1). This was similar to previous years, but below the National Action Plan (3) target of 80% culture confirmation for cases of pulmonary TB (Figure 16). Culture confirmation for extra-pulmonary cases was 37.8% (107 out of 283), lower than the national proportion of 44.2% (1).
Figure 16. Proportion of people notified with pulmonary TB who were culture-confirmed, North West, 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.
Figure 16 is a line chart with error bars showing the proportion of North West pulmonary TB cases between 2017 and 2023 which were culture-confirmed. The proportion has remained fairly stable during this period but remained below the national target of 80% in 2023.
The proportion of culture-confirmed cases with susceptibility results for at least one first line drug (including isoniazid, rifampicin and ethambutol) was 97.6% (331 out of 339), similar to previous years (Figure 17).
Figure 17. Proportion of people culture-confirmed with TB with first line drug results, North West, 2017 to 2023 [note 21]
Note 21: error bars represent upper and lower 95% confidence intervals.
Figure 17 is a line chart with error bars showing the proportion of culture-confirmed pulmonary TB cases in the North West between 2017 and 2023 which had first line drug results. The proportion has remained above 97% during this period.
Drug resistance
The proportion of cases with resistance to at least one first line drug was 12.4% (42 out of 339) in 2023, similar to previous years (Figure 18). The proportion of North West TB cases with isoniazid resistance was 9.1% (31 out of 339) in 2023, higher than in the previous year (6.4%, 20 out of 314) but similar to the years before. Resistance to rifampicin and ethambutol remained low at 2.7% (9 out of 339) and 2.4% (8 out of 339), respectively.
Figure 18. Proportion of people notified with culture-confirmed TB with initial resistance to any first line drug, North West, 2017 to 2023 [note 22]
Note 22: error bars represent upper and lower 95% confidence intervals.
Figure 18 is a line chart with error bars showing the proportion of culture-confirmed pulmonary TB cases in the North West between 2017 and 2023 which had resistance to any first line drugs. The proportion has remained between 9.3% and 15.9% during this period.
TB clusters
Whole-genome sequencing (WGS) is carried out on all culture-confirmed TB cases, providing information on relatedness and possible transmission. The proportion of North West cases that were clustered with at least one other TB case was 32.7% (111 out of 339) in 2023. This is similar to previous years (Table 9) and in line with national levels (1).
Table 9. Number of people notified, proportion with culture confirmation and proportion of notifications identified in a WGS cluster, North West, 2020 to 2023 [note 23] [note 24]
| Year | Total TB cases | Number of cases cultured | Proportion of cases cultured | Number of culture- confirmed cases identified in a cluster with more than one person | Proportion of culture- confirmed cases identified in a cluster with more than one person (%) | 95% confidence interval |
|---|---|---|---|---|---|---|
| 2020 | 456 | 291 | 63.8 | 85 | 29.2 | 24.3 to 34.7 |
| 2021 | 484 | 289 | 59.7 | 104 | 36.0 | 30.7 to 41.7 |
| 2022 | 494 | 314 | 63.6 | 112 | 35.7 | 30.6 to 41.1 |
| 2023 | 586 | 339 | 57.8 | 111 | 32.7 | 28.0 to 37.9 |
| Total | 2,020 | 1,233 | 61.0 | 412 | 33.4 | 30.8 to 36.1 |
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.
TB in children: incidence, epidemiology and microbiology
The incidence of TB in children is an acceptable, indirect indicator of recent transmission within communities, since TB in children is likely to be caused by recent exposure. In the North West, 22 TB cases aged under 15 years were notified in 2023. This was lower than in 2022 (33 cases), but in line with numbers reported since 2013 (Figure 19). The notification rate in TB cases under 15 years was 1.7 per 100,000 population, lower than in 2022 (2.5 per 100,000), but consistent with rates recorded since 2013.
Figure 19. Number of TB notifications in children aged under 15 years, North West, 2001 to 2023
Figure 19 is a line chart showing the number of TB cases aged under 15 years notified in the North West between 2001 and 2023. Numbers peaked in 2011, declined to 2013, and have since remained relatively stable.
The number of TB cases in UK-born children aged under 15 years increased in the North West between 2004 and 2010 (from 15 to 42 cases). There has been a general decreasing trend since 2010, with some fluctuations (Figure 20). Numbers decreased from 27 cases in 2022 to 10 cases in 2023.
Figure 20. Number of TB notifications in UK-born children aged under 15 years, North West, 2001 to 2023
Figure 20 is a line chart showing the number of TB cases in UK-born children aged 0 to 14 years from 2001 to 2023. There has been a generally decreasing trend from 2010. Numbers decreased between 2022 and 2023.
The number of TB cases in children born outside the UK has decreased since 2010 and remained fairly stable, although there was an increase from 6 to 12 cases between 2022 and 2023 (Figure 21).
Figure 21. Number of TB notifications in non-UK-born children aged under 15 years, North West, 2001 to 2023
Figure 21 is a line chart showing the number of TB cases in non-UK-born children aged 0 to 14 years from 2001 to 2023. There has been a generally decreasing trend from 2010, although numbers increased between 2022 and 2023.
The number of U-born children with TB has generally been greater than in the non-UK-born; an average of 22.4 cases between 2001 and 2023, compared with 10.6 cases in the non-UK-born. However, in 2023, the number born outside the UK (12 cases) was higher than the number of UK-born (10 cases)
In 2023, 68.2% of children with TB (15 out of 22) were male. The most common country of birth was the UK (45.5%, 10 out of 22) and the most common ethnic group was Pakistani (36.4%, 8 out of 22). Less than one third (31.8%, 7 out of 22) of children with TB had pulmonary disease, while 81.8% (18 out of 22) were diagnosed with extra-pulmonary TB (Table 10), in addition or without pulmonary TB. Over half (54.4%, 12 out of 22 cases) had TB of the lymph nodes only.
Culture confirmation among children with TB remained low at 13.6% (3 out of 22) overall, compared with 30.3% (10 out of 33) in 2022. Among pulmonary cases, 28.6% (2 out of 7) were confirmed by culture, compared with 36.4% (8 out of 22) in 2022. The culture confirmation rate in this age group is lower than in adults due to the difficulties in obtaining samples from children, who are often treated for TB empirically to avoid invasive procedures.
Table 10. Number of TB notifications by site and severity of disease in children aged under 15 years, North West, 2023 [note 25] [note 26]
| Clinical characteristic | Number of cases in children aged 0 to 4 years | Proportion of cases in children aged 0 to 4 years (%) | Number of cases in children aged 5 to 9 years | Proportion of cases in children aged 5 to 9 years (%) | Number of cases in children aged 10 to 14 years | Proportion of cases in children aged 10 to 14 years (%) | Total | |
|---|---|---|---|---|---|---|---|---|
| All disease sites | 5 | 22.7 | 4 | 18.2 | 13 | 59.1 | 22 | |
| Pulmonary | 3 | 60.0 | 1 | 25.0 | 3 | 23.1 | 7 | |
| Extra-pulmonary | 4 | 80.0 | 4 | 100.0 | 10 | 76.9 | 18 | |
| Severe TB | 1 | 20.0 | 0 | 0.0 | 2 | 15.4 | 3 | |
| Lymph nodes only | 2 | 40.0 | 3 | 75.0 | 7 | 53.8 | 12 | |
| Other | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 |
Note 25: ‘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. ‘Other’ includes gastrointestinal, genitourinary, and/or other extra-pulmonary.
Note 26: percentages may not add up to 100 as children with TB may have more than one site of disease.
TB treatment
TB patients can have complex needs and care requirements which have a subsequent impact on TB services. Cases requiring enhanced case management (ECM) are classified into levels 0 to 3 based on the degree of support required, with level 0 needing the standard level of support and level 3 typically being a more complex case with a much greater degree of support needed (4).
Enhanced case management
In 2023, 49.1% (288 out of 586) of TB cases were classified as ECM level 1 to 3, similar to the previous year (53.8% in 2022). The proportion of cases classified as ECM level 3 has increased since 2021 (Table 11).
Table 11. Number of people with TB receiving enhanced case management, North West, 2021 to 2023 [note 27]
| Year | Total TB notifications | 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 | 484 | 49 | 10.1 | 40 | 8.3 | 41 | 8.5 | 2 | 0.4 |
| 2022 | 494 | 136 | 27.5 | 84 | 17.0 | 46 | 9.3 | 7 | 1.4 |
| 2023 | 586 | 116 | 19.8 | 97 | 16.6 | 75 | 12.8 | 2 | 0.3 |
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.
Approximately a quarter of cases requiring ECM had risk factors recorded (24.7%, 65 out of 263, cases aged 15 and over only). Over half were aged 15 to 44 years (56.8%, 162 out of 285) and 78.2% were born outside the UK (223 out of 285).
Treatment delays
Cases experiencing delays of more than 2 months between symptom onset and treatment start averaged 61.4% for pulmonary cases between 2018 and 2023 (Figure 22). This was greater for extra-pulmonary cases at 67.3%, with the proportion increasing gradually from 61.9% in 2019 to 70.5% in 2023 (Figure 23).
Figure 22. Proportion of people notified with pulmonary TB with a treatment delay over 2 months, North West, 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 when treatment was started from symptom onset.
Figure 22 is a line chart with error bars showing the proportion of North West pulmonary TB cases notified between 2018 and 2023 which had a treatment delay of over 2 months. The proportion has remained between 57.1% and 64.2% during this period.
Figure 23. Proportion of people notified with extra-pulmonary TB with a treatment delay over 2 months, North West, 2018 to 2023 [note 30] [note 31]
Note 30: error bars represent upper and lower 95% confidence intervals.
Note 31: delay to treatment is defined by when treatment was started from symptom onset.
Figure 23 is a line chart with error bars showing the proportion of North West extra-pulmonary TB cases notified between 2018 and 2023 which had a treatment delay of over 2 months. The proportion has remained between 61.9% and 70.5% during this period.
There has been no significant change in treatment delays for pulmonary TB cases since 2018 (Table 12). Approximately one third of cases (29.1%, 62 out of 213) notified in 2023 experienced a delay of 2 to 4 months and another third (34.3%, 73 out of 213) were delayed for over 4 months. These delays are consistent with those reported nationally (1). Two-thirds of pulmonary cases (65.7%, 140 out of 213) started treatment within 4 months of symptom onset.
Table 12. Number and proportion of people notified with pulmonary TB with a treatment delay, time between symptom onset and treatment start, North West, 2018 to 2023 [note 32]
| Year | 2 to 4 months delay (number) | 2 to 4 months delay (proportion) | Over 4 months delay (number) | Over 4 months delay (proportion) | Total | Missing (number) | Missing (proportion) | Total eligible |
|---|---|---|---|---|---|---|---|---|
| 2018 | 54 | 27.3 | 68 | 34.3 | 198 | 37 | 15.7 | 235 |
| 2019 | 63 | 30.0 | 57 | 27.1 | 210 | 58 | 21.6 | 268 |
| 2020 | 43 | 25.1 | 60 | 35.1 | 171 | 33 | 16.2 | 204 |
| 2021 | 54 | 32.7 | 52 | 31.5 | 165 | 52 | 24.0 | 217 |
| 2022 | 55 | 30.4 | 58 | 32.0 | 181 | 45 | 19.9 | 226 |
| 2023 | 62 | 29.1 | 73 | 34.3 | 213 | 64 | 23.1 | 277 |
Note 32: 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.
Among pulmonary cases notified in 2023, the median number of days between symptom onset and treatment start was 84 (Figure 24). This remains above the target of 56 days (3).
Figure 24. Median treatment delays among people notified with pulmonary TB, North West, 2018 to 2023 [note 33] [note 34] [note 35] [note 36]
Note 33: dashed line represents the target treatment delay of 56 days by 2027.
Note 34: ends of the whiskers represent the theoretical lower and upper limits for detecting outliers (lower or upper quartile negative or positive 1.5 times the interquartile range). Outliers falling outside of these limits have been removed.
Note 35: delay to treatment is defined by when treatment was started from symptom onset.
Note 36: 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.
Figure 24 is a box plot showing the median treatment delays among pulmonary TB cases in the North West between 2018 and 2023. The median number of days has remained between 73 and 84 during this period, which is above the target of 56 days.
Among pulmonary cases with treatment delays of more than 4 months, 47.9% (35 out of 73) were in the 15 to 44 years age group, and 69.9% occurred in males (51 out of 73). Almost two-thirds (65.7%, 48 out of 73) were born outside the UK.
There was variation among ethnic groups: 50.0% of pulmonary cases (8 out of 16) in the Indian ethnic group were treated within 2 months of symptom onset, with 18.8% (3 out of 16) starting treatment after 4 months. In contrast, only 31.3% (20 out of 64) in the white ethnic group began treatment within 2 months, with 39.1% (25 out of 64) starting treatment after 4 months. Similarly, 34.0% (18 out of 53) in the Pakistani ethnic group started treatment within 2 months of symptom onset, while 43.4% (23 out of 53) started treatment after 4 months.
TB notification
Cases of active TB should be notified within 3 working days of diagnosis (5). In 2023, 67.8% of pulmonary cases were notified within the required period in the North West (Table 13).
Table 13. Proportion of people notified with pulmonary TB within 3 days of diagnosis by year, North West, 2018 to 2023 [note 37]
| Year | Number of people notified | Proportion of people notified (%) | Total |
|---|---|---|---|
| 2018 | 145 | 61.2 | 237 |
| 2019 | 183 | 66.1 | 277 |
| 2020 | 134 | 66.3 | 202 |
| 2021 | 134 | 59.8 | 224 |
| 2022 | 148 | 67.0 | 221 |
| 2023 | 187 | 67.8 | 276 |
Note 37: includes people with pulmonary TB who were not diagnosed at post-mortem, and where report delay was known and between 0 and 90 days (inclusive).
TB treatment outcomes
Treatment outcomes for the non-MDR (multidrug-resistant) or non-RR (rifampicin-resistant) TB cohort are reported separately for the following groups:
- For patients with an expected treatment duration of less than 12 months, outcomes at 12 months are reported. This group excludes individuals with central nervous system (CNS) disease, who would be treated for 12 months. In addition, those with spinal, cryptic disseminated or miliary disease are excluded from this group, as CNS involvement cannot be reliably ruled out for the purposes of reporting.
- For patients with CNS, spinal, cryptic disseminated or miliary disease, the last recorded treatment outcome is reported.
Outcomes for TB patients in the non-MDR or non-RR TB cohort without central nervous system (CNS) disease
In 2022, there were 466 cases in the non-MDR or non-RR cohort, 89.0% (421 out of 473) of which had non-severe TB with an expected treatment duration of less than 12 months. Of these non-severe cases, 85.5% (360 out of 421) completed treatment within 12 months (Table 14), similar to the previous year (84.5%, 353 out of 418). Nationally, treatment completion was slightly lower at 82.8% (1).
Table 14. 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 of less than 12 months, North West, 2022 [note 38] [note 39]
| 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 | 360 | 85.5 | 375 | 89.1 |
| Died | 10 | 2.4 | 10 | 2.4 |
| Lost to follow-up | 17 | 4.0 | 16 | 3.8 |
| Still on treatment | 2 | 0.5 | 1 | 0.2 |
| Treatment stopped | 12 | 2.9 | 12 | 2.9 |
| Not evaluated | 20 | 4.8 | 7 | 1.7 |
| Total | 421 | 100.0 | 421 | 100.0 |
Note 38: ‘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 39: table does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a post-mortem diagnosis of TB.
In the non-MDR or non-RR cohort with non-severe TB, treatment completion for cases with one or more recorded social risk factors was 73.8%, lower than for cases with no recorded risk factors (87.5%). The proportion completing treatment within 12 months has decreased slightly since 2018 (Figure 25).
Figure 25. Treatment completion within 12 months for TB cases with one or more social risk factors, North West, 2018 to 2022 [note 40]
Note 40: error bars represent upper and lower 95% confidence intervals.
Figure 25 is a line chart with error bars showing the proportion of North West non-MDR and non-RR TB cases without CNS disease and with one or more social risk factors notified between 2018 and 2022 which completed treatment within 12 months. The proportion decreased from 80.0% in 2018 to 73.8% in 2022.
Overall, the proportion of North West cases in the non-MDR or non-RR cohort with non-severe TB which completed treatment within 12 months was lower than the 90% target (3) in 2022 (Figure 26).
Figure 26. 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%, North West, 2018 to 2022 [note 41] [note 42] [note 43]
Note 41: dashed line indicates treatment target of 90%.
Note 42: error bars represent upper and lower 95% confidence intervals.
Note 43: does not include people notified with CNS, spinal, cryptic or miliary TB or people notified with a postmortem diagnosis of TB.
Figure 26 is a line chart with error bars showing the proportion of North West non-MDR and non-RR TB cases without CNS disease notified between 2018 and 2022 which completed treatment within 12 months. The proportion has remained stable during this period (between 84.4% and 86.7%) but has remained below the national target of 90%.
Of cases notified in 2022 that did not complete treatment within 12 months (14.5%, 61 out of 421), the most common reason for not completing treatment was being lost to follow-up (4.0%). Treatment was stopped for 2.9% of cases, 2.4% died and 0.5% of cases were still on treatment (Figure 27). Of the 17 cases that were lost to follow-up, 47.1% (8 cases) left the UK before completing treatment.
Figure 27. Outcomes of people evaluated who did not complete treatment by 12 months for people with non-MDR or non-RR TB who had an expected treatment duration of less than 12 months, North West, 2013 to 2022
Figure 27 is an area chart showing the proportion of North West non-MDR and non-RR TB cases without CNS disease notified between 2013 and 2022 which did not complete treatment within 12 months.
Of the 10 cases notified in 2022 that died before completing treatment, the relationship between TB and death was unknown for 40.0% (4 out of 10). Where information was known, TB caused death in one case, contributed to death in 3, and was incidental to death in 2 cases. The median age of those who died was 76 years.
Table 15. TB outcome at 12 months for people with non-RR or MDR-TB with expected treatment duration of less than 12 months, North West, 2013 to 2022 [note 44]
| 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 | 556 | 41 | 30 | 24 | 19 | 9 | 2 | 640 |
| 2014 | 478 | 37 | 28 | 16 | 19 | 5 | 0 | 546 |
| 2015 | 420 | 53 | 30 | 25 | 10 | 2 | 0 | 487 |
| 2016 | 457 | 40 | 26 | 27 | 7 | 4 | 0 | 521 |
| 2017 | 406 | 33 | 19 | 18 | 19 | 4 | 3 | 469 |
| 2018 | 364 | 36 | 12 | 17 | 7 | 6 | 18 | 424 |
| 2019 | 397 | 39 | 16 | 12 | 9 | 10 | 24 | 468 |
| 2020 | 351 | 30 | 21 | 10 | 2 | 3 | 18 | 405 |
| 2021 | 353 | 38 | 22 | 10 | 3 | 4 | 26 | 418 |
| 2022 | 360 | 45 | 10 | 17 | 2 | 12 | 20 | 421 |
Note 44: 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 16. Proportions of TB outcomes at 12 months for people with non-RR or MDR-TB with expected treatment duration of less than 12 months, North West, 2013 to 2022 [note 45]
| 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 | 86.9 | 6.4 | 4.7 | 3.8 | 3.0 | 1.4 | 0.3 |
| 2014 | 87.5 | 6.8 | 5.1 | 2.9 | 3.5 | 0.9 | 0.0 |
| 2015 | 86.2 | 10.9 | 6.2 | 5.1 | 2.1 | 0.4 | 0.0 |
| 2016 | 87.7 | 7.7 | 5.0 | 5.2 | 1.3 | 0.8 | 0.0 |
| 2017 | 86.6 | 7.0 | 4.1 | 3.8 | 4.1 | 0.9 | 0.6 |
| 2018 | 85.8 | 8.5 | 2.8 | 4.0 | 1.7 | 1.4 | 4.2 |
| 2019 | 84.8 | 8.3 | 3.4 | 2.6 | 1.9 | 2.1 | 5.1 |
| 2020 | 86.7 | 7.4 | 5.2 | 2.5 | 0.5 | 0.7 | 4.4 |
| 2021 | 84.4 | 9.1 | 5.3 | 2.4 | 0.7 | 1.0 | 6.2 |
| 2022 | 85.5 | 10.7 | 2.4 | 4.0 | 0.5 | 2.9 | 4.8 |
Note 45: 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.
Outcomes for TB patients in the non-MDR or non-RR TB cohort with CNS disease
For patients with severe TB (including CNS, spinal, cryptic disseminated or miliary disease), the last recorded treatment outcome is reported.
Of the 52 cases with CNS, spinal, miliary or cryptic disseminated disease in 2022, 80.8% (42 out of 52) had completed treatment at the last recorded outcome. This was similar to the previous year (78.0%, 39 out of 50) and to cases reported nationally (77.8%, 364 out of 468) (1). Over half (57.7%, 30 out of 52) of cases in this cohort completed treatment within 12 months. The most common reason for non-completion of treatment was being lost to follow-up (9.6%, 5 out of 52 cases).
TB treatment outcome at 24 months for patients in the drug-resistant (MDR or RR TB) cohort
In 2021, there were 11 North West cases in the MDR or RR TB cohort. At 24 months, 10 cases (90.9%) had completed treatment and the remaining case had stopped treatment.
TB prevention
Contact tracing
Contact tracing aims to identify cases of undiagnosed active and latent TB and to subsequently provide them with appropriate treatment or vaccination. This process can prevent further transmission and development of more severe illness.
Contact tracing information was available for 74.1% (223 out of 301) of pulmonary TB cases in the North West in 2023, and 15.3% (46 out of 301 cases) had 5 or more contacts identified and screened. The median number of contacts identified and screened was 2.5 (inter-quartile range 1.0 to 4.8), although this was higher in cases of MDR or RR TB (Table 17).
Table 17. Contact tracing information for people with pulmonary TB by demographic and disease characteristics, North West, 2023 [note 46] [note 47]
| 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 | 301 | 223 | 74.1 | 46 | 15.3 | 2.5 | 1.0 to 4.8 |
| Female | 113 | 89 | 78.8 | 25 | 22.1 | 3.0 | 2.0 to 6.0 |
| Male | 188 | 134 | 71.3 | 21 | 11.2 | 2.0 | 1.0 to 4.0 |
| Adults | 293 | 217 | 74.1 | 46 | 15.7 | 3.0 | 1.0 to 5.0 |
| Children (15 years or less) | 8 | 6 | 75.0 | 0 | 0.0 | 1.0 | 1.0 to 2.0 |
| Non-UK-born | 214 | 160 | 74.8 | 32 | 15.0 | 3.0 | 1.0 to 4.0 |
| UK-born | 86 | 62 | 72.1 | 14 | 16.3 | 2.0 | 1.0 to 6.0 |
| No social risk factor | 233 | 172 | 73.8 | 38 | 16.3 | 3.0 | 1.0 to 5.0 |
| At least 1 social risk factor | 68 | 51 | 75.0 | 8 | 11.8 | 2.0 | 0.0 to 4.0 |
| Non-MDR or RR TB | 289 | 213 | 73.7 | 42 | 14.5 | 2.0 | 1.0 to 4.0 |
| MDR or RR TB | 12 | 10 | 83.3 | 4 | 33.3 | 4.0 | 1.8 to 6.0 |
Note 46: 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 47: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of routine contact tracing.
The proportion of pulmonary cases with at least 5 contacts identified and screened increased from 14.2% in 2021 to 24.9% in 2022; although there was a decrease in 2023 to 15.3% (Figure 28).
Figure 28. Proportion of people notified with pulmonary TB with at least 5 contacts identified and screened for active and latent TB by year, North West, 2018 to 2023 [note 48] [note 49]
Note 48: error bars represent upper and lower 95% confidence intervals.
Note 49: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.
Figure 28 is a line chart with error bars showing the proportion of North West pulmonary TB cases notified between 2018 and 2023 with at least 5 contacts identified and screened for active and latent TB. The proportion increased between 2021 and 2022 but decreased in 2023.
Of the pulmonary TB cases notified in 2023, a total of 1026 contacts were identified; 69.5% (713 out of 1026) of which were screened for active and latent TB (Table 18). This proportion was higher in child contacts at 73.8% (211 out of 286). Active TB was identified in 3.9% of the total contacts screened (28 out of 713), while latent TB was found in 15.8% (113 out of 713). Approximately one fifth (21.3%, 45 out of 211) of child contacts were found to have latent TB. Treatment was started for 86.7% (98 out of 113) of all those identified with latent TB, and 78.8% (89 out of 113) completed treatment.
Table 18. Number of contacts identified and screened, screening results and treatment for contacts of people notified with pulmonary TB (index individuals), North West, 2023 [note 50]
| 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 | 740 | Not applicable | 286 | Not applicable | 1,026 | Not applicable |
| Number of contacts screened for active TB and latent TB | 502 | 67.8 | 211 | 73.8 | 713 | 69.5 |
| Number of contacts with active TB | 17 | 3.4 | 11 | 5.2 | 28 | 3.9 |
| Number of contacts with latent TB | 68 | 13.5 | 45 | 21.3 | 113 | 15.8 |
| Number of contacts who started treatment for latent TB | 57 | 83.8 | 41 | 91.1 | 98 | 86.7 |
| Number of contacts who completed treatment for latent tuberculosis | 52 | 76.5 | 37 | 82.2 | 89 | 78.8 |
Note 50: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.
Treatment completion for cases of LTBI (latent TB infection) was slightly higher in contacts of UK-born cases (84.0%, 21 out of 25) than in contacts of those born outside the UK (77.3%, 68 out of 88 cases).
BCG vaccination
Bacillus Calmette-Guérin (BCG) vaccination was confirmed for 36.5% (214 out of 586) of North West TB cases in 2023 (Table 19), slightly higher than in previous years (31.8%, 157 out of 494, in 2022). However, over half (53.2%, 312 out of 586) had no BCG information recorded.
The proportion of cases with a known BCG vaccination status was higher in younger age groups: 81.8% (18 out of 22) in cases aged 0 to 14 years, compared with 42.7% (35 out of 82) of cases aged 65 and over.
Among cases aged under 15 years, the proportion of cases receiving BCG vaccination was higher in those born outside the UK at 83.3% (10 out of 12) compared with 30.0% of UK-born cases (3 out of 10).
Table 19. BCG vaccination coverage among people with TB, North West, 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 | 1 | 1 | 100.0 | 10 | 12 | 83.3 | 161 | 443 | 36.3 |
| UK-born | 1 | 4 | 25.0 | 3 | 10 | 30.0 | 53 | 141 | 37.6 |
| All cases | 2 | 5 | 40.0 | 13 | 22 | 59.1 | 214 | 586 | 36.5 |
Discussion
Numbers and rates of TB in north west England have increased since 2020. Incidence remains below the national level; however, the increasing trend moves the region further away from achieving the goal of a 90% reduction in new TB notifications by 2035.
The ethnic groups with the highest proportion of cases were the Pakistani, White and Black African ethnic groups. Three-quarters of all cases were born outside the UK and, while a significant proportion were resident in the UK for at least 11 years, a third of cases were in new entrants (notified within 2 years of UK entry). This demonstrates the importance of timely identification and treatment of TB and LTBI in migrants arriving from high incidence TB countries via an effective LTBI screening programme, and of maintaining awareness of TB among migrant populations.
The proportion of cases with SRFs has increased to 15.8% in 2023, indicating that underserved populations must remain a priority for intervention. The largest burden of disease falls in the most socio-economically disadvantaged populations. Continued efforts to control TB in these groups present an opportunity to reduce health inequalities.
Two-thirds of pulmonary cases started TB treatment within 4 months of symptom onset. However, the remaining third started treatment more than 4 months after symptom onset, which may have increased the opportunity for TB transmission. It is important to raise awareness of TB among high-risk groups and service providers, and to ensure that clinical pathways are in place to increase detection and diagnosis.
Recommendations
The recommendations below link to the 5 priority areas in the UKHSA ‘Tuberculosis (TB): action plan for England, 2021 to 2026’ (3).
1. Recovery from COVID-19
UKHSA NW 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 NW TB Control Board, cohort steering group, and network meetings.
2. Prevent TB
The increase in TB among recently arrived migrants indicates the need for improvements in this area. Missed opportunities for both pre-entry and new migrant screening should be identified at NW cohort reviews and raised via the TB Control Board to the national UKHSA TB team.
Local LTBI programmes should review local epidemiology, alongside their uptake and testing results, to evaluate their efforts.
NW TB service providers should work with local authorities, integrated care boards (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, and those on immunotherapy).
Contact tracing efforts should continue to be monitored through local cohort reviews, as well as in routine TB surveillance reporting (such as the NW quarterly report).
3. Detect TB
Improving early detection of TB is a priority for the TBCB. Oversight of, and understanding of reasons for, delays should remain a core part of TB cohort reviews. 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 or infectious TB. Diagnosis confidence scores that show if samples are sent for culture and are culture-confirmed have now been introduced to cohort reviews.
4. Control TB disease
There is a need for better engagement with those most at risk of developing TB, particularly migrants and people in inclusion health groups (such as people experiencing homelessness, imprisonment, drug or alcohol dependence, mental health problems or asylum seeker status). Collaborate with partners to develop pathways for detecting TB (including latent TB) and provide relevant support to these groups throughout their treatment.
Work to improve current TB completion rates of 86%, aiming for target of 90% treatment completion rates for TB drug-sensitive cases by 2026.
5. Workforce
Continue education about TB and raise awareness among health and social care services, including primary care, secondary care, prisons and other accommodation settings.
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 integrated care boards (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.
Noting the variation in incidence of TB across the North West, and consider ways to share learning and strengthen networks across lower and higher incidence areas.
Appendix
Rates of TB by upper tier local authority
Figure 29. TB notification rate by upper tier local authority of residence, North West, 2001 to 2023 [note 50]
Note 50: grey lines represent the other upper tier local authorities in the region.
Methods and definitions
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 North West, 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
- the UKHSA Data Science team
- the UKHSA North West Health Protection Team
- the UKHSA Field Service North West team
References
-
Sharon E Cox and others. ‘Tuberculosis in England, 2024 report’ December 2024, National TB Unit, UK Heath Security Agency, London (viewed on 16 July 2025)
-
World Health Organization. ‘The End TB Strategy’ 2015, World Health Organization (viewed on 16 July 2025)
-
UK Health Security Agency and NHS England. ‘Tuberculosis (TB): action plan for England, 2021 to 2026’ July 2021 (viewed on 16 July 2025)
-
Royal College of Nursing. ‘A Case Management Tool for TB Prevention, Care and Control in the UK’ May 2023
-
UK Health Security Agency. ‘Notifying suspected or confirmed active tuberculosis (TB)’ Updated 21 January 2025 (viewed on 16 July 2025)