Research and analysis

South West: tuberculosis in 2023

Published 4 September 2025

Incidence, treatment and prevention of tuberculosis (TB) in the South West using data up until the end of 2023

Executive summary

In the South West in 2023, annual tuberculosis (TB) incidence was 3.6 per 100,000 population (212 cases). This was an annual increase of 29%, compared to an increase of 11% to 8.5 per 100,000 population in England overall. The South West incidence remains comparatively low compared to other regions and is well below the 10 per 100,000 population threshold for a ‘medium prevalence’ area.

There is notable regional variation in TB incidence by upper tier local authority (UTLA). The UTLAs with the highest incidence rates per 100,000 population were Bristol (11.4) and Swindon (10.5). Cornwall and the Isles of Scilly (0.9) has achieved pre-elimination status (less than 1 notification per 100,000 population).

Just over half of cases were male (52.8%, 112 cases). The highest TB notification rate for males was observed among those aged 20 to 29 years old (7.9 per 100,000) and for females, among those aged 30 to 39 years old (7.3 per 100,000).

The majority of TB cases (76%) were born outside the UK. 37.2% of non-UK-born cases were new entrants, notified with TB within 2 years of entering the UK. The most common country of birth among TB cases born outside the UK was India (26.1% of non-UK-born cases), with 56.25% being new entrants. 

The observed increase in cases since last year was predominantly driven by an increase in non-UK-born cases, in particular an increase in those aged 15 today 44 years, which now account for 40% of non-UK-born cases. We have though, seen the first year-on-year increase in UK-born cases since 2019, indicating that domestic transmission is also increasing.

There were 119 notifications of pulmonary tuberculosis (56.1% of 212 notifications), compared to 55% in England overall. Of these, 72.3%, had been confirmed by culture, slightly below the 80% European standard. Where data was available, 62.8% (49 out of 78 pulmonary TB cases) had a delay in treatment (more than 2 months between symptom onset and initiation of treatment).

15.6% of cases reported having one or more comorbidities. The most commonly reported comorbidities were diabetes (8.9%, 17 cases) and immunosuppression (8.9%, 17 cases).

The strong link between inequalities and TB is evident in the South West population. During this year 31.3% of cases lived in the 2 most deprived IMD deciles. The proportion of cases with one or more comorbidities was 15.6%, with the most common being chronic liver disease (10.8%). Social risk factors vary significantly by age, sex and place of birth. The proportion of cases with at least one social risk factor (19.4%) increased since last year and is the highest it has been in the last decade. At 15.1% the proportion of cases that required enhanced case management remained similar to last year.

Just under one third (31.2%) of individuals with a positive TB culture were part of a whole genome sequencing (WGS) cluster, compared to 31.7% in 2022. Regionally, since 2020, a non-significant decreasing trend has been observed in the proportion of culture-confirmed individuals who formed part of a cluster.

Twelve-month treatment outcomes for 2022 cases of non-severe TB treated as non-MDR and non-RR was 69.9%.

The median number of contacts per case was 2.0, and 17.6% of cases had 5 or more contacts identified and screened for active or latent TB. The median number of contacts was slightly higher for female cases (3 contacts) than male cases (2 contacts) and higher for those with at least one social risk factor (4.5 contacts) compared to those with none (2 contacts). Overall, contact information had been entered for 78.2% of pulmonary cases, meaning that contact information was not available for 1 in 5. This proportion was lower in cases with one or more social risk factors, where data was only available for 66.7% of cases, meaning data was unavailable for 1 in 3.

Data for all the graphs in this report can be found in the South West TB report 2023 supplementary data spreadsheet.

TB incidence and epidemiology

Incidence in the South West

In 2023, 212 people were notified with a new tuberculosis diagnosis in South West England (Figure 1). This equates to a notification rate of 3.6 per 100,000 population (95% confidence interval (CI): 3.2 to 4.2), which is higher than the notification rate observed in 2022, at 2.8 notifications per 100,000 population (95% CI: 2.4 to 3.3) (Figure 2). The 2023 notification rate was higher than annual rates observed during the pandemic period (2020 to 2022), but remained lower than the 2019 rate, which was 4.2 per 100,000 population (95% CI: 3.7 to 4.8).

The South West rate in 2023 was lower than the rate for England, which was 8.4 per 100,000 population (95% CI: 8.1 to 8.6). Between 2011 and 2022, the TB notification rate in England declined by 52.8%. However, most of this reduction occurred between 2011 and 2018.

Figure 1. Number of TB notifications per year, South West, 2001 to 2023

Figure 2. TB notification rates per 100,000 population per year, South West, 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, South 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 a 90% reduction in incidence from 2015 baselines by 2035.

TB incidence by upper tier local authority

In 2023, TB incidence was low (less than 10 notifications per 100,000 residents) across all South West UTLAs aside from Bristol (11.4) and Swindon (10.5). Cornwall and the Isles of Scilly has achieved pre-elimination status (less than 1 notification per 100,000 residents) based on its annual incidence rate (0.9) in 2023 (Figure 4 and Figure 5).

Compared to the 5-year average annual incidence rate from 2018 to 2022, the 2023 rates represent a decrease in TB incidence in:

• Cornwall and the Isles of Scilly (down 55%)
• Plymouth (down 38%)
• Bath and North East Somerset (down 26%)
• Devon (down 19%)
• Bournemouth, Christchurch, and Poole (down 11%)

Upper tier local authorities experiencing an increase included:

• Torbay (up 105%)
• North Somerset (up 103%)
• South Gloucestershire (up 40%)
• Swindon (up 28%)
• Bristol (up 27%)
• Wiltshire (up 25%)
• Gloucestershire (up 24%)
• Somerset (up 18%)
• Dorset (up 17%).

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

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

Figure 5. TB notification rate by upper tier local authority of residence, South West, 2023 [note 5]

Note 5: Cornwall and Isles of Scilly upper tier local authorities have been combined due to data suppression regulations.

Incident case demographics

In 2023, there were 100 females (47.2%) and 112 males (52.8%) notified with TB in the South West (Figure 6). This equates to a rate of 3.9 notifications per 100,000 population for males (95% CI: 3.2 to 4.7) and 3.4 per 100,000 population for females (95% CI: 2.7 to 4.1) (Figure 7).

The age range for individuals with a TB notification in 2023 ranged from 3 to 92 years and the median age was 36 years. Female cases had a median age of 37 years and male cases had a median age of 36 years. The highest TB notification rate for males was observed among those aged 20 to 29 years old (7.9 per 100,000) and for females, among those aged 30 to 39 years old (7.3 per 100,000).

TB notification rates in older adult age groups (50 years and older) were lower than those observed for younger adult age groups (20 to 59 years) in both males and females. In the older adult age groups, with the exception of people over 80 years age, higher TB notification rates were observed in males compared with females.

In the youngest age group (0 to 9 years), the TB notification rates in males and females were 0.4 and 0.7 per 100,000 respectively. In older children and young adults aged 10 to 19 years, the notification rates were 2.7 and 1.9 per 100,000 people.

Figure 6. Number of TB notifications by age and sex, South West, 2023

Figure 7. TB notification rate by age and sex, South West, 2023

Country of birth

In 2023, the country of birth was known for 99.5% (211 out of 212) of new TB cases in the South West. Of these, 161 (76.3%) were non-UK-born individuals and 50 (23.7%) were UK-born individuals (Figure 8).

Since 2018, there has been a year-on-year increase in the proportion of annual notifications observed amongst non-UK-born individuals (from 50% in 2018 to 76.3% in 2023). In 2023, the proportion of notifications among people who were not born in the UK was the highest observed since the beginning of the reporting period in 2000.

The 50 UK-born cases in 2023 represented a small increase compared to 2022 (42 cases) and was the first annual increase observed since 2019. However, the 2022 and 2023 annual notification counts represent the lowest counts observed among UK-born individuals since 2000.

Figure 8. Number of TB notifications in non-UK-born and UK-born people by place of birth, South West, 2001 to 2023

In 2023, the highest number of cases in the South West occurred in the 15 to 44 years age group (130 cases, 61.6%), followed by the 45 to 64 years (49 cases, 23.2%), over 65 years (26 cases, 12.3%) and 0 to 14 years (6 cases, 2.8%) age groups (Figure 9). The most notable increase in case numbers compared to 2022 occurred in 15 to 44 year olds, with case numbers rising by 44.4% from 90 to 130. This trend was predominantly driven by a large increase in non-UK-born cases, from 119 in 2022 to 161 in 2023. The proportion of incident cases that were not UK-born remained similar between 2022 (73.4%) and 2023 (75.9%).

For non-UK-born cases, the highest proportion of cases occurred in the 15 to 44 years age group (110 cases, 68.3%), followed by the 45 to 64 years (36 cases, 22.4%), over 65 years (12 cases, 7.5%), and 0 to 14 years (3 cases, 1.9%) age groups.

For UK-born individuals, the highest proportion of cases in 2023 also occurred in the 15-44 years age group (20 cases, 40%), followed by over 65 years (14 cases, 28%), 45 to 64 years (13 cases, 26%) and 0 to 14 years (3 cases, 6%) age groups.

Figure 9. Number of TB notifications in non-UK-born and UK-born people by place of birth and age group, South West, 2001 to 2023

In 2023, the time since entry to the UK (in years) was recorded for 80.1% (129 out of 161) people in the South West who were born outside of the UK. Of these, 37.2% (48 cases) had less than 2 years since entry to the UK, followed by 27.1% (35 cases) with 2 to 5 years, 11.6% (15 cases) with 6 to 10 years, and 24% (31 cases) with at least 11 years since entry (Figure 10). Compared to 2021, this represents a notable increase in the number and proportion of cases who had been in the country less than 2 years (20.4%, 19 cases in 2021 compared to 37.2%, 48 cases in 2023) and a decrease in the number and proportion who had been in the country 11 or more years (40.9%, 38 cases in 2021 compared to 24.0%, 31 cases in 2023).

Figure 10. Proportion of TB notifications by time since entry for people born outside the UK, South West, 2001 to 2023

In 2023, the most common countries of birth for people with TB in the South West were:

• United Kingdom (50)
• India (42)
• Afghanistan (10)
• Nigeria (10)

This data is in Table 1 and Table 2. Comparatively, the most common countries of birth across England were:

• India (1,166)
• United Kingdom (1,116)
• Pakistan (563)
• Nigeria (196)
• Romania (179).

Table 1. Most common countries of birth for people with TB and time between entry to the UK and TB notification, South 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
United Kingdom	50	23.7	Not applicable	Not applicable
India	42	19.9	2.0	1.0 to 8.2
Afghanistan	10	4.7	0.0	0.0 to 1.0
Nigeria	10	4.7	1.0	0.5 to 3.0
Pakistan	8	3.8	4.0	2.2 to 10.2
Somalia	8	3.8	13.0	5.0 to 18.5
Zimbabwe	8	3.8	2.0	1.0 to 4.5
Philippines	7	3.3	2.0	1.5 to 2.5
Romania	7	3.3	7.0	6.0 to 8.0
Bangladesh	5	2.4	2.0	1.0 to 11.0
Nepal	5	2.4	1.5	0.8 to 2.5
Other	51	24.2	5.5	0.2 to 15.0
Total	211	100.0	Not applicable	Not applicable

Note 6: ‘Other’ includes all countries with less than 5 people notified.

The trends in the numbers of TB notifications in the 6 most commonly recorded non-UK countries of birth (based upon 2023 annual counts) in the South West is visualised in Figure 11. It can be seen that (excluding the United Kingdom), India has consistently been the most frequently reported country of birth. It had case numbers increase year-on-year since 2018. There was a notable increase from 2022 (31 cases) to 2023 (42 cases). Among those born in India, the median time between entry in the UK and TB notification was 2 years (interquartile range: 1 to 8.2). Since 2016, the annual count for those born in in Nigeria, Pakistan, Somalia, and Zimbabwe have varied year-on year without showing any notable trends.

Figure 11. Numbers of TB notifications for the most common countries of birth for people with TB born outside the UK, South West, 2013 to 2023 [note 7]

Note 7: figure shows the top 6 countries in 2023.

Table 2. Characteristics of people with TB from the most common (non-UK) countries of birth, South 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 (%)
India	42	37.9	40.5	40.5	31.2	50.0
Afghanistan	10	24.8	100.0	70.0	88.9	75.0
Nigeria	10	42.7	50.0	30.0	57.1	0.0
Pakistan	8	36.8	75.0	37.5	16.7	0.0
Somalia	8	36.9	37.5	37.5	14.3	100.0
Zimbabwe	8	48.0	50.0	50.0	42.9	33.3

Ethnicity

In 2023, ethnicity data was available for 98% (207 out of 212) of individuals with TB in the South West. For UK-born individuals, the most commonly recorded ethnic groups were:

• White (85%)
• Black African (8.3%)
• Black Caribbean (4.2%)
• Asian-Other (2.1%)
• Indian (2.1%)

For individuals who were not born in the UK, the most commonly recorded ethnic groups were:

• Indian (29%)
• Black African (23.2%)
• Asian-Other (20%)
• White (11%)
• Mixed or other (6.5%)

This data is displayed on Figure 12.

Figure 12. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), South West, 2023 [note 8]

Note 8: figure ordered by total number of notifications within each ethnicity irrespective of place of birth.

Among people with TB in South West England, South Asian was the most commonly recorded ethnic group (28.5%, 59 out of 207), followed by the White (28.0%, 58 cases), Mixed or other (22.2%, 46 cases) and Black (21.3%, 44 cases) ethnic groups.

The South Asian ethnic group also had the highest number of notifications amongst non-UK-born individuals (36.7%, 58 out of 158), followed by Mixed or other (28.5%, 45 cases), Black (24.1%, 38 cases) and White (10.8%, 17 cases) ethnic groups. Compared to 2022, in 2023 there was a slight decrease in the number of TB notifications for individuals in the White ethnic group and increases in other groups.

For UK-born individuals, White was the most commonly reported ethnic group (83.7%, 41 out of 50 cases) and the number of annual notifications for individuals within the Black, South Asian and Mixed or other ethnic groups remained low.

Figure 13. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), South West, 2001 to 2023

Site of disease

In the South West in 2023, there were 119 notifications of pulmonary tuberculosis (56.1% of 212 notifications) (Table 3). Of these individuals, 90 (49.5%) were recorded as having pulmonary TB only, whilst 7 individuals (3.3%) had miliary TB only. There were no individuals with exclusively laryngeal TB. Across England, 55% of all TB notifications involved pulmonary TB, including 3% of notifications with miliary and 0.3% laryngeal TB.

Table 3. Number of pulmonary TB notifications by site of disease, South West, 2023 [note 9] [note 10]

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All pulmonary	119	56.1
Pulmonary only	90	42.5
Miliary only	7	3.3
Laryngeal only	0	0.0

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 or extra-pulmonary TB.

There were 122 individuals (57.5% of 212 notifications) with an extra-pulmonary site of disease recorded in 2023 (Table 4). The most commonly recorded extra-pulmonary site of disease were extra-thoracic lymph nodes (46 individuals, 21.7%), similar to other English regions: across England, 22.0% of notifications were recorded in extra-thoracic lymph nodes, 13.7% in intra-thoracic lymph nodes, 8.1% in pleura, and 4.4% in the spine.

Table 4. Number of extra-pulmonary TB notifications by site of disease, South West, 2023 [note 11]

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All extra-pulmonary	122	57.5
Other extra-pulmonary	49	23.1
Extra-thoracic lymph nodes	46	21.7
Intra-thoracic lymph nodes	14	6.6
Pleural	14	6.6
Bone - spine	11	5.2
Gastrointestinal	8	3.8
Genitourinary	6	2.8
Bone - not spine	3	1.4
Central nervous system - meningitis	3	1.4
Central nervous system - other	2	0.9
Cryptic disseminated	0	0.0

Note 11: percentages may not add up to 100 as people with TB may have more than one site of disease.

In 2023, the site of disease was known for all individuals notified with TB in the South West. Of these cases, 56.1% (95% CI 49.4% to 62.6%) were recorded as pulmonary, which represents the lowest proportion of pulmonary cases observed since 2013, with the largest year-on-year decrease in the proportion of cases occurring between 2022 and 2023 (Figure 14).

Figure 14. Proportion of people notified with pulmonary TB, South West, 2013 to 2023 [note 12]

Note 12: error bars represent upper and lower 95% confidence intervals.

Comorbidities

The National TB Surveillance System (NTBS) records data on several common and clinically significant comorbidities: chronic liver disease, chronic renal disease, diabetes, hepatitis B, hepatitis C and immunosuppression (Table 5). In 2023, 15.6% of cases reported having one or more comorbidities (33 out of 212 cases where data for at least one comorbidity was available). The most commonly reported comorbidities were diabetes (8.9%, 17 cases) and immunosuppression (8.9%, 17 cases).
The proportions of cases with comorbidities in the South West were roughly similar to those in England overall, where diabetes (11.5%) and immunosuppression (9.0%) were again the most commonly reported. Data completeness for each comorbidity category in the South West varied between 91% for immunosuppression and 85% for Hepatitis C.

Table 5. Number and proportion of people with TB with comorbidities, South West, 2023 [note 13]

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	212	33	15.6	Not applicable	Not applicable
Chronic liver disease	189	2	1.1	23	10.8
Chronic renal disease	190	3	1.6	22	10.4
Diabetes	190	17	8.9	22	10.4
Hepatitis B	182	2	1.1	30	14.2
Hepatitis C	181	0	0.0	31	14.6
Immunosuppression	191	17	8.9	21	9.9

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.

Human immuno-deficiency virus (HIV) infection

Untreated HIV infection increases the risk of developing active TB disease. The WHO End TB Strategy recommends that universal HIV testing should be conducted within TB programmes. An important key target of the Strategy states that 100% of individuals with new or relapse TB episodes should be offered a HIV test by 2025. The proportion of people being offered HIV testing is recorded in NTBS.

Information on HIV testing was available for 96.7% (205 out of 212) of South West cases reported in 2023. Of these, 94.6% (194 out of 205) were offered an HIV test, which was comparable to the proportion offered annually between 2018 and 2022 (Figure 15). Of those offered, 87.1 (169 out of 194 completed a test; 1.55% did not complete a test (3 out of 194) and for the remaining 11.3% (22 out of 194 HIV status was already known.

Figure 15. Proportion of people with TB offered an HIV test by year, South West, 2018 to 2023 [note 14] [note 15]

Note 14: dashed line indicates the WHO End TB target of 100% of incident cases being offered an HIV test.
Note 15: error bars represent upper and lower 95% confidence intervals.

Social risk factors

Tuberculosis is known to disproportionately impact certain populations with social risk factors. The 2024 WHO operational handbook on tuberculosis highlights a number of significant comorbidities that are closely associated with TB, including drug misuse, alcohol misuse, and mental health conditions. Additionally, the WHO recommends systematic assessment of eligibility and provision of TB preventive treatment among several at-risk populations, including prisoners, people experiencing homelessness, people who inject drugs, and those who have recently arrived from countries with high TB burdens.

In 2023, 19.4% of cases reported having one or more social risk factors (40 out of 206 cases where data for at least one social risk factor was available) (Table 6). The most commonly reported social risk factors were asylum seeker status (9.4%, 18 of 192 cases) and homelessness (6.8%, 12 of 177 cases). Data completeness for each social risk factor varied from 95.5% for ‘Asylum seeker (current)’ to 81.1% for ‘Prison (current or previous)’.

Individuals with multiple social risk factors are at greater risk of contracting tuberculosis and going on to develop severe disease. For cases where data for 2 or more social risk factors were available, 19.4% of cases reported having more than one social risk factor (13 out of 188 cases).

Table 6. Number and proportion of people with TB aged 15 years or over with individual social risk factors, South 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	206	40	19.4	Not applicable	Not applicable
More than one social risk factor	188	13	6.9	18	8.7
Alcohol misuse (current)	187	9	4.8	19	9.2
Asylum seeker (current)	192	18	9.4	9	4.5
Drug misuse (current or previous)	175	10	5.7	31	15
Homelessness (current or previous)	177	12	6.8	29	14.1
Mental health needs (current)	175	3	1.7	31	15
Prison (current or previous)	167	6	3.6	39	18.9

Note 16: people with TB are reported as having ‘At least one named social risk factor’ if any of the 6 social risk factors had ‘yes’ recorded. As a result, the denominator for this category 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.

When compared to previous years, the proportion of annual TB cases with a social risk factor has increased from 9.5% in 2018 to 19.3% in 2023, with a slight decrease to 11.3% during the COVID-19 pandemic in 2021 (Figure 16, Table 7). However, this increase must be interpreted with the caveat that data on mental health needs was not collected in 2018 or 2019.

Figure 16. Proportion of people with TB aged 15 years or over with at least one social risk factor (SRF), South West, 2018 to 2023 [note 17] [note 18]

Note 17: error bars represent upper and lower 95% confidence intervals.
Note 18: not all social risk factors were captured before 2021.

Table 7. Number and proportion of people with TB aged 15 years or over reporting at least one social risk factor, South West, 2013 to 2023 [note 19]

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	36	11.5	314
2014	26	8.6	302
2015	33	11.9	278
2016	30	12.7	236
2017	25	11.6	216
2018	18	10.0	180
2019	36	15.9	226
2020	30	18.5	162
2021	17	11.3	151
2022	28	17.5	160
2023	40	19.4	206

Note 19: not all social risk factors were captured before 2021. This table includes people in the denominator who have no social risk factor information recorded.

A breakdown of social risk factors by sex, age place of birth and employment status for 2023 cases aged over 15 is shown in Table 8 below. All social risk factors are more common in males than females, and the majority (all other than prison or mental health needs) are more common in those aged 15 to 44 compared to older age groups. In terms of proportions, all social risk factors other than ‘Asylum seeker’ are all more common in UK-born individuals compared to non-UK-born, though due to non-UK-born individuals making up the majority of cases, for many of these risk factors the number of non-UK-born individuals is still greater.

Table 8. Number and proportion of people with TB aged 15 years or over with a social risk factor (SRF) by demographic characteristics, South 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	3	3.5	2	2.2	1	1.2	0	0.0	3	3.3	1	1.2
Male	7	7.8	7	7.1	11	11.8	6	7.1	15	14.3	2	2.2
Aged 15 to 44	7	6.4	7	5.8	8	7.2	3	2.9	18	14.6	2	1.8
Aged 45 to 64	2	4.8	1	2.3	3	7.1	1	2.4	0	0.0	1	2.4
Aged 65 or older	1	4.3	1	4.2	1	4.2	2	9.1	0	0.0	0	0.0
Non-UK-born	3	2.2	6	4.1	8	5.9	4	3.1	18	12.1	0	0.0
UK-born	7	17.5	3	7.3	4	9.8	2	5.0	0	0.0	3	7.5
Unemployed	4	9.1	3	6.0	4	8.5	1	2.3	11	20.4	1	2.2

Deprivation

In 2023 in the South West region, Index of Multiple Deprivation (IMD) decile information was available for 98.1% (208 out of 212) of individuals with TB in the South West. During this year 31.3% of cases with available data lived in the most deprived (34 cases), and second most deprived (31 cases) IMD deciles.

Figure 17. TB notification rate by deprivation decile, South West, 2023 [note 20]

Note 20: error bars represent upper and lower 95% confidence intervals.

TB diagnosis, microbiology, and drug resistance

Culture confirmation

A positive M. tuberculosis or M. tuberculosis complex (MTBC) culture is required before an individual’s sample can be typed or processed for drug resistance information. The 2021 to 2026 TB National Action Plan for England outlines the target of increasing the proportion of culture-confirmed cases to the European standard of 80% for pulmonary TB by 2024 to 2025, at both the regional and national levels.

In 2023, the proportion of cases with pulmonary disease with culture confirmation (72.3%, 86 out of 119 cases), was comparable to the proportion observed in 2022 (72.2%). For the past 3 years the proportion confirmed by culture has been below the European standard of 80%.

Figure 18. Proportion of people notified with pulmonary TB who were culture-confirmed, South West, 2017 to 2023 [note 21] [note 22]

Note 21: dashed line indicates target of 80% culture confirmation.
Note 22: error bars represent upper and lower 95% confidence.

Drug resistance

Among individuals notified with culture-confirmed TB in the South West region in 2023, regardless of their recorded site of disease, 77.6% (97 out of 125) had sensitivity results available for all 4 first-line drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol).

From 2017 to 2021, the overall proportion of individuals with sensitivity data available for all first-line drugs remained relatively stable, ranging from 93.1% to 98.3% (Figure 19). However, since 2021, there appears to have been a decrease from 97.9% in 2021 to 77.6% in 2023. The reasons for this decrease are currently being investigated by regional and national UK Health Security Agency (UKHSA) teams.

Figure 19.  Proportion of people culture-confirmed with TB with first line drug results, South West, 2017 to 2023 [note 23]

Note 23: error bars represent upper and lower 95% confidence intervals.

Among the 125 culture-confirmed individuals with TB in the South West region notified in 2023, 8.0% (10) had samples exhibiting resistance to at least one first-line drug, regardless of site of disease (Figure 20). Note that the 2023 proportion was calculated using only 3 of the 4 first line agents (rifampicin, isoniazid and ethambutol). We are not reporting on the proportion with resistance to pyrazinamide in 2023 because the laboratory testing was adversely impacted by a problem with quality control in the supply chain for the media used for phenotypic drug-susceptibility testing (pDST) for this drug. The manufacturer issued a Field Safety Notice in July 2024 stating that there may have been false detection of resistance from June 2023.

Between 2017 and 2023, the number of cases showing resistance to at least one of the 4 first-line drugs has shown no clear trend, with annual proportions ranging between 4.3% to 10.6%.

Figure 20. Proportion of people notified with culture-confirmed TB with initial resistance to any first line drug, South West, 2017 to 2023 [note 24]

Note 24: error bars represent upper and lower 95% confidence intervals.

Whole genome sequencing (WGS) of TB isolates

Whole genome sequencing provides information on isolate relatedness and potential transmission sources. In England, individuals with a positive culture are grouped into genomic clusters if at least one other individual is identified with a sample within 12 single nucleotide polymorphisms (SNPs). This information is used to guide contact tracing and public health action. More information can be found in the WGS handbook.

Within the South West in 2023, 31.2% (95% confidence interval 23.7% to 39.8%) of individuals with a positive TB culture were part of a cluster, compared to 31.7% (95% confidence interval 23.6% to 39.8%) of individuals in 2022 (Table 9). Regionally, since 2020, a non-significant decreasing trend has been observed in the proportion of culture-confirmed individuals who formed part of a cluster.

Nationally, a decrease in the proportion of individuals with a positive TB culture who were part of a cluster from 2019 to 2023 has also been identified. The reasons for the decrease are likely to include a combination of changes in transmission patterns as a result of more importation of new strains from recent migrants and, possibly, better awareness regarding airborne transmission and how to limit this due to the COVID-19 pandemic.

Table 9.  Number of people notified, proportion with culture confirmation and proportion of notifications identified in a WGS cluster, South West, 2020 to 2023 [note 25] [note 26]

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 cluster with more than one person (%)	95% confidence interval
2020	167	116	69.5	40	34.5	26.5 to 43.5
2021	159	94	59.1	31	33.0	24.3 to 43
2022	162	104	64.2	33	31.7	23.6 to 41.2
2023	212	125	59.0	39	31.2	23.7 to 39.8
Total	700	439	62.7	143	32.6	28.4 to 37.1

Note 25: a WGS cluster is defined as 2 or more individuals that have isolates with a less than 12 SNP difference.
Note 26: 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

Incidence in the South West

In 2023, 6 children aged under 15 years were notified with TB in the South West region of England (Figure 21). This equates to a rate of 0.7 per 100,000 population (95% confidence interval 0.2 to 1.4) (Figure 21). The rate in 2023 was higher than the rate in 2022, which was 0.2 per 100,000 population (95% confidence interval 0.0 to 0.8) (Figure 22). Since 2017, there has been an overall decreasing trend in the TB notification rate amongst children aged under 15 years in the South West.

Nationally, the number of tuberculosis (TB) notifications in children aged 0 to 14 years of age in England increased by 12.1%, from 231 children in 2022 to 259 in 2023, similar to the rise observed for all TB notifications (11.0%); the notification rate in children increased from 1.9 per 100,000 in 2022 to 2.2 per 100,000 in 2023.

Figure 21. Number of TB notifications in children aged under 15 years, South West, 2001 to 2023

Figure 22. TB notification rate in children aged under 15 years, South West, 2001 to 2023 [note 27]

Note 27: error bars represent upper and lower 95% confidence intervals.

Country of birth

In 2023, data on country of birth was available for all TB notifications in children aged under 15 years in the South West. For these individuals, 50% (3 out of 6) were UK-born and 50% (3 out of 6) were non-UK-born individuals (Figure 23 and Figure 24). Amongst children aged under 15 years who were born in the UK, the annual number of TB notifications since 2001 has ranged from 0 to 9 notifications, and no significant trends in notification can be observed. Similarly, for children aged under 15 years who were not born in the UK, there were no significant trends in notification observed, with a range of 0 to 8 annual notifications.

Figure 23. Number of TB notifications in UK-born children aged under 15 years, South West, 2001 to 2023

Figure 24. Number of TB notifications in non-UK-born children aged under 15 years, South West, 2001 to 2023

From 2020 to 2023, the United Kingdom was the most frequently recorded country of birth among children aged under 15 years notified with TB in the South West (16 individuals, 80%). No other country of birth had 5 or more individual notifications among children aged under 15 years across the 2020 to 2023 time-period.

Table 10. Most common countries of birth for children aged under 15 years with TB, South West, 2020 to 2023 [note 28]

Country of birth	Number of TB notifications in children	Proportion of notifications in children (%)
United Kingdom	16	80.0

Note 28: where there are countries of birth with fewer than 5 cases, these have been suppressed.

TB treatment

Enhanced case management

The 2022 Joint Case Management tool provides standardised recommendations for enhanced case management (ECM) in individuals receiving anti-TB treatment with clinical or social complexities. Where there are social risk factors (SRFs) or MDR or RR TB, the case may be deemed ECM level 3 and require direct (DOT) or video (VOT) observed therapy, following National Institute of Health and Care Excellence (NICE) guidelines. The ECM levels are:

• ECM Level 1: people with clinical or social issues which impact on treatment, for example, children with TB, or those taking antiretrovirals
• ECM Level 2: people with complex clinical or social issues which 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 and or social issues which impact on treatment, for example, SRFs or MDR or RR TB which necessitates DOT or VOT

In 2023, data on enhanced case management was available for all individuals with TB in the South West (Table 11). 13.7% (29 out of 212) of individuals with TB were supported with ECM in 2023, with 17 individuals (8%) receiving ECM Level 1, 4 individuals (1.9%) receiving ECM Level 2 and 8 individuals (3.8%) receiving ECM Level 3. From 2021 to 2023 in the South West, the number of individuals of ECM has increased from 21 to 29, however the proportion of cases receiving any ECM has remained fairly stable.

Table 11. Number of people with TB receiving enhanced case management, South West, 2021 to 2023 [note 31]

Year	Total TB  notifications	Any ECM (number)	Any ECM (proportion)	Level 1 (number)	Level 1 (proportion)	Level 2 (number)	Level 2 (proportion)	Level 3 (number)	Level 3 (proportion)	Unknown level (number)	Unknown level (proportion)
2021	158	24	15.2	10	6.3	8	5.1	6	3.8	1	0.6
2022	162	29	17.9	9	5.6	10	6.2	10	6.2	0	0.0
2023	212	32	15.1	17	8.0	4	1.9	11	5.2	0	0.0

Note 31: ‘Total TB notifications’ includes all people notified with TB regardless of whether they are receiving ECM or not, or if this information is missing.

Treatment delays of over 2 months

The term ‘treatment delay’ describes instances where the time between TB symptom onset and initiation of treatment exceeds 2 months. For cases of pulmonary TB in 2023, data for treatment delay was available for 65.5% (78 out of 119) individuals. Of those, 62.8% (49 out of 78) had a treatment delay over 2 months (Figure 25). One case with a treatment delay of over 2 years was excluded from these figures.

Since 2020, the overall proportion of individuals with a treatment delay over 2 months has remained stable, ranging from 62.3% to 65.0% in this time period.

Figure 25. Proportion of people notified with pulmonary TB with a treatment delay over 2 months, South West, 2018 to 2023 [note 32] [note 33]

Note 32: error bars represent upper and lower 95% confidence intervals.
Note 33: delay to treatment is defined by when treatment was started from symptom onset.

Among those with extra-pulmonary disease, data for treatment delay was available for 64% (78 out of 122) of cases in the South West in 2023. Of those, 65.4% (51 out of 78) had a treatment delay over 2 months (Figure 26). Two cases were excluded from these figures due to having a treatment delay of over 2 years.

The proportion of individuals with a treatment delay of 2 months or more remained relatively constant within the 6 years prior to 2023, with a notable decrease to 42.2% in 2022. However, note that the proportion of cases with missing treatment delay information was higher in 2022 (45.1%, 37 out of 82) than in previous years.

Figure 26. Proportion of people notified with extra-pulmonary TB with a treatment delay over 2 months, South West, 2018 to 2023 [note 34] [note 35]

Note 34: error bars represent upper and lower 95% confidence intervals.
Note 35: delay to treatment is defined by when treatment was started from symptom onset.

Treatment delays: length of delay

In 2023, 24.7% (19 out of 78) and 39.0% (30 out of 78) of people notified with pulmonary TB had a treatment delay of 2 to 4 months and 4 months to 2 years respectively (Table 12).

Between 2021 and 2023, the proportion of people notified with pulmonary TB with a 2- to 4-month delay has decreased from 34.6% to 24.7%, and the proportion of those with a delay of over 4 months has increased from 32.1% to 39.0%.

Table 12. Number and proportion of people notified with pulmonary TB with a treatment delay, time between symptom onset and treatment start, South West, 2018 to 2023 [note 36]

Year	2 to 4 months delay (number)	2 to 4 months delay (proportion)	Over 4 months delay (number)	Over 4 months delay (proportion)	Total	Missing (number)	Missing (proportion)	Total eligible
2018	36	33.0	41	37.6	109	12	9.9	121
2019	33	22.1	51	34.2	149	11	6.9	160
2020	28	31.5	31	34.8	89	8	8.2	97
2021	27	34.6	25	32.1	78	17	17.9	95
2022	17	25.0	26	38.2	68	27	28.4	95
2023	19	24.7	30	39.0	77	21	21.4	98

Note 36: excludes cases diagnosed at postmortem and cases not known to have started treatment. ‘Total’ column (used to calculate delay proportions) additionally excludes ‘Missing’ cases where time from symptom onset to treatment start was unknown or missing. ‘2 to 4 month delay’ includes people with a delay of 61 to 121 days inclusive. An ‘over 4 month delay’ includes people with a delay between 122 and 730 days inclusive.

In 2023, the median treatment delay among people notified with pulmonary TB in the South West was 84 days (interquartile range: 42 to 164). Since 2018, the median treatment delay has ranged from 69 to 99 days and does not show a clear increasing or decreasing trend.

Figure 27. Median treatment delays among people notified with pulmonary TB, South West, 2018 to 2023 [note 37] [note 38] [note 39] [note 40]

Note 37: dashed line represents the target treatment delay of 56 days by 2027.
Note 38: ends of the whiskers represent the minimum and maximum values where outliers (lower or upper quartile negative or positive 1.5 times the interquartile range) have been removed.
Note 39: ‘Delay to treatment’ is defined as the time-period between symptom onset and treatment.
Note 40: excludes cases diagnosed postmortem, cases where time from symptom onset to treatment start was unknown or missing, and cases where treatment delay was over 2 years.

Timeliness of notification

According to the 2010 Health Protection (Notification) Regulations, a TB notification must be made within a mandatory statutory reporting period, defined as 3 working days following diagnosis. This proportion is calculated for pulmonary TB cases, excluding those diagnosed postmortem or with a known reporting delay of over 90 days. In 2023, 67.0% (73 out of 109) of people meeting these criteria were notified within 3 days of diagnosis in the South West (Table 13). Since 2019, there has been a general increasing trend in the proportion of people with pulmonary disease being notified within 3 days of their diagnosis.

Table 13. Proportion of people notified with pulmonary TB within 3 days of diagnosis by year, South West, 2018 to 2023 [note 41]

Year	Number of people notified within 3 days	Proportion of people notified within 3 days (%)	Total
2018	55	50.9	108
2019	67	44.7	150
2020	46	46.5	99
2021	43	45.7	94
2022	54	58.7	92
2023	73	67.0	109

Note 41: excludes cases diagnosed postmortem and those with a known reporting delay of over 90 days

Time between symptom onset and treatment

Table 14 below provides details of pulmonary TB cases in the South West, split by length of time between symptom onset and treatment, and by year.  

Data for the time between symptom onset and treatment start was available for 78.4% (77 out of 98) individuals with pulmonary TB in the South West in 2023 (excluding those with a post-mortem diagnosis or with a treatment delay of over 2 years). The number of total notifications within this group has decreased in the recent period from 2020 onwards (2015 to 2019 ranged from 121 to 160 notifications; 2020 to 2023 ranged from 94 to 98 notifications).

In 2023, 28.6% of cases had a delay of 0 to 2 months, 19.4% a delay of 2 to 4 months, and 30.6% had a delay of 4 months to 2 years between symptom onset and treatment start.  These counts and proportions are broadly similar to those observed in 2022. In the period from 2020 to 2023, counts in all 3 groups have decreased over time as there appears to be an increased proportion of cases with missing data.

In 2023, the median time between symptom onset and treatment was 84 days (interquartile range: 42.5 to 166.2 range), which falls within the 2 to 4 month category. The median time between onset and treatment has notably decreased since 2018 and has ranged from 84.0 to 87.0 days since 2020.

Table 14. Time between symptom onset and treatment start in people with pulmonary TB, South West, 2015 to 2023 [note 42]

Year	0 to 2 months (number)	0 to 2 months (proportion)	2 to 4 months (number)	2 to 4 months (proportion)	More than 4 months (number)	More than 4 months (proportion)	Total	Median time in days	IQR of time in days
2015	66	36.3	62	34.1	54	29.7	182	80.0	40.2 to 156.5
2016	50	34.0	43	29.3	54	36.7	147	91.0	48.5 to 165.0
2017	47	34.3	29	21.2	61	44.5	137	98.0	39.0 to 182.0
2018	32	29.4	36	33.0	41	37.6	109	99.0	52.0 to 184.0
2019	65	43.6	33	22.1	51	34.2	149	69.0	39.0 to 168.0
2020	30	33.7	28	31.5	31	34.8	89	82.0	43.0 to 153.0
2021	26	33.3	27	34.6	25	32.1	78	78.5	51.2 to 168.8
2022	25	36.8	17	25.0	26	38.2	68	92.5	35.8 to 144.2
2023	28	36.4	19	24.7	30	39.0	77	84.0	42.0 to 164.0

Note 42: excludes cases diagnosed postmortem, cases where time from symptom onset to treatment start was unknown or missing, and cases where treatment delay was over 2 years.

TB treatment outcomes

TB treatment outcomes for individuals are reported by UKHSA according to the year of their notification. People with non-severe, non-multidrug-resistant (non-MDR), or non-rifampicin-resistant (non-RR) TB have an expected treatment duration of less than 12 months. Non-severe TB is defined as tuberculosis without central nervous system (CNS) involvement, including those with cryptic disseminated or miliary disease where CNS disease cannot be reliably ruled out.

For cases with RR- or MDR-TB, treatment is expected to be longer, and outcomes are reported at 24 months. As such, as of the end of 2023, annual treatment outcome data is available for non-MDR or non-RR cases without CNS disease notified up until 2022, and for MDR or RR cases notified up to 2021.

Non-severe TB treated as non-MDR and non-RR TB

Twelve-month treatment outcomes for cases of non-severe TB treated as non-MDR and non-RR, diagnosed in 2022, are shown in Table 15. Data on treatment outcome was available for 85.2% (138 out of 162) of cases. Of those, 70.3% had completed treatment, 4.3% had died, 4.3% were lost to follow-up, 0.7% were still on treatment, 3.6% had stopped treatment and 16.7% had not had their 12-month treatment outcome evaluated.

Table 15. 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, South West, 2022 [note 43] [note 44]

Outcome	TB treatment outcome at 12 months (number)	TB treatment outcome at 12 months (proportion)	Last recorded treatment outcome (number)	Last recorded treatment outcome (proportion)
Treatment completed	97	70.3	105	76.1
Died	6	4.3	7	5.1
Lost to follow-up	6	4.3	6	4.3
Still on treatment	1	0.7	1	0.7
Treatment stopped	5	3.6	6	4.3
Not evaluated	23	16.7	13	9.4
Total	138	100.0	138	100.0

Note 43: not evaluated indicates that the treatment outcome was coded as ‘not evaluated’, ‘not recorded’ or ‘unknown’ and the final outcome was not ‘still on treatment’ nor ‘died’.
Note 44: excludes severe and MDR or RR TB cases as well as those diagnosed postmortem.

In 2022, 70.3% (97 out of 138) cases with non-severe, non-MDR, and non-RR TB completed treatment within 12 months, which is a year-on-year decrease compared with 2020 (83.8%, 109 out of 130) and 2021 (76.7%, 112 out of 146). The 2022 proportion is below the TB Action Plan target of 90% and was the lowest observed proportion having completed treatment in the past 5 years.

Figure 28. Proportion of people with non-severe, non-MDR, non-RR TB who completed treatment within 12 months compared with TB Action Plan targets, South West, 2018 to 2022 [note 45] [note 46]

Note 45: dashed line indicates treatment target of 90%.
Note 46: error bars represent upper and lower 95% confidence intervals.

Since 2020, the proportion of people treated for non-MDR or non-RR TB without severe disease and with one or more social risk factors who completed treatment at 12 months has shown a decreasing trend, from 92% (23 out of 25) in 2020 to 59.1% (13 out of 22) in 2022.

Figure 29. Proportion of people with non-severe TB treated for non-MDR or non-RR TB with one or more social risk factors, who completed treatment within 12 months, South West, 2018 to 2022 [note 47]

Note 47: error bars represent upper and lower 95% confidence intervals.

People with non-MDR or non-RR TB who do not complete treatment after 12 months typically fall into one of 4 broad categories: death, loss to follow-up, ongoing treatment, and treatment cessation. Compared with 2021, there have been increases observed in those lost to follow-up and those with treatment stopped in 2022 amongst people with non-MDR or non-RR with non-severe disease in the South West (Figure 30).

Figure 30. Outcomes of people with non-MDR or non-RR TB who were evaluated but did not complete treatment by 12 months, South West, 2013 to 2022

Figure 31. Proportion of people with non-MDR or non-RR TB with death as their last recorded treatment outcome and had an expected treatment duration of less than 12 months, South West, 2017 to 2022 [note 48] [note 49] [note 50]

Note 48: death could be due to TB or any other cause.
Note 49: does not include individuals with CNS, spinal, cryptic or miliary TB.
Note 50: error bars represent upper and lower 95% confidence intervals.

Table 16 refers to individuals with an expected treatment duration of 12 months or less and compares the outcomes of those notified with TB in the last 10 years. The total number of individuals with any treatment outcome recorded has declined by 56% between 2013 and 2022. Similar 10 year decreases can be observed among individual outcome categories, including a 59% decrease in individuals having completed treatment, a 45% decrease in treatment completion among those with social risk factors, a 65% decrease in TB deaths, a 60% decrease in those lost to follow-up, and a 94% decrease among individuals continuing treatment beyond 12 months.

Taking decreased case counts into account, the relative proportions of individuals in each treatment outcome category have largely remained stable within the last 10 years (Table 17). However, 2022 marked the year with the lowest proportion of treatment completion (69.9%) since 2013, and the highest proportions of treatment cessation before completion (3.8%) and non-evaluation (16.5%). These trends have worsened since the beginning of the COVID-19 pandemic in 2020 and may reflect increased capacity demands among TB case managers. 2022 additionally featured the lowest proportion of those continuing treatment beyond one year (0.8%).

Table 16. TB outcome at 12 months for people with non-severe TB treated as non-RR and non-MDR-TB, South West, 2013 to 2022 [note 51]

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	229	24	17	15	17	2	20	300
2014	221	15	22	19	23	2	4	291
2015	198	23	12	12	15	6	3	246
2016	174	21	8	11	8	3	5	209
2017	167	20	15	8	8	3	3	204
2018	127	14	11	8	10	2	4	162
2019	164	22	8	10	3	6	16	207
2020	109	23	5	3	2	0	11	130
2021	112	12	9	3	2	1	19	146
2022	97	13	6	6	1	5	23	138

Note 51: not evaluated indicates that the treatment outcome was coded as ‘not evaluated’, ‘not recorded’ or ‘unknown’ and the final outcome was not ‘still on treatment’ nor ‘died’ within the timeframe of 12 months. Cases where treatment outcome was null were excluded. Data does not include severe TB cases (CNS, spinal, cryptic or miliary TB).

Table 17. Proportions of TB outcomes at 12 months for people with non-severe TB treated as non-RR and non-MDR-TB, with expected treatment duration of less than 12 months, South West, 2013 to 2022 [note 52]

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	76.3	8.0	5.7	5.0	5.7	0.7	6.7
2014	75.9	5.2	7.6	6.5	7.9	0.7	1.4
2015	80.5	9.3	4.9	4.9	6.1	2.4	1.2
2016	83.3	10.0	3.8	5.3	3.8	1.4	2.4
2017	81.9	9.8	7.4	3.9	3.9	1.5	1.5
2018	78.4	8.6	6.8	4.9	6.2	1.2	2.5
2019	79.2	10.6	3.9	4.8	1.4	2.9	7.7
2020	83.8	17.7	3.8	2.3	1.5	0.0	8.5
2021	76.7	8.2	6.2	2.1	1.4	0.7	13.0
2022	70.3	9.4	4.3	4.3	0.7	3.6	16.7

Note 52: not evaluated indicates that the treatment outcome was coded as ‘not evaluated’, ‘not recorded’ or ‘unknown’ and the final outcome was not ‘still on treatment’ nor ‘died’ within the timeframe of 12 months. Cases where treatment outcome was null were excluded. Data does not include severe TB cases (CNS, spinal, cryptic or miliary TB).

Non-RR and non-MDR severe TB

In 2022, treatment was recorded as completed for 56% (5 out of 9) of non-RR or non-MDR severe TB cases, with the outcome not evaluated for the other 4 (Table 18).

Table 18. Outcome at 12 months for people with rifampicin-sensitive, CNS, miliary or cryptic disseminated disease, South West, 2022 [note 53]

Outcome at 12 months	Number of TB notifications	Proportion of TB notifications
Treatment completed	5	55.6
Not evaluated	4	44.4
Total	9	100.0

Note 53: excludes cases where rifampicin sensitivity is not known. Not evaluated indicates that the treatment outcome was coded as ‘not evaluated’, ‘not recorded’ or ‘unknown’ and the final outcome was not ‘still on treatment’ nor ‘died’ within the timeframe of 12 months.

TB prevention

Contact tracing remains a cornerstone of TB management and prevention by interrupting chains of transmission and reducing the overall burden of disease. Contact tracing has 3 main objectives:

• identification of individuals with undiagnosed active TB
• testing to identify people with latent infection followed by chemoprophylaxis to prevent development of active disease
• vaccination with Bacillus Calmette-Guérin (BCG) of those eligible

Assessment and screening of close contacts should be undertaken in line with National Institute for Health and Care Excellence (NICE) guidance.

There is evidence that treating latent infection with chemoprophylaxis is safe and prevents progression to active disease, reducing morbidity and mortality for the individual and further spread of TB into the population.

Number of contacts per case notified with pulmonary TB

Table 19 summarises contact tracing metrics for 119 cases notified with pulmonary TB (index individuals) in the South West in 2023. The median number of contacts for these cases was 2.0, and  17.6% (21 cases) had 5 or more contacts identified and screened for active or latent TB. The median number of contacts for female cases (3 contacts) was slightly higher than for male cases (2 contacts) and higher for those with at least one social risk factor (4.5 contacts) compared to those with none (2 contacts).

Overall, contact information had been entered for 78.2% of pulmonary cases, meaning that contact information was not available for 1 in 5. This proportion was lower in cases with one or more social risk factors, where data was only available for 66.7% of cases, meaning data was unavailable for 1 in 3.

Table 19. Contact tracing information for people with pulmonary TB by demographic and disease characteristics, South West, 2023 [note 54] [note 55]

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	119	93	78.2	21	17.6	2.0	1.0 to 6.0
Female	53	40	75.5	11	20.8	3.0	1.0 to 7.5
Male	66	53	80.3	10	15.2	2.0	1.0 to 4.0
Adults	117	91	77.8	21	17.9	2.0	1.0 to 6.0
Non-UK-born	84	67	79.8	15	17.9	2.0	1.0 to 5.2
UK-born	34	26	76.5	6	17.6	2.0	1.0 to 6.0
No social risk factor	89	73	82.0	12	13.5	2.0	1.0 to 4.0
At least 1 social risk factor	30	20	66.7	9	30.0	4.5	1.0 to 10.8
Non-MDR or RR TB	117	91	77.8	20	17.1	2.0	1.0 to 5.5

Note 54: 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 55: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of routine contact tracing.

Over the past 5 years, the proportion of pulmonary TB cases where contact tracing information had been entered, where at least 5 contacts have been reported, has shown no clear trend and remains well below the target of 50%. In 2023, 22.6% of cases (21 out of 93) reported 5 or more contacts, slightly lower than the previous year (25.5%, 24 out of 94).

Figure 32. Proportion of people notified with pulmonary TB with at least 5 contacts identified and screened for active and latent TB by year, South West, 2018 to 2023 [note 56] [note 57]

Note 56: error bars represent upper and lower 95% confidence intervals.
Note 57: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

Contact characteristics

In 2023, 429 individuals were identified as contacts of people with pulmonary TB in the South West (Table 20). Of these, 22.8% (98 out of 429) were children and 77.2% (331 out of 429) were adults. Among all contacts, 74.6% (320 out of 429) individuals were screened for active and latent TB; this includes 69.4% (68 out of 98) of child contacts and 76.1% (252 out of 331) of adult contacts.

Amongst those screened, 2.2% of individuals had active TB (7 out 320) and 11.9% had latent TB (38 out of 320). A higher proportion of children were diagnosed with active TB (5.9%, 4 out of 68) compared to adults (1.2%, 3 out of 252). This was also the case for latent TB, which was diagnosed in 14.7% of children (10 out of 68) and 11.1% of adults (28 out of 252).

For contacts with latent TB, 76.3% (29 out of 38) started treatment for latent TB, including 80% of child contacts (8 out of 10) and 75% of adult contacts (17 out of 21). Overall, 63.2% (24 out of 38) completed treatment, with a higher proportion completing treatment amongst children (70%, 7 out of 10) than adults (60.7%, 17 out of 21).

Table 20. Number of contacts identified, screened, screening results and treatment for contacts of people notified with pulmonary TB (index individuals), South West, 2023 [note 58]

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	331	Not applicable	98	Not applicable	429	Not applicable
Number of contacts screened for active TB and latent TB	252	76.1	68	69.4	320	74.6
Number of contacts with active TB	3	1.2	4	5.9	7	2.2
Number of contacts with latent TB	28	11.1	10	14.7	38	11.9
Number of contacts who started treatment for latent TB	21	75	8	80	29	76.3
Number of contacts who completed treatment for latent tuberculosis	17	60.7	7	70	24	63.2

Note 58: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

In the South West in 2023, UKHSA recorded 38 close contacts of adult index individuals with latent TB, of which 24 (63.2%) completed treatment by the end of the year (Figure 33). In the same year, treatment completion was higher amongst contacts of UK-born index individuals (80%, 8 out of 10), compared with contacts of non-UK-born individuals (57.1%, 16 out of 28).

Figure 33. LTBI treatment completion in close contacts of adult or child and UK-born or non-UK-born index individuals, South West, 2023 [note 59]

Note 59: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

Proportion of TB notifications occurring within 5 years of entry to the UK

Between 2017 and 2023, place of birth was available for 1,336 people (98.7%). Of these, 816 (61.1%) people were non-UK-born, and 17 (1.3%) people had an unknown country of birth. Data was available on time since entry to the UK to diagnosis for 710 (87.0%) of non-UK-born cases. Of these, a total of 362 (44.4%) had a TB diagnosis within 5 years of entry to the UK. Between 2019 and 2023 the percentage of cases diagnosed within 5 years of entry has increased annually, increasing from 43.6% to 64.3%.

Figure 34. Proportion of TB notifications occurring within 5 years of entry to the UK for all countries of birth outside of the UK, South West, 2017 to 2023 [note 60] [note 61]

Note 60: error bars represent upper and lower 95% confidence intervals.
Note 61: within 5 years refers to a time since entry of less than 1 year to 5 years inclusive.

BCG vaccination

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.

In 2023 in the South West, BCG vaccination status was available for 40% of TB cases (85 out of 212). This is lower compared to the previous year (43.8%). Of all cases, 28.3% (60 out of 212) had received a BCG vaccination, similar to the proportion in 2022 (28.4%) (Table 21). Of those, 47 (78.3%) were non-UK-born, again similar to the 2022 figure (76.0%). Of 6 children under 15 years old, 2 (33.3%) had received a BCG vaccination and 4 (66.3%) had unknown vaccination status.

Table 21. BCG vaccination coverage among people with TB, South 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	0	1	0	1	3	33	47	161	29
UK-born	0	1	0	1	3	33	13	50	26
All cases	0	2	0	2	6	33	60	212	28

Discussion

In 2023, after 3 years, of relatively stable TB incidence, both the South West and England overall saw a notable increase. Although regional incidence remains well below that of England, the South West has observed a more rapid annual increase compared to nationally (29% compared to 11%). There continues to be notable variation in TB incidence within the South West, with 2 UTLAs in particular (Bristol and Swindon) having an incidence around 2 or more times higher than other areas. However, increased regional incidence has been driven by an increase across a number of UTLAs, indicating that continued region-wide support for TB will be critical in reducing incidence to meet the WHO 90% reduction target by 2025.

In terms of demographics, there remains a relatively even split of cases by gender, with 52.8% of cases being male, and the highest incidence seen in young- to middle-aged adults (20 to 49 years). The main driver in increased incidence this year was an increase proportion of cases who were non-UK-born, highlighting the importance of a consistent and reliable approach to TB detection and management for new entrants. The most common country of birth among TB cases born outside the UK was India (26.1% of non-UK-born cases). Compared to non-UK-born cases overall, a higher proportion of cases born in India were detected as new entrants, indicating that early screening is important more broadly to ensure cases don’t remain in the community undiagnosed.

The strong link between deprivation and TB is evident in the South West population, with TB incidence in the 2 most deprived deciles being more than twice that of those less deprived. The proportion of cases with one or more comorbidities was 15.6%, with the most common being chronic liver disease (10.8%). The proportion of cases with at least one social risk factor (19.4%) increased since last year and is the highest it has been in the last decade. Social risk factors vary significantly by age, sex and place of birth. As such different bespoke approaches for addressing TB in different population groups should be considered. At 15.1% the proportion of cases that required enhanced case management remained similar to last year. The management of complex TB situations, such as those involving health and social care settings, remains challenging in a region with limited resources. It has been noted locally that there is a need for greater focus on raising TB awareness and reducing stigma, especially in underserved populations.

For the past 3 years the proportion of pulmonary TB confirmed by culture has been below the European standard of 80% (72.3%, 86 out of 119 cases in 2023). Increasing this proportion would allow additional diagnostic testing, assisting with detection of drug resistance and WGS clusters.

Over the past 5 years, the South West Region has not managed to achieve the TB Action Plan target of 90% of people with non-severe, non-MDR, and non-RR TB completing treatment within 12 months, and at 69.9% in the most recent year (2022) was the lowest in the past 5 years. This proportion was even lower in those with one or more social risk factors (60%).  

Contact tracing and screening for latent and active TB remain key public health control measures in the prevention of TB transmission. The median number of contacts per case, and proportion of cases with 5 or more contacts, are lower in the South West than England overall. This will in part be due to reduced cluster size observed in the South West compared to some areas, but efforts to conduct contact tracing activities in the South West can also be challenging due to the limited resources available. The lower than national proportion of cases confirmed by culture will also result in fewer and smaller clusters being detected through WGS and potentially reduce the number of cases found during cluster investigations, as will regional data completeness for case contacts. Overall, contact information had been entered for 78.2% of pulmonary cases, meaning that contact information was not available for 1 in 5. This proportion was lowest in cases with one or more social risk factors, where data was only available for 66.7% of cases, meaning data was unavailable for 1 in 3. Adequate resource for administration and recording of data for effective case management and surveillance remains challenging.

Screening of TB contacts found active TB in 2.2% of individuals and latent TB in 11.9%. The higher proportion of screened children diagnosed with active (5.9%) and latent (14.7%) TB means that screening in this age group is of particular importance.

As a low prevalence area, early detection and diagnosis of TB remain a challenge. For cases of pulmonary TB for whom treatment delay data was available 62.8% (49 out of 78) reported a treatment delay of over 2 months. As this data was not available for over one third of cases, the actual proportion could vary notably.  

The South West remains an area of low TB prevalence, which comes with a range of challenges. A low clinical suspicion for TB, the need for generalist respiratory staff rather than those dedicated to TB makes rapid diagnosis and treatment of TB more challenging. Being a large, predominantly rural area, it also poses challenges for accessibility, adequate resourcing and resilience, particularly for more intensive support such as DOT and VOT. In an environment where resources are stretched, it can be challenging for staff to find time for administration and data management, which results in the under-reporting of some metrics used for surveillance and service evaluation.

Recommendations

Important recommendations for UKHSA and the NHS are derived from the data presented in this report are listed below, under the headings for the 5 key priority areas outlined in the Tuberculosis (TB): action plan for England, 2021 to 2026.

1. Recovery from COVID-19

UKHSA FS SW should continue to develop surveillance and reporting capabilities to support TB control board and Cohort Review processes, including advocating for data quality and completeness.

Facilitate appropriate use of technology for appointments and directly observed therapy (VOT or DOT).

2. Prevent TB

Work collaboratively with regional partners to develop an action plan to improve the detection and treatment of LTBI in new migrants.

Review and improve the effectiveness and delivery of communications used to increase awareness of TB in at-risk populations and healthcare workers, particularly those in primary care and emergency departments.

Improve the availability of data for contacts of cases, and facilitate effective, proportionate contact tracing and screening, including increasing the median number of contacts identified per case and the number where 5 or more contacts are identified.

Review regional research into reasons for treatment delays and investigate how this can be operationalised.

Continue to manage TB incidents and outbreaks in health care, schools, prisons and the community.

3. Detect TB

Increase the proportion of culture-confirmed cases regionally, achieving the 80% target for pulmonary disease.

Increase the number of people tested for latent TB infection (LTBI) as part of the national new entrant LTBI testing and treatment programme, to minimise the backlog of people eligible for LTBI testing.

Continue to use surveillance data and WGS diagnostic capabilities to monitor and reduce transmission of TB.

4. Control TB disease

Work to improve current 12-month completion rates, aiming for target of 90% treatment completion rates for cases with non-severe, non-MDR, and non-RR TB .

Ensure timely and complete reporting or notification by NHS teams.

5. Workforce

Work with regional partners to ensure continuation of a functional TB services in the South West during upcoming organisational restructures

Regional TB services should review the data provided by the NHSE Getting it right first time (GIRFT) review, and work with ICBs and wider stakeholders to help ensure that services are equipped to meet needs of local communities.

Appendices

Methods

Full details of the data sources and methodologies used in this report 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 South West of England, including nurses, physicians, microbiologists, scientists, outreach and social care and administrative staff. We also acknowledge colleagues at the UKHSA National Mycobacterium Reference Service for information on culture confirmation and drug-susceptibility testing.

Further thanks are due to:

• the UKHSA National TB Unit for providing the cleaned matched data set
• UKHSA Regional Data Science for developing an R package for the data analysis
• the South West Health Protection Team
• the Field Service South West team for their work supporting Tuberculosis Surveillance