West Midlands: tuberculosis in 2023

Question 1

Executive summary

Accepted Answer

In 2023, there were 580 tuberculosis (TB) case notifications for individuals resident in the West Midlands, a rate of 9.5 cases per 100,000 population (95% confidence interval (CI) 8.8 to 10.3). There was a 7% increase in TB cases between 2022 and 2023. The West Midlands has the second highest TB rate in the country after London and figures remain above the TB rate for England as a whole (8.4 per 100,000, with a 95% CI 8.2 to 8.7).

Wolverhampton local authority had the highest TB rate in the West Midlands in 2023, with 20.6 cases per 100,000. This was followed by Birmingham (18.5 per 100,000) and Coventry (17.7 per 100,000). Increases in cases were observed between 2022 and 2023 in 9 out of the 14 local authorities in the West Midlands, with increases also seen in low incidence areas.

The highest age and sex specific rates of TB in the West Midlands were recorded among men aged 20 to 29 years (22.0 per 100,000) and women aged 20 to 29 years (14.5 per 100,000).

In 2023, the majority of people with TB in the West Midlands were born outside the UK (73.2%). The number of cases born outside of the UK has increased by 14.6% between 2022 and 2023 (423 versus 369 in 2022). The number of TB notifications in the West Midlands among UK-born individuals decreased in 2023.

Among people with TB who were born outside of the UK, there was an increase in the proportion of cases that occurred in those that had been in the UK for less than 2 years prior to their diagnosis (32.4%). Although the proportion of cases that entered the UK 11 or more years ago remained slightly higher at 34.4%.

India continues to be the most common country of birth outside of the UK for people with TB. It accounts for a quarter of cases (25.4%). This was followed by Pakistan (12.6%) and Eritrea (3.5%). The number of cases from India increased between 2022 and 2023.

In 2023, 57.4% of TB cases diagnosed were pulmonary TB which is generally considered infectious. Of those, only 70.0% of pulmonary TB cases were confirmed by culture of a TB isolate, which is below the national target of 80%. Over one quarter of people with pulmonary TB in the West Midlands had a delay of more than 4 months from becoming unwell to starting treatment (29.9%). Contact tracing for pulmonary cases of TB found a median of only 3 contacts identified and screened per case.

In the West Midlands, 20.9% of TB cases reported having at least one of the named comorbidities, with diabetes being the most commonly reported (13.3%). HIV tests were offered to the majority of eligible people with TB in 2023 (98.9%), with nearly all of these receiving a test.

Treatment was completed within 12 months by 84.0% (382 out of 455) of people with non-multidrug-resistant (MDR) or non-rifampicin-resistant (RR) TB diagnosed in 2022 whose expected treatment duration was less than 12 months. This was a slight decrease compared to 2021 (85.7%) and below the 90% national standard. The most common reason for not completing treatment was the case had died (3.7%), followed by treatment being stopped (3.5%).

Of the culture-confirmed TB cases in the West Midlands, 11.2% had first line drug resistance which was an increase compared to 2022 (9.9%).

TB continued to be associated with deprivation, with higher TB case rates among residents in more deprived areas in the West Midlands. People with at least one recorded social risk factor for TB (including alcohol misuse, asylum seeker, drug misuse, homelessness, mental health needs, and prison), accounted for 17.5% of TB cases. This is a decrease from 2022 (19.5%) which was the highest proportion in recent years. In addition, 9.2% of TB cases had more than one social risk factor for TB recorded. Having a social risk factor was more common in male TB cases and those who were UK-born. In 2023, 39.8% of cases required enhanced case management.

In conclusion, the overall number of TB notifications has increased in the West Midlands. We need to renew efforts to reverse this trend and achieve the World Health Organization’s (WHO) End TB Strategy target by 2035. TB needs to remain a health priority. Importantly, this report demonstrates how the burden of TB falls on more socio-economically challenged groups. The high number of individuals with TB and social risk factors underlines the need for services to work collaboratively across the range of health and social care issues. We need to make a continued effort to support the early diagnosis of TB and deliver effective packages of TB care to maximise treatment completion and minimise transmission.

See the supplementary data for this report

Question 2

TB incidence and epidemiology

Accepted Answer

In 2023, 580 cases of tuberculosis were reported among residents in the West Midlands. This is a crude rate of 9.5 cases per 100,000 population (95% CI 8.8 to 10.3) (Figure 1). This represents an increase of 42 cases from 2022. The West Midlands had the second highest TB rate in the country after London and the rate for 2023 remained above the TB rate for England (8.5 per 100,000, with a 95% CI from 8.2 to 8.7) (Figure 2) (1).

Case numbers have been gradually declining in the West Midlands since 2012 with an increase in cases over the past few years, mirroring the national trend. There was a 7% increase in the West Midlands rate between 2022 and 2023 compared to a 9% increase in the number of people with TB in England over the same period (7.7 per 100,000 in 2022 versus 8.4 per 100,000 in 2023).

The TB notification rate in the West Midlands is currently higher than the rate required to meet the WHO End TB 2035 goal of a 90% reduction in TB incidence (2). The required rate for 2023 is 7.8 per 100,000 (Figure 3).

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

Figure 2. TB notification rates per 100,000 population per year, West Midlands, 2001 to 2023 [note 1]

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

Figure 3. Observed TB notification rate compared with required TB notification rates to meet the WHO End TB 2035 goal of 90% reduction in incidence by 2035, West Midlands, 2015 to 2023 [note 2] [note 3]

Note 2: error bars represent upper and lower 95% confidence intervals.
Note 3: dashed line represents required TB notification rates to meet the WHO End TB 2035 goal of 90% reduction in incidence by 2035.

TB case rates for upper tier local authorities (UTLAs) are presented in Figure 4. The local authority with the highest TB notification rate in 2023 was Wolverhampton where the rate of TB was 20.6 per 100,000, followed by Birmingham (18.5 per 100,000) and Coventry (17.7 per 100,000) (Figure 4 and Figure 5).

Case numbers decreased in 5 out of 14 local authorities between 2022 and 2023, with the largest reduction in numbers observed in Shropshire (-75%, 2 cases in 2023 versus 8 in 2022) followed by Dudley (-43%, 13 cases in 2023 versus 23 cases in 2022). An increase in cases was observed in 9 out of 14 local authorities between 2022 and 2023. The largest increases in cases were observed in Solihull (+100%, 10 cases in 2023 versus 5 in 2022) and Warwickshire (+83%, 33 cases in 2023 versus 18 in 2022). Herefordshire also saw a large increase (+300%, 4 cases in 2023 versus 1 in 2022) but small numbers should be interpreted with caution.

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

Note 4: the blue line represents the upper tier local authority noted and the grey lines represent the other upper tier local authorities in the region as a comparator.

Figure 5. TB notification rate by upper tier local authority of residence, West Midlands, 2023

In the West Midlands, there were more male cases (61.2%, 355 out of 580) compared to female cases in 2023 (Figure 6). Using 10-year age groups, crude rates of TB were highest for those aged 20 to 29 years for both males (22.0 per 100,000) and females (14.5 per 100,000) (Figure 7). There were more male cases than female cases in all age groups, except the 70 to 79 years and 80 years and over age groups where 50% (25 out of 50) and 54.2% (13 out of 24) were female respectively.

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

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

The rates of TB among people born outside the UK should be interpreted in the context of changes to the pre-UK entry screening policies. In 2005, the UK piloted the pre-entry screening of long-term migrants to the UK for active pulmonary TB in 15 high TB incidence countries. In 2012, this pre-entry screening was extended to all countries with a high incidence of TB (more than 40 cases per 100,000 population) (3).

In 2023, 99.7% of TB cases had a recorded country of birth, and of these, almost three-quarters (73.2%, 423 out of 578) were born outside the UK (Figure 8). In 2023, the number of TB notifications increased by 14.6% in people born outside of the UK (423 in 2023 versus 369 in 2022) and decreased by 8.3% in those that were UK-born (155 in 2023 versus 169 in 2022).

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

In 2023, the number of TB notifications were highest in the 15 to 44 years age group for both cases born outside of the UK (267 cases) and UK-born cases (66 cases) (Figure 9).

The age distribution of TB cases varied between patients born within and outside the UK. The proportion of cases that were UK-born was higher than non-UK-born in cases aged 0 to 14 years (7.7% UK-born versus 1.7% non-UK-born), 45 to 64 years (29.0% UK-born versus 19.6% non-UK-born) and 65 years and over (20.6% UK-born versus 15.6% non-UK-born). For the 15 to 44 year age group, the proportion of cases was higher in non-UK-born cases (63.1%) compared to UK-born cases (42.6%).

The number of non-UK-born cases aged 15 to 44 years has increased in 2023 compared to 2022. The numbers have remained relatively stable or decreased in the other age groupings.

In cases notified in 2023, the year of entry to the UK was reported by 84.6% (358 out of 423) of TB patients born outside the UK. Of those, the largest proportion (34.4%, 123 out of 358) had arrived in the UK 11 or more years prior to their TB diagnosis although this represents a decrease in the proportion of TB cases that had arrived 11 or more years prior compared to recent years (Figure 10). These cases could be reactivation of latent disease, although some could be new acquisitions. The second largest proportion (32.4%, 116 out of 358) had arrived in the UK less than 2 years prior to their TB diagnosis which has been increasing since 2021.

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

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

The 5 most common countries of birth for all TB cases notified in 2023 in the West Midlands were:

the United Kingdom (26.8%, 155 out of 578)
India (25.4%, 147 out of 578)
Pakistan (12.6%, 73 out of 578)
Eritrea (3.5%, 20 out of 578)
Somalia (2.9%, 17 out of 578)

These countries made up 71.3% of all cases (412 out of 578) (Table 1). The median time between entry to the UK and TB notification was the highest in people with TB born in Zimbabwe (22 years) followed by Pakistan (15 years) whilst the lowest was in people with TB born in Nigeria (1 year), followed by Eritrea (1.5 years) and Afghanistan (1.5 years).

Table 1. Most common countries of birth for people with TB and time between entry to the UK and TB notification, West Midlands, 2023 [note 5]

Country of birth	Number of people notified with TB	Proportion of people notified with TB (%)	Median time since entry to UK in years	IQR of time since entry to UK in years
United Kingdom	155	26.8	Not applicable	Not applicable
India	147	25.4	2.0	1.0 to 10.2
Pakistan	73	12.6	15.0	4.0 to 36.5
Eritrea	20	3.5	1.5	1.0 to 3.8
Somalia	17	2.9	8.0	0.8 to 18.0
Romania	15	2.6	5.0	2.5 to 7.2
Nigeria	14	2.4	1.0	0.0 to 1.2
Bangladesh	13	2.2	9.5	1.0 to 22.2
Afghanistan	11	1.9	1.5	0.0 to 13.2
Zimbabwe	11	1.9	22.0	3.0 to 22.0
Other	102	17.6	5.0	2.8 to 14.0
Total	578	100.0	Not applicable	Not applicable

Note 5: other includes all countries with fewer than 11 people notified.

When removing the UK-born cases and only looking at TB patients born outside of the UK, the 5 most common countries of birth for TB notified in 2023, were:

India (34.8%, 147 out of 423)
Pakistan (17.3%, 73 out of 423)
Eritrea (4.7%, 20 out of 423)
Somalia (4.0%, 17 out of 423)
Romania (3.6%, 15 out of 423)

You can find this information in Figure 11 and Table 2. Numbers of TB cases born in India, Eritrea, and Somalia increased compared to the previous year.

The clinical characteristics for people with TB from the most common non-UK countries of birth varied (Table 2). The median age for cases was highest in people with TB born in Pakistan (51.5 years) and lowest in people with TB born in Eritrea (27.0 years). The majority (over 50%) of the cases across each of the 5 most common countries of birth were male. In TB cases born in Eritrea, Somalia and Romania, the majority (over 50%) had pulmonary TB. In people with TB who entered the UK less than 2 years prior to their notification, over half had pulmonary TB, with the exception of India where this was 48.9% and Pakistan at 50.0%.

The 5 most common countries of birth outside of the UK make up 46.9% of all TB cases notified in 2023 in the West Midlands (272 out of 580).

Figure 11. Numbers of TB notifications for the most common countries of birth for people with TB born outside the UK, West Midlands, 2013 to 2023 [note 6]

Note 6: figure shows the top 5 countries in 2023.

Table 2. Characteristics of people with TB from the most common (non-UK) countries of birth, West Midlands, 2023

Country of birth	Number of people notified with TB	Mean age (years)	Proportion male (%)	Proportion pulmonary (includes laryngeal and miliary) (%)	Proportion with UK entry less than 2 years (%)	Proportion pulmonary of those in the UK less than 2 years (%)
India	147	41.4	59.9	44.9	39.2	48.9
Pakistan	73	51.5	61.6	49.3	20.9	50.0
Eritrea	20	27.0	85.0	80.0	50.0	66.7
Somalia	17	41.3	76.5	52.9	37.5	66.7
Romania	15	39.6	80.0	86.7	25.0	100.0

Note: proportion of those with UK entry less than 2 years is calculated out of those where an entry date was available.

In 2023, 98.5% (571 out of 580) of patients with TB had an ethnicity recorded, of which 7.5% (43 out of 571) were recorded as mixed or other. The highest number of TB notifications were in patients with a recorded Indian ethnicity which accounted for 28.6% of cases (163 out of 571), followed by the White (20.1%, 115 out of 571) and Black African ethnic groups (17.7%, 101 out of 571) (Figure 12).

Collectively, patients with a recorded South Asian ethnicity made up 47.3% of cases (270 out of 571), of which 11.1% (30 out of 270) were UK-born (Figure 13). Patients of White ethnicity made up 20.1% of cases (115 out of 571), of whom the majority (80.9%, 93 out of 115) were UK-born. Patients of Black ethnicity made up 20.0% of cases (114 out of 571 cases), of whom 13.2% (15 out of 114) were UK-born.

All ethnic groups saw small increases in the number of TB cases between 2022 and 2023 (Figure 13). The greatest increases were in the South Asian ethnic group with an increase of 16 cases, and the Black ethnic group with an increase of 15 cases.

Figure 12. Number of TB notifications in ethnic groups by place of birth (UK and non-UK-born), West Midlands, 2023 [note 7]

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

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

In 2023, site of disease was recorded for all 580 cases. The majority (57.4%, 333 out of 580) of patients had pulmonary TB disease (with or without extra-pulmonary sites) which is a similar proportion to previous years (Figure 14). People with pulmonary TB have the potential to be infectious to others. 40% of TB cases had pulmonary TB disease only (232 out of 580). In 2023, 60% (348 out of 580) of TB cases had extra-pulmonary TB disease (with or without pulmonary sites). Lymph nodes were the next most common site of disease (28.6%, 166 out of 580), of which 33.7% (56 out of 166) were intra-thoracic and 66.3% were extra-thoracic (110 out of 166). Other extra-pulmonary sites of unknown origin also make up a large proportion of cases (25.5%, 148 out of 580) (Table 3 and Table 4).

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

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All pulmonary	333	57.4
Pulmonary only	232	40.0
Miliary only	19	3.3
Laryngeal only	2	0.3

Note 8: percentages may not add up to 100 as people with TB may have more than one site of disease.
Note 9: ‘pulmonary only’ includes people notified with only pulmonary TB and therefore have not also been notified with miliary, laryngeal and/or extra-pulmonary TB.

Table 4. Number of extra-pulmonary TB notifications by site of disease, West Midlands, 2023 [note 10]

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All extra-pulmonary	348	60.0
Other extra-pulmonary	148	25.5
Extra-thoracic lymph nodes	110	19.0
Intra-thoracic lymph nodes	56	9.7
Pleural	38	6.6
Bone - spine	25	4.3
Central nervous system - meningitis	20	3.4
Gastrointestinal	20	3.4
Bone - not spine	5	0.9
Central nervous system - other	5	0.9
Genitourinary	3	0.5
Cryptic disseminated	0	0.0

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

Figure 14. Proportion of people notified with pulmonary TB, West Midlands, 2013 to 2023 [note 11]

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

Data for several comorbidities (diabetes, hepatitis B and C, chronic liver disease, chronic renal disease, and immunosuppression) is routinely collected as part of TB surveillance. In 2023, the numbers of TB cases reporting data for each of the named comorbidities varied (Table 5). Of all TB cases notified in 2023, 20.9% of TB cases reported having at least one of the named comorbidities (121 out of 580). The most commonly reported comorbidity was diabetes with 13.3% (66 out of 495) of TB cases reporting this, followed by immunosuppression (8.2%, 40 out of 487).

Table 5. Number and proportion of people with TB with comorbidities, West Midlands, 2023 [note 12]

Comorbidity	Total with data reported	Number of people notified with TB with comorbidities	Proportion of people notified with TB with comorbidities (%)	Number of people notified with TB missing comorbidity data	Proportion of people notified with TB missing comorbidity data (%)
At least one of the named comorbidities	580	121	20.9	Not applicable	Not applicable
Chronic liver disease	477	4	0.8	103	17.8
Chronic renal disease	482	12	2.5	98	16.9
Diabetes	495	66	13.3	85	14.7
Hepatitis B	472	7	1.5	108	18.6
Hepatitis C	470	8	1.7	110	19
Immunosuppression	487	40	8.2	93	16

Note 12: people with TB are reported as having at least one of the named comorbidities if any of the 6 comorbidities (chronic liver disease, chronic renal disease, diabetes, hepatitis B, hepatitis C or immunosuppression) had ‘yes’ recorded. As a result, the denominator is all notifications. This assumes that people for whom no data was recorded for individual comorbidities were a ‘no’ and may result in under-estimation.

For some patients who have TB, treatment can be more complicated because they also have HIV infection. However, both conditions can be successfully treated with a combination of antiretroviral therapy (ART) and appropriate TB antibiotic treatment (4). To optimise their outcome and reduce the risk of TB and HIV transmission to others, it is essential that all patients with TB undergo HIV testing to allow curative TB treatment and ART to be started as soon as possible.

In 2023, HIV testing status was recorded for 91.6% of TB cases (531 out of 580). HIV tests were offered, or results were already known for 98.9% (525 out of 531) of these, whilst 1.1% of cases were not offered a test (6 out of 531) (Figure 15). Of the cases that were offered a test, 91.8% received a test (482 out of 525) and 2.7% (14 out of 525) did not receive the test. The proportion of people with TB that were offered a test increased in 2023.

Figure 15. Proportion of people with TB offered an HIV test by year, West Midlands, 2018 to 2023 [note 13] [note 14]

Note 13: dashed line indicates target of 100% of people offered HIV test.
Note 14: error bars represent upper and lower 95% confidence intervals.

Data for social risk factors (alcohol misuse, asylum seeker status, drug misuse, homelessness, mental health needs, and prison) is routinely collected as part of TB surveillance. In 2023 in the West Midlands, 17.5% of TB cases aged 15 years or over reported at least one social risk factor (98 out of 561) and 9.2% of TB cases reported having more than one social risk factor (46 out of 501) (Table 6). The most common social risk factor reported was current alcohol misuse (7.1%, 35 out of 492) and current or previous drug misuse (7.1%, 35 out of 491), followed by prison (6.2%, 30 out of 484).

The prevalence of social risk factors decreased in 2023 (17.5%, 98 out of 561) compared to 2022 where 19.5% (101 out of 519) reported at least one social risk factor (Table 7, Figure 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	561	98	17.5	Not applicable	Not applicable
More than one social risk factor	501	46	9.2	60	10.7
Alcohol misuse (current)	492	35	7.1	69	12.3
Asylum seeker (current)	487	22	4.5	26	5.1
Drug misuse (current or previous)	491	35	7.1	70	12.5
Homelessness (current or previous)	491	24	4.9	70	12.5
Mental health needs (current)	480	22	4.6	81	14.4
Prison (current or previous)	484	30	6.2	77	13.7

Note 15: people with TB are reported as having at least one of the named social risk factors if any of the 6 social risk factors (current alcohol misuse, current or a history of homelessness, drug misuse, imprisonment, current asylum seeker status and current mental health needs) had ‘yes’ recorded. As a result, the denominator is all notifications. This assumes that people for whom no data was recorded for individual social risk factors were a ‘no’ and may result in under-estimation.

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

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	91	9.6	945
2014	66	8.8	749
2015	84	12.5	670
2016	70	10.1	694
2017	83	13.1	635
2018	95	16.0	593
2019	98	17.8	552
2020	58	11.0	528
2021	101	18.6	542
2022	101	19.5	519
2023	98	17.5	561

Note 18: not all social risk factors were captured before 2021 and that this table includes people with no information recorded in the denominator.

In 2023, male TB cases were more likely to report all social risk factors compared to female TB cases (Table 8). In males, alcohol misuse was most common (10.1%), and in females drug misuse was most common (3.1%).

Experience of social risk factors varied by age group. Drug misuse was the most common social risk factor reported by TB cases aged between 15 and 44 years (8.2%). For those aged between 45 and 64 years alcohol misuse was reported most (16.1%), with prison or alcohol misuse most common among those aged 65 years and older (2.3%).

UK-born TB cases were more likely to report all social risk factors compared to non-UK-born, with the exception of asylum seeker status. For TB cases born outside the UK the most commonly reported social risk factor was seeking asylum (5.6%), and for UK-born TB cases drug misuse was most common (21.6%).

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	6	3.1	5	2.6	3	1.5	1	0.5	4	1.9	5	2.6
Male	29	9.8	30	10.1	21	7.1	29	10.0	18	5.6	17	5.9
Aged 15 to 44	24	8.2	15	5.1	14	4.8	18	6.2	22	6.9	13	4.6
Aged 45 to 64	10	9.1	18	16.1	9	7.9	10	9.2	0	0.0	9	8.0
Aged 65 or older	1	1.1	2	2.3	1	1.1	2	2.3	0	0.0	0	0.0
Non-UK-born	8	2.2	12	3.3	15	4.1	12	3.3	22	5.6	6	1.7
UK-born	27	21.6	23	18.5	9	7.4	18	14.8	0	0.0	16	13.3
Unemployed	16	7.3	24	10.8	11	5.0	18	8.3	12	4.9	12	5.6

Based on the Index of Multiple Deprivation (IMD 2019) deciles assigned to geographical areas in the West Midlands, the deprivation decile with the highest rate of TB was decile 1 (21 per 100,000), followed by deciles 2 (17.8 per 100,000), 3 (10.7 per 100,000), and 4 (7.3 per 100,000) (Figure 17). As in previous years, generally there is a higher TB case rate among residents in more deprived areas in the West Midlands.

Figure 17. TB notification rate by deprivation decile, West Midlands, 2023 [note 19]

Note 19: error bars represent upper and lower 95% confidence intervals.

Question 3

TB diagnosis, microbiology and drug resistance

Accepted Answer

In 2023, 56.9% (330 out of 580) of people with TB in the West Midlands had their diagnosis culture-confirmed. For pulmonary TB cases, 70.0% (233 out of 333) were confirmed by culture of a TB isolate which is lower than the 80% target (Figure 18). This proportion is consistent with previous years, though represents a decrease from last year following a slight increase in 2022 where 72.0% (224 out of 311) of pulmonary TB cases were culture-confirmed.

Figure 18. Proportion of people notified with pulmonary TB who were culture-confirmed, West Midlands, 2017 to 2023 [note 20] [note 21]

Note 20: dashed line indicates target of 80% culture confirmation.
Note 21: error bars represent upper and lower 95% confidence.

There are several groups of TB antibiotics, and resistance to TB antibiotic drugs may occur to one or more of these drugs and in different combinations. A distinction is made between first, second and third line TB antibiotic drugs depending upon their clinical effectiveness (5). First line drugs include rifampicin, isoniazid, pyrazinamide and ethambutol. Second line drugs include injectable agents (for example, amikacin, capreomycin, kanamycin), fluoroquinolones (for example, moxifloxacin, ofloxacin, ciprofloxacin) and other oral bacteriostatic agents. Multi-drug-resistant cases (MDR-TB) are initially resistant to at least isoniazid and rifampicin. Extensively drug-resistant TB cases (XDR-TB) are both MDR and resistant to at least one injectable agent, one of which must be a fluoroquinolone (6).

In 2023, of the 330 TB patients confirmed by culture, 94.8% (313 out of 330) received first line drug results (Figure 19). This proportion is a decrease compared to previous years. Of the 330 culture-confirmed TB cases in the West Midlands, 11.2% (37 out of 330) had initial resistance to at least one first line drug (Figure 20). This is an increase compared to last year where 9.9% (30 out of 304) of culture-confirmed TB cases had resistance to at least one first line drug.

Figure 19. Proportion of people culture-confirmed with TB with first line drug results, West Midlands, 2017 to 2023 [note 22]

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

Figure 20. Proportion of people notified with culture-confirmed TB with initial resistance to any first line drug, West Midlands, 2017 to 2023 [note 23]

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

TB cases are assigned to whole genome sequencing (WGS) clusters when 2 or more individuals have isolates with less than 12 single nucleotide polymorphisms (SNP) difference. In 2023, 35.5% (117 out of 330) of culture-confirmed TB cases were identified in a cluster with more than one other person by WGS (Table 9). The number of TB cases identified as being part of a cluster is similar to the proportion in 2020 where 40.7% (129 out of 317) of people with culture-confirmed TB were in a WGS cluster.

Table 9. Number of people notified, proportion with culture confirmation and proportion of notifications identified in a WGS cluster, West Midlands, 2020 to 2023 [note 24] [note 25]

Year	Total TB notifications	Number of notifications cultured	Proportion of notifications cultured	Number of culture-confirmed notifications identified in a cluster with more than one person	Proportion of culture-confirmed notifications identified in a cluster with more than one person (%)	95% confidence interval
2020	541	317	58.6	129	40.7	35.4 to 46.2
2021	563	332	59.0	166	50.0	44.7 to 55.3
2022	538	304	56.5	123	40.5	35.1 to 46.1
2023	580	330	56.9	117	35.5	30.5 to 40.8
Total	2,222	1,283	57.7	535	41.7	39 to 44.4

Note 24: a WGS cluster is defined as 2 or more individuals that have isolates with a less than 12 SNP difference.
Note 25: WGS cluster reporting has changed over time. These changes are likely to have affected the most recent year’s data.

Question 4

TB in children: incidence, epidemiology and microbiology

Accepted Answer

In 2023 in the West Midlands, there were 19 cases of TB in children aged under 15 years, this represents a TB case rate of 1.7 per 100,000 in this age group (Figure 21 and Figure 22). The rate of TB in children aged under 15 years in the West Midlands has decreased overall between 2001 and 2023.

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

Figure 22. TB notification rate in children aged under 15 years, West Midlands, 2001 to 2023 [note 26]

Note 26: error bars represent upper and lower 95% confidence intervals.

In 2023, 12 (63.2%, 12 out of 19) of the TB cases in children aged under 15 years were born in the UK. Between 2001 and 2023 there has been an overall decrease in the number of TB cases aged under 15 years that are born in the UK. There were also 7 (36.8%, 7 out of 19) TB cases in children under 15 years who were born outside of the UK. This was a slight increase when compared to 2022. The most common country of birth for children under 15 years with TB was the United Kingdom (63.2%, 12 out of 19), other countries of birth had less than 5 cases.

In 2023, 84.2% (16 out of 19) of children aged under 15 years with TB had pulmonary TB with or without extrapulmonary sites, and 5.3% (1 out of 19) had severe TB. Severe TB includes cases with CNS, spinal, cryptic and miliary TB.

Question 5

TB treatment

Accepted Answer

The Royal College of Nursing TB case management tool provides standardised recommendations for enhanced case management (ECM) in individuals receiving anti-TB treatment with clinical or social complexities.

In 2023, 39.8% of TB cases (231 out of 580) in the West Midlands received Enhanced Case Management (ECM) (Table 10). There was a similar proportion of TB cases receiving each level of ECM with the highest proportion receiving level 3 ECM (14.7%, 85 out of 580). In 2023, the proportion of cases receiving ECM was lower than 2022, where 42.4% of TB cases (228 out of 538) received any ECM. Information on ECM was not recorded for one TB case.

Table 10. Number of people with TB receiving enhanced case management, West Midlands, 2021 to 2023 [note 31]

Year	Total TB notifications	Any ECM (number)	Any ECM (proportion)	Level 1 (number)	Level 1 (proportion)	Level 2 (number)	Level 2 (proportion)	Level 3 (number)	Level 3 (proportion)	Unknown level (number)	Unknown level (proportion)
2021	563	174	30.9	35	6.2	47	8.3	92	16.3	0	0.0
2022	538	228	42.4	60	11.2	54	10.0	114	21.2	0	0.0
2023	580	231	39.8	80	13.8	65	11.2	85	14.7	1	0.2

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

Treatment delay is defined as the time from symptom onset to treatment start. Information on delay was calculated for 80.4% (254 out of 316) of pulmonary TB cases who did not have a postmortem diagnosis. In 2023, 58.3% (148 out of 254) of pulmonary TB cases had a treatment delay of over 2 months (Figure 23).

Between 2018 and 2023 there has been an overall increase in the percentage of pulmonary TB patients starting treatment more than 2 months after symptom onset. In 2018, 50.3% (165 out of 328) of pulmonary TB cases started treatment over 2 months after symptom onset.

Figure 23. Proportion of people notified with pulmonary TB with a treatment delay over 2 months, West Midlands, 2018 to 2023 [note 32] [note 33]

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

In 2023, 28.4% (72 out of 254) of pulmonary TB cases started treatment with a 2 to 4 month delay (61 to 121 days), and 29.9% (76 out of 254) started treatment more than 4 months (122 to 730 days) after symptom onset, indicating a prolonged period of infectiousness (Table 11). These proportions were a decrease compared to the previous year. The time between symptom onset and treatment start was unknown or missing in 19.6% (62 out of 316) of pulmonary TB cases.

Table 11. Number and proportion of people notified with pulmonary TB with a treatment delay, time between symptom onset and treatment start, West Midlands, 2018 to 2023 [note 36]

Year	2 to 4 months delay (number)	2 to 4 months delay (proportion)	Over 4 months delay (number)	Over 4 months delay (proportion)	Total	Missing (number)	Missing (proportion)	Total eligible
2018	92	28.0	73	22.3	328	19	5.5	347
2019	97	31.3	96	31.0	310	11	3.4	321
2020	72	29.0	85	34.3	248	7	2.7	255
2021	92	33.3	94	34.1	276	19	6.4	295
2022	87	33.9	82	31.9	257	46	15.2	303
2023	72	28.3	76	29.9	254	62	19.6	316

Note 36: all people included in this table are people with pulmonary TB who did not have a postmortem diagnosis and it was known that they had started treatment. People included within the ‘Total’ includes these individuals and where the time from symptom onset to treatment start was also known. ‘Total eligible’ includes people in ‘Total’ plus those people where the time from symptom onset to treatment start was unknown 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.

In 2023, the median treatment delay for pulmonary TB cases was 76 days (interquartile range (IQR) 38 to 136) (Figure 24). This was lower when compared to last year where the median treatment delay was 84 days for cases with pulmonary TB. This is above the target treatment delay of achieving a median of 56 days delay by 2027 (7).

Figure 24. Median treatment delays among people notified with pulmonary TB, West Midlands, 2018 to 2023 [note 37] [note 38] [note 39] [note 40]

Note 37: dashed line represents the target treatment delay of 56 days by 2027.
Note 38: ends of the whiskers represent the theoretical lower and upper limits for detecting outliers (lower or upper quartile negative or positive 1.5 times the interquartile range). Outliers falling outside of these limits have been removed.
Note 39: delay to treatment is defined by when treatment was started from symptom onset.
Note 40: all people included in this figure are people with pulmonary TB who did not have a postmortem diagnosis and it was known that they had started treatment. It excludes individuals with a delay over 730 days.

Question 6

TB treatment outcomes

Accepted Answer

For the purposes of TB outcome reporting, drug-sensitive cases are defined as sensitive to rifampicin. Under this definition, cases with resistance to isoniazid, ethambutol or pyrazinamide but sensitive to rifampicin are included in the drug-sensitive cohort. Drug-resistant strains are defined as those with resistance to rifampicin and cases with suspected rifampicin-resistance (RR) (initial or acquired) including non-culture-confirmed patients treated for presumptive MDR-TB (6).

For the drug-sensitive cohort, patients with an expected duration of treatment less than 12 months, outcomes at 12 months are reported. This group excludes individuals with central nervous system (CNS) disease, spinal, cryptic disseminated or miliary disease where expected treatment durations are longer. Treatment outcomes for patients with CNS, spinal, cryptic disseminated or miliary disease are reported separately.

Among people notified in 2022, 84.0% (382 out of 455) of non-MDR or non-RR TB cases with an expected treatment duration of less than 12 months had completed treatment at 12 months (Table 12). This proportion is a slight decrease compared to 2021 (85.7%) and remains below the target of 90% (Figure 25).

There were 73 TB cases who were recorded as not completing treatment at 12 months. The most common reason for not completing treatment at 12 months was the case had died (3.7%, 17 out of 455), followed by treatment being stopped 3.5% (16 out of 455). There were also 21 cases where treatment outcome was not evaluated, not recorded or is unknown at 12 months

At the last recorded outcome, a further 22 cases had completed treatment, bringing completion to 88.8% (404 out of 455). There was an additional 2 cases (2.4%, 11 out of 455) that were lost to follow up and 1 further case (4.0%, 18 out of 455) that had died.

Table 12. Treatment outcome at 12 months and last recorded outcome for people notified in 2022 with non-MDR or non-RR TB with expected treatment duration less than 12 months, West Midlands, 2022 [note 43] [note 44]

Outcome	TB treatment outcome at 12 months (number)	TB treatment outcome at 12 months (proportion)	Last recorded treatment outcome (number)	Last recorded treatment outcome (proportion)
Treatment completed	382	84.0	404	88.8
Died	17	3.7	18	4.0
Lost to follow up	9	2.0	11	2.4
Still on treatment	10	2.2	2	0.4
Treatment stopped	16	3.5	16	3.5
Not evaluated	21	4.6	4	0.9
Total	455	100.0	455	100.0

Figure 25. Proportion of people with non-severe TB treated for non-MDR or non-RR TB who completed treatment within 12 months compared with the target of 90%, West Midlands, 2018 to 2022 [note 44] [note 46] [note 47]

Note 44: table does not include people notified with CNS, spinal, cryptic and/or miliary TB or people notified with a postmortem diagnosis of TB.
Note 46: dashed line indicates treatment target of 90%.
Note 47: error bars represent upper and lower 95% confidence intervals.

Among those notified in 2022, there were 82 non-MDR or non-RR TB cases without CNS disease with one or more social risk factors, and of these 84.1% (69 out of 82) had completed treatment at 12 months (Figure 26). This was a similar proportion compared to the last few years, however represents an overall increase since 2018 when 74.7% (65 out of 87) of cases with social risk factors had completed treatment at 12 months.

Note 44: table does not include people notified with CNS, spinal, cryptic and/or miliary TB or people notified with a postmortem diagnosis of TB.
Note 45: error bars represent upper and lower 95% confidence intervals.

In the West Midlands, of those notified in 2022, 2.0% (9 out of 455) were lost to follow up at 12 months, this was a slight increase compared to 2021 (1.8%, 9 out of 497) (Figure 27).

The proportion that had stopped treatment at 12 months increased in 2022 (3.5%, 16 out of 455) compared to 2021 (2.8%, 14 out of 497).

In 2022, 3.7% (17 out of 455) of TB cases died before completing treatment, this was a small decrease compared to the previous year (5.6%, 28 out of 497) (Figure 27).

In 2022, there were also 2.2% (10 out of 455) of cases still on treatment at 12 months which was a decrease compared to 2021 where 2.6% (13 out of 497) remained on treatment.

Figure 27. Outcomes of people evaluated who did not complete treatment by 12 months for people with non-MDR or non-RR TB and expected treatment duration of less than 12 months, West Midlands, 2013 to 2022

Table 13. TB outcome at 12 months for people with non-RR or MDR-TB with expected treatment duration of within 12 months, West Midlands, 2013 to 2022 [note 52]

Year	Treatment completed (number)	Treatment completed with any social risk factor (number)	Died (number)	Lost to follow up (number)	Still on treatment (number)	Treatment stopped (number)	Not evaluated (number)	Total (number)
2013	750	64	29	31	29	12	1	852
2014	584	45	44	26	20	10	0	684
2015	515	62	34	23	34	9	1	616
2016	549	51	36	23	24	6	2	640
2017	515	61	29	12	23	6	1	586
2018	479	65	31	15	17	7	9	558
2019	451	71	23	10	17	10	12	523
2020	396	43	26	14	18	8	13	475
2021	426	66	28	9	13	14	7	497
2022	382	69	17	9	10	16	21	455

Note 52: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not ‘still on treatment’ or ‘died’ within the timeframe of 12 months. Data includes all sites except cases with CNS, spinal, cryptic or miliary TB.

Table 14. Proportions of TB outcomes at 12 months for people with non-RR or MDR-TB with expected treatment duration of less than 12 months, West Midlands, 2013 to 2022 [note 53]

Year	Treatment completed (proportion)	Treatment completed with any social risk factor (proportion)	Died (proportion)	Lost to follow up (proportion)	Still on treatment (proportion)	Treatment stopped (proportion)	Not evaluated (proportion)
2013	88.0	7.5	3.4	3.6	3.4	1.4	0.1
2014	85.4	6.6	6.4	3.8	2.9	1.5	0.0
2015	83.6	10.1	5.5	3.7	5.5	1.5	0.2
2016	85.8	8.0	5.6	3.6	3.8	0.9	0.3
2017	87.9	10.4	4.9	2.0	3.9	1.0	0.2
2018	85.8	11.6	5.6	2.7	3.0	1.3	1.6
2019	86.2	13.6	4.4	1.9	3.3	1.9	2.3
2020	83.4	9.1	5.5	2.9	3.8	1.7	2.7
2021	85.7	13.3	5.6	1.8	2.6	2.8	1.4
2022	84.0	15.2	3.7	2.0	2.2	3.5	4.6

Note 53: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not ‘still on treatment’ or ‘died’ within the timeframe of 12 months. Data includes all sites except cases with CNS, spinal, cryptic or miliary TB.

Table 15. Outcome at 12 months for people with rifampicin-sensitive, CNS, miliary or cryptic disseminated diseases, West Midlands, 2022 [note 51]

Outcome at 12 months	Number of TB notifications	Proportion of TB notifications
Treatment completed	18	52.9
Died	6	17.6
Still on treatment	1	2.9
Treatment stopped	1	2.9
Not evaluated	8	23.5
Total	34	100.0

Note 51: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not still on treatment nor died.

For people with MDR and RR TB, treatment outcome is measured at 24 months, so outcomes are presented for people notified up to 2021. In 2021 in the West Midlands there were 5 patients diagnosed with RR or MDR TB that did not have CNS, spinal, cryptic or miliary TB, this was a lower number compared to 2020 (7 cases). At 24 months, 40% (2 out of 5) had completed treatment but 60% (3 out of 5) had an outcome not evaluated.

Question 7

TB prevention

Accepted Answer

In 2023 in the West Midlands, 76.9% (256 out of 333) of pulmonary TB cases had information about their contacts recorded (Table 16). In 2023, 17.4% (58 out of 333) of TB cases had 5 or more contacts identified and screened. The median number of contacts identified and screened for each pulmonary TB case was 3 (IQR 1 to 5), and this was similar for all demographic groups and disease characteristics. The proportion of people notified with at least 5 contacts identified and screened has decreased since 2022 (Figure 28).

Females were slightly more likely to have 5 or more contacts identified and screened than males (19.5% versus 16.2%).

TB cases born in the UK were more likely to have 5 or more contacts identified and screened than cases born outside the UK (19.5% versus 16.4%).

TB cases with social risk factors had a higher proportion of cases with 5 or more contacts identified and screened compared to those with no social risk factors (20.3% versus 16.5%).

Patients diagnosed with non-MDR or non-RR TB were more likely to have 5 or more contacts identified and screened than those diagnosed with MDR or RR TB (17.6% versus 0%). In the West Midlands no MDR or RR TB cases had 5 or more contacts identified and screened.

Adult TB cases were more likely to have 5 or more contacts identified and screened than child TB cases (18.1% versus 5.6%).

Table 16. Contact tracing information for people with pulmonary TB by demographic and disease characteristics, West Midlands, 2023 [note 56] [note 57]

Category	Total	Contact information entered (number)	Contact information entered (proportion)	5 or more contacts identified and screened (number)	5 or more contacts identified and screened (proportion)	Median contacts identified and screened (median)	IQR of contacts identified and screened
All people with pulmonary TB	333	256	76.9	58	17.4	3	1.0 to 5.0
Female	123	98	79.7	24	19.5	4	2.0 to 5.0
Male	210	158	75.2	34	16.2	3	0.0 to 5.0
Adults	315	242	76.8	57	18.1	3	1.0 to 5.0
Children (15 years or less)	18	14	77.8	1	5.6	0	0.0 to 3.0
Non-UK-born	219	163	74.4	36	16.4	3	1.0 to 5.0
UK-born	113	93	82.3	22	19.5	3	1.0 to 5.0
No social risk factor	254	187	73.6	42	16.5	3	1.0 to 5.0
At least 1 social risk factor	79	69	87.3	16	20.3	3	0.0 to 5.0
Non-MDR or RR TB	330	255	77.3	58	17.6	3	1.0 to 5.0
MDR or RR TB	3	1	33.3	0	0.0	4	4.0 to 4.0

Note 56: routine contact tracing information is collected from close contacts only. Individuals identified as part of an incident are collected separately and not included in this table.
Note 57: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

Figure 28. Proportion of people notified with pulmonary TB with at least 5 contacts identified and screened for active and latent TB by year, West Midlands, 2018 to 2023 [note 58] [note 59]

Note 58: error bars represent upper and lower 95% confidence intervals.
Note 59: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

There were a total of 1,070 contacts of pulmonary TB cases identified in 2023 in the West Midlands (Table 17). Of these 74.7% (799 out of 1070) were screened for active and latent TB and as a result 2.3% (18 out of 799) were diagnosed with active TB and 16.9% (135 out of 799) were diagnosed with latent TB. Of the contacts diagnosed with latent TB, 78.5% (106 out of 135) started treatment and 62.2% (84 out of 135) completed latent TB treatment.

The proportion of contacts that started and completed latent TB treatment was higher in child contacts (92.9%, 52 out of 56 started and 78.6%, 44 out of 52 completed) compared to adult contacts (68.4%, 54 out of 79 started and 50.6%, 40 out of 54 completed).

Table 17. Number of contacts identified, screened, screening results and treatment for contacts of people notified with pulmonary TB (index individuals), West Midlands, 2023 [note 60]

Treatment and screening categories	All adult contacts (number)	All adult contacts (proportion)	All child contacts (number)	All child contacts (proportion)	Total contacts (number)	Total contacts (proportion)
Number of contacts identified	789	Not applicable	281	Not applicable	1,070	Not applicable
Number of contacts screened for active TB and latent TB	573	72.6	226	80.4	799	74.7
Number of contacts with active TB	8	1.4	10	4.4	18	2.3
Number of contacts with latent TB	79	13.8	56	24.8	135	16.9
Number of contacts who started treatment for latent TB	54	68.4	52	92.9	106	78.5
Number of contacts who completed treatment for latent tuberculosis	40	50.6	44	78.6	84	62.2

Note 60: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

BCG immunisation is recommended for people at higher risk of exposure to TB, particularly to protect against serious forms of disease in infants. Those eligible are:

all infants (up to 12 months) with a parent or grandparent born in a country where incidence of TB is over 40 cases per 100,000 population per year
all infants living in an area of the UK with an incidence above 40 per 100,000 population

The timing of the neonatal BCG immunisation was changed to a 28-day immunisation programme in September 2021. This change was prompted by the addition of screening for severe combined immunodeficiency (SCID) to the routine newborn screening test at 5 days of age (8).

In 2023 in the West Midlands, 45% (261 out of 580) of all TB cases had received the BCG vaccination. There was a higher BCG vaccination coverage in TB cases born outside of the UK (46%, 196 out of 423) compared to UK-born TB cases (42%, 65 out of 155). In 2023, 47% of children under 15 years old diagnosed with TB were vaccinated (9 out of 19).

Question 8

Discussion

Accepted Answer

This report of TB in the West Midlands includes data up until the end of 2023 and provides the latest epidemiological picture of TB in the area.

TB rates have increased in the West Midlands compared to 2022 which is of concern and highlights the challenge of TB elimination and meeting the WHO End TB 2035 goal. To reverse this trend, renewed control efforts are required along with ongoing surveillance.

The West Midlands has the second highest TB rate in the country after London and figures remain above the TB rate for England as a whole. There remains variation in TB across the West Midlands with the highest rates of TB continuing to be concentrated in the large urban areas. In 2023, TB incidence increased in 9 out of 14 West Midlands UTLAs compared to 2022, including the high incidence areas of Birmingham and Wolverhampton. There were also notable increases seen in historically low incidence areas.

The number of TB cases in people who were born outside the UK continues to increase in the West Midlands with almost three-quarters of TB cases in the West Midlands born outside of the UK. India was the most common country of birth for non-UK-born cases, accounting for approximately one quarter of cases in the West Midlands which is similar to the proportion for England. There has been an increasing trend in the number of TB cases in recent migrants, particularly in the proportion of TB cases that entered the UK less than 2 years prior to their diagnosis. This increasing pattern of TB in recent migrants has also been observed nationally and is thought to reflect recent changes in migration patterns in England. A particular focus is required on this population group to optimise screening opportunities.

Over half of the TB cases in the West Midlands are pulmonary TB which is generally considered to be infectious. The proportion of pulmonary TB cases that were culture-confirmed decreased in 2023 and remained below the national target. Culture confirmation is important to ensure drug-resistant infections can be identified, and effective treatment regimens put in place and to allow WGS cluster identification.

The time between symptom onset and starting treatment for pulmonary TB patients is of concern with over one quarter of cases having a treatment delay of over 4 months. Although this has improved slightly from 2022, this delay in treatment increases the opportunity for TB transmission to others and the risk of adverse outcomes for the patient. This highlights the need for continuing programmes of awareness raising and education surrounding TB amongst communities and healthcare professionals.

TB treatment completion for drug-sensitive patients within 12 months decreased slightly in 2022 and is below the 90% treatment target. Increases were seen in the number of TB cases where treatment had been stopped which needs to be further understood.

TB is known to be associated with deprivation and that is seen in the West Midlands, with higher TB rates amongst residents in more deprived areas. TB cases often have complex health and social needs. One fifth of cases reported at least one named comorbidity with diabetes being the most reported. There has been a slight decrease in the proportion of cases reporting one or more social risk factors but this still accounted for 17.5% of cases and a further area to focus screening. The most reported risk factor was alcohol misuse and drug misuse, having a social risk factor was more commonly reported in males and those that were UK-born. Enhanced case management was required by nearly 40% of cases in the West Midlands reflecting the complexity of health and social needs and will have an impact on TB services workload.

The proportion of people notified with at least 5 contacts identified and screened decreased in 2023. Contact tracing is important for preventing further cases through identifying those at highest risk of exposure, finding people with disease earlier and also treating latent infection.

TB needs to remain a health priority for partners in the West Midlands. Certain risk groups continue to be more likely to be affected than others within the West Midlands. This underlines the need for services to work collaboratively, across the range of health and social care issues. A continued effort is needed to support the early diagnosis of TB and deliver effective packages of TB care to maximise treatment completion and minimise transmission.

Question 9

Recommendations

Accepted Answer

To reverse the increasing trend in TB there are some important themes to focus on, which are summarised in the following recommendations linked to the 5 priority areas in the TB action plan Tuberculosis (TB): action plan for England, 2021 to 2026.

1. Recovery from COVID-19

Continue and strengthen the multi-agency oversight of TB control in the West Midlands, supporting implementation of the TB action plan and identify areas for regional collaborative working.

UK Health Security Agency (UKHSA) teams should continue to monitor TB notifications and provide timely information (including more in-depth annual reports) to key local partners and services.

Continue to strengthen local TB clinical networks particularly where these were paused during the COVID-19 pandemic.

2. Prevent TB

Through multi agency working, identify opportunities to offer appropriate screening for high-risk groups such as those with social risk factors and inclusion health groups.

The increase in TB amongst recently arrived migrants suggest systems would benefit from increased focus on this population group. TB services and commissioners should identify missed opportunities for pre-entry and new migrant screening and consider best practice for screening new entrants.

3. Detect TB

Partners and TB services should try to improve early detection of TB by investigating and understanding the components that contribute to treatment delays.

TB services should continue efforts to achieve the target of 80% of pulmonary TB cases being culture-confirmed to enable WGS and the identification of clusters and drug resistance.

4. Control TB

Partners and TB services should work to understand the reduction seen in current TB treatment completion rates, identify areas for collaboration and work with system partners such as drug support services and community outreach teams, with the aim of improving treatment completion rates for TB drug-sensitive cases and meeting the 90% target.

5. Workforce

TB services should review the data provided by the NHSE commissioned Getting It Right First Time (GIRFT) TB review, and working with NHS Trust management, ICBs and wider stakeholders ensure that services are equipped to meet the needs of local communities.

Question 10

Appendix

Accepted Answer

Methods

Full details of the data sources, methodologies and a glossary of the terms used in this reports are available in the Tuberculosis in England 2024 report.

Acknowledgements

We are grateful to all those who contribute information on people with tuberculosis in the West Midlands, including nurses, physicians, microbiologists, scientists, outreach and social care and administrative staff. We also acknowledge colleagues at the UKHSA National Mycobacterium Reference Service for information on culture confirmation and drug susceptibility testing. Further thanks are due to the UKHSA National TB Unit for providing the cleaned matched data set, the West Midlands Health Protection Team and the Field Service (Midlands) team for their work supporting Enhanced Tuberculosis Surveillance.

Question 11

References

Accepted Answer

UKHSA (2024). ‘Tuberculosis in England, 2024 report’ (presenting data to end of 2023)
WHO (2015). ‘The end TB strategy’
UKHSA (2021). ‘UK pre-entry tuberculosis screening report 2020’
WHO (2025). ‘WHO consolidated guidelines on tuberculosis. Module 4: treatment and care’
Joint Formulary Committee. ‘British National Formulary 2018’ 3 October 2018
WHO (2013). ‘Definitions and reporting framework for tuberculosis – 2013 revision’
UKHSA (2021). ‘TB Action Plan for England, 2021 to 2026’
UKHSA (2021). ‘BCG vaccination programme’

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