Research and analysis

West Midlands: tuberculosis in 2024

Published 23 March 2026

Executive summary

In 2024, there were 709 TB case notifications among residents of the West Midlands, a rate of 11.5 per 100,000 population (95% CI 10.6 to 12.3). This represents a substantial increase of 131 cases from 2023 and a regional TB rate increase of 21% (2023 rate 9.5 per 100,000, 95% CI 8.7 to 10.3), compared with a 13% national increase over the same period. The West Midlands reported the second‑highest TB rate in England after London. The observed incidence remains well above the 2024 World Health Organization (WHO) ‘End TB Strategy’ goals for 2035 benchmark for the region (7.2 per 100,000), underscoring the need for sustained public health effort.

TB burden remains unevenly distributed across upper‑tier local authorities (UTLAs). In 2024, Wolverhampton recorded the highest rate (29.9 per 100,000), followed by Coventry (23.0 per 100,000) and Sandwell (20.6 per 100,000); while Birmingham accounted for the largest number of cases, with 228 notifications (rate 19.3 per 100,000). Increases occurred between 2023 and 2024 in 13 of 14 UTLAs; the steepest rises were seen in Dudley (increase of 69%, from 13 cases to 22 cases in 2024) and Telford and Wrekin (increase of 60%, from 10 cases to 16 cases in 2024). Warwickshire was the only UTLA to report a reduction. These patterns highlight broad, region‑wide increases across the West Midlands.

Consistent with national trends, more cases were diagnosed in men (62.2%) than in women and age‑specific rates were highest among young adults, particularly males aged 20 to 29 years (28.5 per 100,000) and females aged 20 to 29 years (19.3 per 100,000).

Three-quarters of TB cases in 2024 were born outside the UK (75.1%) however notifications increased for both non‑UK‑born (increase 25.2%) and UK‑born cases (increase 15.8%) compared with 2023. Among non‑UK‑born individuals, the largest proportions were diagnosed either within 2 years of arrival (31.1%) or 11+ years after arrival (31.3%), suggesting a combination of both recent infection and reactivation of latent TB infection. The 5 most common countries of birth comprised 74.7% of all notifications with India being the most common (29.9%), followed by the United Kingdom (24.9%), Pakistan (12.6%), Eritrea (4.0%) and Romania (3.4%).

In 2024, 55.4% of TB cases had pulmonary disease which has the potential for transmission of infection. TB was culture‑confirmed in 76.1% of pulmonary cases which remained below the national target of 80%. This can limit timely drug‑resistance detection and the use of whole genome sequencing (WGS) to identify transmission clusters. Over one quarter (28.7%) of pulmonary TB cases in the West Midlands experienced a delay of more than 4 months from symptom onset to starting treatment, prolonging infectiousness and reflecting potential barriers in the system. 

There has been an increase in West Midlands paediatric cases (<18 years) in 2024 corresponding to a rate of 3 per 100,000 (40 cases). Of these, 42.5% were aged between 15 and 17 years and 45% were UK‑born. Two-thirds (67.5%) of paediatric cases had pulmonary TB, raising implications for contact tracing and early detection in household and educational settings

TB incidence remained strongly associated with socioeconomic deprivation with the most deprived IMD decile (decile 1) experienced the highest TB rate (27 per 100,000). This gradient mirrors longstanding regional and national patterns. Among individuals aged 15 years and over, 13.6% reported at least one social risk factor (SRF) (including alcohol misuse, asylum seeker, drug misuse, homelessness, mental health needs, and prison). The most common SRF was current asylum seeker status (6.4%), followed by drug misuse (5.9%). SRFs were more common in men (19%) and higher in UK‑born individuals (18.4%). These patterns reflect significant social disparities in TB determinants and indicate potential challenges with access to care.

At least one comorbidity was reported in 15.9% of new TB case notifications, with diabetes being the most common (12.5%). These conditions can complicate TB management and lead to poorer outcomes, highlighting the need for integrated TB and long‑term condition pathways.

Among people notified in 2023 with drug‑sensitive, non‑severe TB and expected to complete treatment within 12 months, 84.4% had completed treatment by 12 months, which was below the 90% national target. Enhanced case management (ECM) was required for 35.4% of TB cases in 2024, a reduction from 42% in 2023 yet still reflecting the high clinical and social complexity of cases.

Initial resistance to any first‑line drug was identified in 7.9% of culture‑confirmed cases, representing an increase from 5.7% in 2023. Whole‑genome sequencing (WGS) identified 34.8% of culture‑confirmed cases as part of a genomic cluster, similar to 2023 (36.8%).

These findings demonstrate that TB must remain a West Midlands health priority, with rising TB incidence and widening inequalities. TB continues to disproportionately affect the populations experiencing social and economic inequities, highlighting the continued need for equitable, targeted and integrated public health responses and health services across the West Midlands region, working collaboratively across a range of health and social issues. There is a need for continued focus on surveillance, early diagnosis, delivery of effective packages of care, screening programmes and TB workforce capacity. These elements will be essential to reverse current trends and progress towards the WHO ‘End TB Strategy’ goals for 2035.

The data used in the figures in this report can be found in the accompanying supplementary tables.

TB incidence and epidemiology

In 2024, 709 cases of tuberculosis were reported among residents in the West Midlands, a rate of 11.5 cases per 100,000 population (95% CI 10.6 to 12.3) (Figure 1). This represents an increase of 131 cases from 2023. The West Midlands had the second highest TB rate in the country after London and the rate for 2024 was higher than the TB rate for England (9.4 per 100,000, with a 95% CI from 9.1 to 9.6) (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 21% increase in the West Midlands rate between 2023 and 2024 compared to a 13% increase in the number of people with TB in England over the same period (8.3 per 100,000 in 2023 versus 9.4 per 100,000 in 2024).

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 2024 is 7.2 per 100,000 (Figure 3).

Figure 1. Number of TB notifications per year, West Midlands, 2001 to 2024

Figure 2. TB notification rates per 100,000 population per year, West Midlands and England, 2001 to 2024 [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 2024 [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 2024 was Wolverhampton where the rate of TB was 29.9 per 100,000, followed by Coventry (23.0 per 100,000) and Sandwell (20.6 per 100,000) (Figure 4, Figure 5 and Table 1).

Case numbers decreased in 1 out of 14 local authorities between 2023 and 2024, with a reduction in numbers observed in Warwickshire (-22%, 25 cases in 2024 versus 32 in 2023). An increase in cases was observed in 13 out of 14 local authorities between 2023 and 2024. The largest increases in cases were observed in Dudley (+69.2%, 22 cases in 2024 versus 13 in 2023) and Telford and Wrekin (+60%, 16 cases in 2024 versus 10 in 2023). Shropshire also saw a large increase (+800%, 9 cases in 2024 versus 1 in 2023) but small numbers should be interpreted with caution.

Figure 4. TB notification rate per 100,000 population by UTLA of residence, West Midlands, 2001 to 2024 [note 4]

Note 4: the blue line represents the UTLA noted and the grey lines represent the other UTLAs in the region.

Figure 5. TB notification rate per 100,000 population by UTLA of residence, West Midlands, 2024

Table 1. Number of TB notifications and rate per 100,000 population by UTLA of residence, West Midlands, 2024

UTLA	Number of TB notifications	TB notification rate per 100,000 population	Lower 95% CI	Upper 95% CI
Wolverhampton	84	29.9	23.8	37.0
Coventry	85	23.0	18.4	28.5
Sandwell	73	20.6	16.2	25.9
Birmingham	228	19.3	16.8	21.9
Walsall	41	13.9	9.9	18.8
Stoke-on-Trent	37	13.7	9.6	18.9
Telford and Wrekin	16	8.2	4.7	13.3
Dudley	22	6.6	4.2	10.0
Solihull	14	6.3	3.5	10.6
Worcestershire	29	4.7	3.1	6.7
Staffordshire	40	4.4	3.1	6.0
Warwickshire	25	4.0	2.6	5.8
Herefordshire	6	3.1	1.2	6.8
Shropshire	9	2.7	1.2	5.1

In the West Midlands, there were more male cases (62.2%, 441 out of 709) compared to female cases in 2024 (Figure 6). Using 10-year age groups, rates of TB were highest for those aged 20 to 29 years for both males (28.5 per 100,000) and females (19.3 per 100,000) (Figure 7). There were more male cases than female cases in all age groups, except the 0 to 9 years age group where 80% (8 out of 10) were female (Figure 6).

Figure 6. Number of TB notifications by age and sex, West Midlands, 2024

Figure 7. TB notification rate by age and sex, West Midlands, 2024

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 (greater than 40 cases per 100,000 population) (3).

In 2024, 99.9% (708 out of 709) of TB cases had a recorded country of birth, and of these, three-quarters (75.1%, 532 out of 708) were born outside the UK (Figure 8). In 2024, the number of TB notifications increased by 25.2% in people born outside of the UK (532 in 2024 versus 425 in 2023) and increased by 15.8% in those that were UK born (176 in 2024 versus 152 in 2023).

Figure 8. Number of TB notifications in non-UK born and UK born people by place of birth, West Midlands, 2001 to 2024

In 2024, the number of TB notifications were highest in the 15 to 44 years age group for both cases born outside of the UK (355 cases) and UK born cases (72 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 (7.4% UK born versus 1.9% non-UK born), 45 to 64 years (33.5% UK born versus 18.4% non-UK born) and 65 years and over (18.2% UK born versus 13.0% non-UK born). For the 15 to 44 year age group, the proportion of cases was higher in non-UK born cases (66.7%) compared to UK born cases (40.9%).

The number of non-UK born cases aged 15 to 44 years has increased in 2024 compared to 2023. The numbers have remained relatively stable in the other age groupings with small increases seen in all age groups in 2024.

In cases notified in 2024, the year of entry to the UK was reported by 91.9% (489 out of 532) of TB patients born outside the UK. Of those, the largest proportion (31.3%, 153 out of 489) 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. There was a similar proportion (31.1%, 152 out of 489) of cases that had arrived in the UK less than 2 years prior to their TB diagnosis which is a slight decrease compared to 2023 following an increase in recent years. The combined group of those that entered the UK within 5 years of diagnosis (less than 2 years and 2 to 5 years) accounted for 56.3% of the TB cases born outside of the UK in the West Midlands in 2024 which is similar to 2023 (55.9%).

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 2024

Figure 10. Proportion of TB notifications by time since entry for people born outside the UK, West Midlands, 2001 to 2024

The 5 most common countries of birth for all TB cases notified in 2024 in the West Midlands were India (29.9%, 212 out of 708), United Kingdom (24.9%, 176 out of 708), Pakistan (12.6%, 89 out of 708), Eritrea (4.0%, 28 out of 708) and Romania (3.4%, 24 out of 708), making up 74.7% of all cases (529 out of 708) (Table 2). The median time between entry to the UK and TB notification was the highest in people with TB born in Pakistan (14 years) followed by Romania (6.5 years) whilst the lowest was in people with TB born in Afghanistan (1 year) and Sudan (1 year).

Table 2. Most common countries of birth for people with TB and time between entry to the UK and TB notification, West Midlands, 2024 [note 5] [note 6] [note 7] [note 8] [note 9]

Country of birth	Number of people notified with TB	Proportion of people notified with TB (%)	Median time since entry to UK in years	IQR of time since entry to UK in years
India	212	29.9	3.0	1.0 to 13.0
United Kingdom	176	24.9	Not applicable	Not applicable
Pakistan	89	12.6	14.0	2.0 to 34.0
Eritrea	28	4.0	2.0	0.0 to 7.0
Romania	24	3.4	6.5	4.0 to 8.2
Nigeria	21	3.0	2.0	1.2 to 2.8
Afghanistan	13	1.8	1.0	0.5 to 2.5
Bangladesh	13	1.8	1.5	0.8 to 3.5
Sudan	13	1.8	1.0	0.0 to 1.0
Somalia	11	1.6	2.5	1.2 to 15.5
Other	108	15.3	6.0	1.0 to 18.8
Total	708	100.0	Not applicable	Not applicable

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

Note 6: place of birth (UK or non-UK) or country of birth is missing for 1 notification in 2024.

Note 7: lower quartile is the 25th percentile and upper quartile is the 75th percentile, representing the interquartile range (IQR).

Note 8: time between entry to the UK and TB notification is calculated as whole years (only year of entry is reported to the National TB Surveillance (NTBS)).

Note 9: time since entry to the UK was not known for 43 people in 2024.

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 2024, were India (39.8%, 212 out of 532), Pakistan (16.7%, 89 out of 532), Eritrea (5.3%, 28 out of 532), Romania (4.5%, 24 out of 532) and Nigeria (3.9%, 21 out of 532) (Figure 11 and Table 3). Numbers of TB cases born in all 5 most common countries of birth increased compared to the previous year.

The characteristics for people with TB from the most common non-UK countries of birth varied (Table 3). The median age for cases was highest in people with TB born in Pakistan (48.3 years) and lowest in people with TB born in Eritrea (31.6 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 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 of those born in Pakistan and Romania had pulmonary TB.

The 5 most common countries of birth outside of the UK make up 52.8% of all TB cases notified in 2024 in the West Midlands (374 out of 708).

Figure 11. Numbers of TB notifications for the most common countries of birth for people with TB born outside the UK, West Midlands, 2014 to 2024 [note 10]

Note 10: figure 11 shows the top 5 countries in 2024.

Table 3. Characteristics of people with TB from the most common (non-UK) countries of birth, West Midlands, 2024

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	212	40.8	54.2	46.2	31.8	46.8
Pakistan	89	48.3	73.0	42.7	22.9	57.9
Eritrea	28	31.6	78.6	64.3	48.0	50.0
Romania	24	37.8	75.0	83.3	12.5	100.0
Nigeria	21	31.8	71.4	42.9	27.8	40.0

In 2024, 99.0% (702 out of 709) of patients with TB had an ethnicity recorded, of which 9.3% (65 out of 702) were recorded as mixed or other. The highest number of TB notifications were in patients with a recorded Indian ethnicity which accounted for 34.6% of cases (243 out of 702), followed by the White (17.2%, 121 out of 702) and Black African ethnic groups (16.1%, 113 out of 702) (Figure 12).

When ethnicity and country of birth data were combined, data was known for 701 cases. Collectively, patients with a recorded South Asian ethnicity made up 52.0% of cases (365 out of 701), of which 12.3% (45 out of 365) were UK born (Figure 13). Patients of White ethnicity made up 17.3% of cases (121 out of 701), of whom the majority (81.0%, 98 out of 121) were UK born. Patients of Black ethnicity made up 17.5% of cases (123 out of 701 cases), of whom 10.6% (13 out of 123) were UK born.

All ethnic groups saw increases in the number of TB cases between 2023 and 2024 (Figure 13). The greatest increases were in the South Asian ethnic group with an increase of 92 cases, particularly in non-UK born TB cases, followed by the Mixed or Other ethnic group with an increase of 21 cases.

Figure 12. Number of TB notifications in ethnic groups by place of birth (UK and non-UK born), West Midlands, 2024 [note 11] [note 12]

Note 11: 8 cases have been excluded from the above figure due to missing ethnicity or place of birth data.

Note 12: 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 2024 [note 13] [note 14]

Note 13: 8 cases have been excluded from the above figure due to missing ethnicity or place of birth data.

Note 14: the South Asian ethnicity group comprises people of Indian, Pakistani and Bangladeshi ethnicities.

In 2024, site of disease was recorded for all 709 cases. The majority (55.4%, 393 out of 709) of patients had pulmonary TB disease (with or without extra-pulmonary sites) which is a similar proportion to previous years (Figure 14 and Table 4). People with pulmonary TB have the potential to be infectious to others and 38.9% of TB cases had pulmonary TB disease only (276 out of 709). In 2024, 61.1% (433 out of 709) of TB cases had extra-pulmonary TB disease (with or without pulmonary sites). Lymph nodes were the next most common site of disease (31.9%, 226 out of 709), of which 31.0% (70 out of 226) were intra-thoracic and 69.0% were extra-thoracic (156 out of 226). Other extra-pulmonary sites of unknown origin also make up a large proportion of cases (21.0%, 149 out of 709) (Table 5).

Table 4. Number of pulmonary TB notifications by site of disease, West Midlands, 2024 [note 15] [note 16]

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All pulmonary	393	55.4
Pulmonary only	276	38.9
Miliary only	29	4.1
Laryngeal only	0	0.0

Note 15: percentages may not add up to 100 as people with TB may have more than one site of disease.

Note 16: ‘pulmonary only’ includes people notified with only pulmonary TB and therefore have not also been notified with miliary, laryngeal or extra-pulmonary TB.

Table 5. Number of extra-pulmonary TB notifications by site of disease, West Midlands, 2024 [note 17]

Site of disease	Number of people notified with TB	Proportion of people notified with TB (%)
All extra-pulmonary	433	61.1
Extra-thoracic lymph nodes	156	22.0
Other extra-pulmonary	149	21.0
Intra-thoracic lymph nodes	70	9.9
Pleural	53	7.5
Gastrointestinal	36	5.1
Bone - spine	33	4.7
Central nervous system - meningitis	17	2.4
Bone - not spine	11	1.6
Genitourinary	8	1.1
Cryptic disseminated	5	0.7
Central nervous system - other	2	0.3

Note 17: 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, 2014 to 2024 [note 18]

Note 18: 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 2024, the numbers of TB cases reporting data for each of the named comorbidities varied (Table 6). Of all TB cases notified in 2024, 15.9% of TB cases reported having at least one of the named comorbidities (113 out of 709). The most commonly reported comorbidity was diabetes with 12.5% (69 out of 554) of TB cases reporting this, followed by immunosuppression (4.7%, 25 out of 534).

Table 6. Number and proportion of people with TB with comorbidities, West Midlands, 2024 [note 19]

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	709	113	15.9	Not applicable	Not applicable
Chronic liver disease	540	5	0.9	169	23.8
Chronic renal disease	544	14	2.6	165	23.3
Diabetes	554	69	12.5	155	21.9
Hepatitis B	512	10	2.0	197	27.8
Hepatitis C	512	7	1.4	197	27.8
Immunosuppression	534	25	4.7	175	24.7

Note 19: people with TB are reported as having at least one of the named comorbidities if any of the 6 comorbidities (current 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 2024, HIV testing status was recorded for 87.9% of TB cases (623 out of 709). HIV tests were offered, or results were already known for 98.1% (611 out of 623) of these, whilst 1.9% of cases were not offered a test (12 out of 623) (Figure 15). Of the cases that were offered a test, 92.0% received a test (562 out of 611) and 3.1% (19 out of 611) did not receive the test. The proportion of people with TB that were offered a test decreased slightly in 2024.

Figure 15. Proportion of people with TB offered an HIV test by year, West Midlands, 2019 to 2024 [note 20] [note 21]

Note 20: dashed line indicates target of 100% of people offered HIV test.

Note 21: 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 2024 in the West Midlands, 13.6% of TB cases aged 15 years or over reported at least one social risk factor (93 out of 686) and 6.3% of TB cases reported having more than one social risk factor (35 out of 552) (Table 7). The most common social risk factor reported was current asylum seeker (6.4%, 34 out of 532) followed by current or previous drug misuse (5.9%, 31 out of 524).

The prevalence of social risk factors decreased in 2024 (13.6%, 93 out of 686) compared to 2023 where 18.4% (103 out of 559) reported at least one social risk factor (Table 8, Figure 16).

Table 7. Number and proportion of people with TB aged 15 years or over with individual social risk factors, West Midlands, 2024 [note 22] [note 23]

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	686	93	13.6	Not applicable	Not applicable
More than one social risk factor	552	35	6.3	134	19.5
Alcohol misuse (current)	529	20	3.8	157	22.9
Asylum seeker (current)	532	34	6.4	65	10.9
Drug misuse (current or previous)	524	31	5.9	162	23.6
Homelessness (current or previous)	533	19	3.6	153	22.3
Mental health needs (current)	508	16	3.1	178	25.9
Prison (current or previous)	512	19	3.7	174	25.4

Note 22: people with TB are reported as having ‘at least one named social risk factor’ 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 for this metric is all TB 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 23: the denominator for people with TB reported as having ‘more than one social risk factor’ is the number of people with TB for whom data are recorded for at least 2 out of the 6 social risk factors collected. This differs to the ‘at least one named social risk factor’ metric described above.

Figure 16. Proportion of people with TB aged 15 years or over with at least one social risk factor (SRF), West Midlands, 2019 to 2024 [note 24] [note 25]

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

Note 25: not all social risk factors were captured before 2021.

Table 8. Number and proportion of people with TB aged 15 years or over reporting at least one social risk factor, West Midlands, 2014 to 2024 [note 26]

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
2014	66	8.8	749
2015	84	12.5	671
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	102	18.8	542
2022	101	19.5	519
2023	103	18.4	559
2024	93	13.6	686

Note 26: not all social risk factors were captured before 2021 and that this table includes people with no information recorded in the denominator.

In 2024, male TB cases were more likely to report social risk factors compared to female TB cases (19.0% of males versus 4.3% of females) (Table 9). The age group that reported the highest proportion of social risk factors was those aged 15 to 44 years (15.0%, 64 out of 427) whilst those aged 65 years and above reported the lowest proportion of social risk factors (7.9%, 8 out of 101). UK born TB cases reported a higher proportion of social risk factors (18.4%, 30 out of 163) compared to non-UK born TB cases (11.9%, 62 out of 522).

Table 9. Number and proportion of people with TB aged 15 years or over with a social risk factor (SRF) by demographic characteristics, West Midlands, 2024 [note 27]

Demographic characteristics	Number of people with demographic characteristic who have any social risk factor	Total number of people with demographic characteristic	Proportion of people with demographic characteristic who have any social risk factor
Female	11	254	4.3
Male	82	432	19.0
Aged 15 to 44	64	427	15.0
Aged 45 to 64	21	158	13.3
Aged 65 or older	8	101	7.9
Non-UK-born	62	522	11.9
UK-born	30	163	18.4

Note 27: one case has been excluded from the above table due to missing demographic characteristic data

Based on the Index of Multiple Deprivation (IMD 2025) deciles assigned to geographical areas in the West Midlands, the deprivation decile with the highest rate of TB was decile 1 (27 per 100,000), followed by deciles 2 (20.7 per 100,000) and 3 (12.8 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, 2024 [note 28] [note 29]

Note 28: error bars represent upper and lower 95% confidence intervals.

Note 29: the Index of Multiple Deprivation (IMD) ranks small areas in England by deprivation using 7 main domains including, but not limited to, income, housing, employment, crime and environment. Each area is scored and ranked nationally from most to least deprived.

TB diagnosis, microbiology and drug resistance

In 2024, 60.4% (428 out of 709) of people with TB in the West Midlands had their diagnosis culture confirmed. For pulmonary TB cases, 76.1% (299 out of 393) 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 an increase from last year where 71.3% (236 out of 331) of pulmonary TB cases were culture confirmed.

Figure 18. Proportion of people notified with pulmonary TB who were culture confirmed, West Midlands, 2018 to 2024 [note 30] [note 31]

Note 30: dashed line indicates target of 80% culture confirmation.

Note 31: 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. Multidrug-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 2024, of the TB patients confirmed by culture, 98.8% (423 out of 428) received first-line drug results (Figure 19). This proportion is an increase compared to 2023 and is now consistent with the proportion reported between 2018 and 2022. Of the 428 culture-confirmed TB cases in the West Midlands, 7.9% (34 out of 428) had initial resistance to any first-line drug (Figure 20). This is an increase compared to last year where 5.7% (19 out of 334) of culture-confirmed TB cases had resistance to any first-line drug. However, pyrazinamide resistance has not been reported for 2023 and 2024.

Figure 19. Proportion of people culture confirmed with TB with first-line drug results, West Midlands, 2018 to 2024 [note 32] [note 33]

Note 32: error bars represent upper and lower 95% confidence intervals.

Note 33: We are not reporting on the proportion with resistance to pyrazinamide (and therefore the category of any first-line agent only includes rifampicin, isoniazid, and ethambutol) in 2023 and 2024 because the laboratory testing was adversely impacted by a problem with quality control in the supply chain for the media used for 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.

Figure 20. Proportion of people notified with culture-confirmed TB with initial resistance to any first-line drug, West Midlands, 2018 to 2024 [note 34] [note 35]

Note 34: error bars represent upper and lower 95% confidence intervals.

Note 35: due to quality control issues, resistance to any first-line drug excludes pyrazinamide for 2023 and 2024.

Between 2018 and 2024 in the West Midlands, there were a total of 169 culture-confirmed TB cases with initial drug resistance (7.0%, 169 out of 2414) (Table 10). The most common type of resistance was isoniazid resistance (4.6%, 112 out of 2414). There were also 10 cases (0.4%, 10 out of 2414) of pre-XDR TB and 2 cases of XDR TB (0.1%, 2 out of 2414) reported between 2018 and 2024.

Table 10. Number and proportion of people with culture-confirmed TB with initial drug resistance, West Midlands, 2018 to 2024

Initial drug resistance	Number of cases	Percentage of total cultured cases
Isoniazid resistance without MDR TB	112	4.6
Rifampicin-resistant MDR TB	45	1.9
Pre-XDR	10	0.4
XDR	2	0.1

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 2024, 34.8% (149 out of 428) of culture-confirmed TB cases were identified in a cluster with more than one other person by WGS (Table 11). The number of TB cases identified as being part of a cluster is similar to the proportion in 2023 where 36.8% (123 out of 334) of people with culture-confirmed TB were in a WGS cluster.

Table 11. Number of people notified, proportion with culture confirmation and proportion of notifications identified in a WGS cluster, West Midlands, 2021 to 2024 [note 36] [note 37]

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
2021	563	332	59.0	169	50.9	45.5 to 56.2
2022	538	305	56.7	126	41.3	35.9 to 46.9
2023	578	334	57.8	123	36.8	31.8 to 42.1
2024	709	428	60.4	149	34.8	30.5 to 39.4
Total	2,388	1,399	58.6	567	40.5	38 to 43.1

Note 36: a WGS cluster is defined as 2 or more individuals that have isolates with a less than 12 SNP difference.

Note 37: WGS cluster reporting has changed over time. These changes are likely to have affected the most recent year’s data.

TB in children aged 0 to 17: incidence, epidemiology and microbiology

In 2024 in the West Midlands, there were 40 cases of TB in children aged under 18 years, this represents a TB case rate of 3.0 per 100,000 in this age group (Figure 21 and Figure 22). The rate of TB in children aged under 18 years in the West Midlands has increased since 2023 (2.4 per 100,000 population).

Figure 21. Number of TB notifications in children aged under 18 years, West Midlands, 2001 to 2024

Figure 22. TB notification rate in children aged under 18 years, West Midlands, 2001 to 2024 [note 38]

Note 38: error bars represent upper and lower 95% confidence intervals.

In 2024, 18 (45%, 18 out of 40) of the TB cases in children aged under 18 years were born in the UK (Figure 23). This was an increase compared to 2023 (14 cases). There were also 22 (55.0%, 22 out of 40) TB cases in children under 18 years who were born outside of the UK (Figure 24). This was a slight increase when compared to 2023. After the United Kingdom (45.0%, 18 out of 40), the most common country of birth for children under 18 years with TB was Afghanistan (15.0%, 6 out of 40), other countries of birth had less than 5 cases (Table 12). 

Figure 23. Number of TB notifications in UK born children aged under 18 years, West Midlands, 2001 to 2024

Figure 24. Number of TB notifications in non-UK born children aged under 18 years, West Midlands, 2001 to 2024

Table 12. Most common countries of birth for children aged under 18 years with TB, West Midlands, 2024 [note 39]

Country of birth	Number of TB notifications in children	Proportion of notifications in children (%)
United Kingdom	18	45.0
Afghanistan	6	15.0

Note 39: where there are fewer than 5 cases by country of birth, these have been suppressed. This may lead to no data being shown in the table.

Of the 40 children aged under 18 years with TB, 17.5% (7 out of 40) were aged between 0 and 4 years, 7.5% (3 out of 40) were aged between 5 and 9 years, 32.5% (13 out of 40) were aged 10 to 14 years, and 42.5% (17 out 40) were aged between 15 and 17 years. In 2024, 67.5% (27 out of 40) of children aged under 18 years with TB had pulmonary TB with or without extrapulmonary sites, and 10.0% (4 out of 40) had severe TB. Severe TB includes cases with central nervous system (CNS), spinal, cryptic and miliary TB.

TB treatment

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

In 2024, 35.4% of TB cases (251 out of 709) in the West Midlands received Enhanced Case Management (ECM) (Table 13). There was a similar proportion of TB cases receiving each level of ECM with the highest proportion receiving level 3 ECM (12.8%, 91 out of 709). In 2024, the proportion of cases receiving ECM was lower than 2023, where 42.0% of TB cases (243 out of 578) received any ECM. Information on ECM was not recorded for 5 TB cases.

Table 13. Number of people with TB receiving enhanced case management, West Midlands, 2022 to 2024 [note 40]

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	177	31.4	37	6.6	47	8.3	93	16.5	0	0.0
2022	538	230	42.8	60	11.2	55	10.2	115	21.4	0	0.0
2023	578	243	42.0	84	14.5	68	11.8	90	15.6	1	0.2
2024	709	251	35.4	85	12.0	70	9.9	91	12.8	5	0.7

Note 40: 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 272 pulmonary TB cases where symptom onset and treatment start dates were available and who did not have a postmortem diagnosis. In 2024, 59.2% (161 out of 272) of pulmonary TB cases had a treatment delay of over 2 months (Figure 25). This was similar to 2023 where 57.6% (151 out of 262) of pulmonary TB cases started treatment over 2 months after symptom onset.

Figure 25. Proportion of people notified with pulmonary TB with a treatment delay over 2 months, West Midlands, 2019 to 2024 [note 41] [note 42] [note 43]

Note 41: error bars represent upper and lower 95% confidence intervals.

Note 42: delay to treatment is defined by when treatment was started from symptom onset.

Note 43: all cases where delay to treatment is greater than 730 days have been removed from this analysis.

In 2024, 30.5% (83 out of 272) of pulmonary TB cases started treatment with a 2 to 4 month delay (61 to 121 days), and 28.7% (78 out of 272) started treatment more than 4 months (122 to 730 days) after symptom onset, indicating a prolonged period of infectiousness (Table 14). The proportion starting treatment more than 4 months after symptom onset was similar to the previous year (29.0%, 76 out of 262).

Table 14. Time between symptom onset and treatment start in people with pulmonary TB, West Midlands, 2016 to 2024 [note 44]

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
2016	134	36.4	118	32.1	116	31.5	368	82.0	42.5 to 144.0
2017	148	40.9	114	31.5	100	27.6	362	75.0	39.0 to 129.0
2018	163	49.7	92	28.0	73	22.3	328	62.5	32.0 to 115.0
2019	117	37.7	97	31.3	96	31.0	310	79.5	39.2 to 138.0
2020	91	36.7	72	29.0	85	34.3	248	82.5	46.5 to 158.2
2021	90	32.6	92	33.3	94	34.1	276	84.5	40.0 to 171.0
2022	89	34.5	87	33.7	82	31.8	258	84.0	45.0 to 144.0
2023	111	42.4	75	28.6	76	29.0	262	76.5	37.2 to 132.8
2024	111	40.8	83	30.5	78	28.7	272	80.5	38.8 to 132.2

Note 44: this table includes people with pulmonary TB where they did not have a postmortem diagnosis, they had started treatment and the start of treatment date was known. Total includes all these people including where the time between symptom onset and treatment start was missing or not known. It excludes individuals with a delay over 730 days.

In 2024, the median treatment delay for pulmonary TB cases was 80.5 days (interquartile range [IQR] 38.8 to 132.3) (Figure 26). This was higher when compared to last year where the median treatment delay was 76.5 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 26. Median treatment delays among people notified with pulmonary TB, West Midlands, 2019 to 2024 [note 45] [note 46] [note 47] [note 48]

Note 45: dashed line represents the target treatment delay of 56 days by 2027.

Note 46: ends of the whiskers represent the theoretical lower and upper limits for detecting outliers (lower/upper quartile negative/positive 1.5 times the interquartile range). Outliers falling outside of these limits have been removed.

Note 47: delay to treatment is defined by when treatment was started from symptom onset.

Note 48: all people included in this figure are people with pulmonary TB who did not have a postmortem diagnosis and it was known that they had started treatment. It excludes individuals with a delay over 730 days.

TB treatment outcomes

For the purposes of TB outcome reporting, drug-sensitive cases are defined as sensitive to rifampicin. 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).

Treatment outcomes for people with non-severe and non-MDR/non-RR TB are presented only among people who would usually have standard treatment regimens for TB: this excludes people who were treated for multidrug-resistant (MDR) and rifampicin-resistant (RR) TB, as well as those with severe disease (defined as CNS, spinal, miliary or cryptic disseminated disease among adults, and TB meningitis, miliary or cryptic disseminated among children aged 0 to 14 years), where expected treatment durations are longer (treatment outcomes for these patients are reported separately). This definition of severe disease may not capture all clinically severe or extensive disease involving other sites of disease.

Among people notified in 2023, 84.4% (428 out of 507) 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 15). This proportion is similar to 2022 (84.2%, 384 out of 456) and remains below the target of 90% (Figure 27).

There were 79 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 (5.5%, 28 out of 507), followed by still being on treatment (3.0%, 15 out of 507). There were also 18 cases where treatment outcome was not evaluated, not recorded or is unknown at 12 months

At the last recorded outcome, a further 17 cases had completed treatment, bringing completion to 87.8% (445 out of 507). There were an additional 2 cases (2.8%, 14 out of 507) that had stopped treatment and 1 further case (1.4%, 7 out of 507) that was lost to follow up.

Table 15. Treatment outcome at 12 months and last recorded outcome for people notified with non-severe TB treated for non-MDR or non-RR TB, West Midlands, 2023 [note 49] [note 50]

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	428	84.4	445	87.8
Died	28	5.5	28	5.5
Lost to follow up	6	1.2	7	1.4
Still on treatment	15	3.0	6	1.2
Treatment stopped	12	2.4	14	2.8
Not evaluated	18	3.6	7	1.4
Total	507	100.0	507	100.0

Note 49: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not still on treatment nor died.

Note 50: non-severe TB is defined as those cases without CNS, spinal, cryptic or miliary disease.

Figure 27. 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, 2019 to 2023 [note 51] [note 52] [note 53]

Note 51: dashed line indicates treatment target of 90%.

Note 52: error bars represent upper and lower 95% confidence intervals.

Note 53: non-severe TB is defined as those cases without CNS, spinal, cryptic or miliary disease.

Among those notified in 2023, there were 94 non-MDR or non-RR TB cases without CNS disease with one or more social risk factors, and of these 77.7% (73 out of 94) had completed treatment at 12 months (Figure 28). This was a similar proportion compared to the last few years, however, represents a decrease from 2022 when 85.2% (69 out of 81) of cases with social risk factors had completed treatment at 12 months.

Figure 28. Proportion of people with non-severe TB treated for non-MDR or non-RR TB and with one or more social risk factors who completed treatment within 12 months, West Midlands, 2019 to 2023 [note 54] [note 55] [note 56]

Note 54: Not all social risk factors were captured before 2021.

Note 55: error bars represent upper and lower 95% confidence intervals.

Note 56: non-severe TB is defined as those cases without CNS, spinal, cryptic or miliary disease.

In the West Midlands, of those notified in 2023, 1.2% (6 out of 507) were lost to follow up at 12 months, this was a slight decrease compared to 2022 (2.0%, 9 out of 456) (Figure 29).

The proportion that had stopped treatment at 12 months decreased in 2023 (2.4%, 12 out of 507) compared to 2022 (3.5%, 16 out of 456).

In 2023, 5.5% (28 out of 507) of TB cases died before completing treatment, this was an increase compared to the previous year (3.9%, 18 out of 456).

In 2023, there were also 3.0% (15 out of 507) of cases still on treatment at 12 months which was a small decrease compared to 2022 where 3.3% (15 out of 456) remained on treatment.

Figure 29. Outcomes of people evaluated who did not complete treatment by 12 months for people with non-severe TB treated for non-MDR or non-RR TB, West Midlands, 2014 to 2023 [note 57]

Note 57: non-severe TB is defined as those cases without CNS, spinal, cryptic or miliary disease.

Table 16. TB outcome at 12 months for people with non-severe TB treated for non-MDR or non-RR TB, West Midlands, 2014 to 2023 [note 58]

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)
2014	584	45	44	26	20	11	0	685
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	0	585
2018	480	65	31	15	17	7	9	559
2019	450	71	23	10	17	10	11	521
2020	395	43	26	14	18	8	13	474
2021	425	66	28	9	13	14	8	497
2022	384	69	18	9	15	16	14	456
2023	428	73	28	6	15	12	18	507

Note 58: 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. Non-severe TB is defined as those cases without CNS, spinal, cryptic or miliary disease.

Table 17. Proportions of TB outcomes at 12 months for people with non-severe TB treated for non-MDR or non-RR TB, West Midlands, 2014 to 2023 [note 59]

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)
2014	85.3	6.6	6.4	3.8	2.9	1.6	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	88.0	10.4	5.0	2.1	3.9	1.0	0.0
2018	85.9	11.6	5.5	2.7	3.0	1.3	1.6
2019	86.4	13.6	4.4	1.9	3.3	1.9	2.1
2020	83.3	9.1	5.5	3.0	3.8	1.7	2.7
2021	85.5	13.3	5.6	1.8	2.6	2.8	1.6
2022	84.2	15.1	3.9	2.0	3.3	3.5	3.1
2023	84.4	14.4	5.5	1.2	3.0	2.4	3.6

Note 59: 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. Non-severe TB is defined as those cases without CNS, spinal, cryptic or miliary disease.

There were 65 people notified in 2023 with CNS, miliary or cryptic disseminated TB, that was non-MDR or non-RR. At the last recorded outcome, 76.9% (50 out of 65) had completed treatment, 16.9% (11 out of 65) had died, 1.5% (1 out of 65) were lost to follow up, 1.5% (1 out of 65) were still on treatment, and 1.5% (1 out of 65) had stopped treatment (Table 18). There was 1.5% (1 out of 65) of cases where the treatment outcome was not evaluated, not recorded or is unknown at the last recorded outcome. Treatment is expected to take longer than 12 months for people with these types of TB.

Table 18. Last recorded outcome for people treated for non-MDR or non-RR TB with severe disease, West Midlands, 2023 [note 60] [note 61]

Last recorded outcome	Number of TB notifications	Proportion of TB notifications
Treatment completed	50	76.9
Died	11	16.9
Lost to follow up	1	1.5
Still on treatment	1	1.5
Treatment stopped	1	1.5
Not evaluated	1	1.5
Total	65	100.0

Note 60: not evaluated indicates that the treatment outcome was not evaluated, not recorded or is unknown and the final outcome is not still on treatment nor died.

Note 61: severe TB is defined as those cases with CNS, spinal, cryptic or miliary disease.

For people with MDR and rifampicin-resistant TB, treatment outcome is measured at 24 months, so outcomes are presented for people notified up to 2022. In 2022 in the West Midlands there were 8 patients diagnosed with RR or MDR TB that did not have CNS, spinal, cryptic or miliary TB, this was a higher number compared to the previous year (n=5). At 24 months, 75% of cases had completed treatment (6 out of 8), of which 25% (2 out of 6 ) had reported having any social risk factor. This is a higher proportion of MDR or RR TB cases that had completed treatment at 24 months compared to 2021.

TB prevention 

In 2024 in the West Midlands, 19.1% (75 out of 393) of pulmonary TB cases had 5 or more contacts identified and screened for active and latent TB (Figure 30). This proportion has been decreasing since 2022.

There was a total of 1122 contacts of pulmonary TB cases identified in 2024 in the West Midlands including 860 adults and 262 children (Table 19). Of these 71.5% (802 out of 1122) were screened for active and latent TB, this was a decrease from 83.9% in 2023 (993 out of 1183). As a result of this screening, 2.6% (21 out of 802) were diagnosed with active TB and 18.7% (150 out of 802) were diagnosed with latent TB. Of the contacts diagnosed with latent TB, 81.3% (122 out of 150) started treatment and 64.7% (97 out of 150) completed latent TB treatment.

The proportion of contacts that started and completed latent TB treatment was higher in child contacts (96.4%, 53 out of 55 started and 74.5%, 41 out of 55 completed) compared to adult contacts (72.6%, 69 out of 95 started and 58.9%, 56 out of 95 completed).

Figure 30. Proportion of people notified with pulmonary TB with at least 5 contacts identified and screened for active and latent TB by year, West Midlands, 2019 to 2024 [note 62] [note 63]

Note 62: error bars represent upper and lower 95% confidence intervals.

Note 63: individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

Table 19. Number of contacts identified, screened, screening results and treatment for contacts of people notified with pulmonary TB (index individuals), West Midlands, 2024 [note 64] [note 65] [note 66] [note 67]

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	860	Not applicable	262	Not applicable	1,122	Not applicable
Number of contacts screened for active TB and latent TB	585	68	217	82.8	802	71.5
Number of contacts with active TB	15	2.6	6	2.8	21	2.6
Number of contacts with latent TB	95	16.2	55	25.3	150	18.7
Number of contacts who started treatment for latent TB	69	72.6	53	96.4	122	81.3
Number of contacts who completed treatment for latent tuberculosis	56	58.9	41	74.5	97	64.7

Note 64: the denominator for the proportion of contacts screened for active TB and latent TB infection (LTBI) is number of contacts identified.

Note 65: the denominator for the proportion of contacts positive for active TB and LTBI is the number of contacts screened.

Note 66: the denominator for the proportion of contacts who started and completed treatment is the number of contacts positive for LTBI.

Note 67: 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 2024, the highest proportion of contacts that were screened for latent TB were contacts of UK born TB cases (73.9%, 297 out of 402), followed by contacts of child TB cases (73.2%, 52 out of 71), contacts of adult TB cases (71.4%, 750 out of 1051), and contacts of non-UK born TB cases (70.1%, 505 out of 720). Following this screening it was identified that 14.5% of contacts of UK born TB cases, 26.9% of contacts of child TB cases, 18.1% of contacts of adult TB cases and 21.2% of contacts of non-UK born TB cases were found to have latent TB.

The proportion of close contacts that completed latent TB treatment was highest in contacts of adult TB cases (66.9%, 91 out of 136) and UK born TB cases (65.1%, 28 out of 43) (Figure 31).

Figure 31. LTBI treatment completion in close contacts of adult or child and UK born or non-UK born index individuals with pulmonary TB, West Midlands, 2024 [note 68]

Note 68: 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). Coverage data for BCG is available from the Cover of vaccination evaluated rapidly (COVER) programme.

In 2024 in the West Midlands, 41% (294 out of 709) of all TB cases had received the BCG vaccination. There was a higher BCG vaccination coverage in TB cases born outside of the UK (43%, 228 out of 532) compared to UK born TB cases (38%, 66 out of 176). In 2024, 43% of children under 15 years old diagnosed with TB were vaccinated (10 out of 23).

Discussion

This report of TB in the West Midlands includes data until the end of 2024 and provides the latest epidemiological picture of TB in the region.

TB incidence in the West Midlands continued its upward trajectory in 2024, with a 21% increase in TB notifications compared with 2023. This rise mirrors the national trend of increasing TB burden, but the West Midlands continues to exceed the national rate and reports the second highest TB incidence in England, second to London. The region remains well above the threshold required to meet the WHO ‘End TB 2035’ incidence reduction trajectory, demonstrating that TB remains a significant public health issue requiring sustained and coordinated action.

Almost all West Midlands local authorities saw increases in TB notifications in 2024, and urban areas such as Wolverhampton, Coventry and Sandwell continue to report the highest TB rates. These patterns demonstrate that TB transmission is not confined to a single locality, but reflects wider demographic, socioeconomic and structural determinants operating across the region.

Demographic patterns show that TB in the West Midlands disproportionately affects younger adults and men, with the highest rates in men aged 20 to 29 years. This reflects an ongoing burden among working‑age populations, with implications for employment, family stability, and health service accessibility. Sex and age disparities also highlight the need to understand potential gendered patterns of exposure, healthcare‑seeking behaviour, and occupational or social settings that may influence risk.

In 2024, there was a 25% increase in the number of TB cases in people who were born outside of the UK compared to 2023, with three-quarters of TB cases born outside the UK. Among non‑UK‑born individuals, the 5 most common countries of birth were India, Pakistan, Eritrea, Romania and Nigeria, with the majority either reporting arrival within the past 2 years or having lived in the UK for over a decade. This dual pattern suggests both recent infection and reactivation of long‑standing latent TB infection. All ethnic groups experienced increases in TB notifications, reflecting broad transmission dynamics, rather than changes confined to a single population. These findings reinforce the need for interventions that address both diagnosis of active disease and systematic latent TB testing, alongside culturally competent services tailored to diverse communities, enhancing equitable access to care.

Although the number of cases in UK-born people is substantially lower than those not born in the UK, UK born cases have also seen a 16% increase for 2024, which follows national trends. This indicates an ongoing issue with domestic transmission and a focus on also addressing TB rates in this group, to reduce TB in the West Midlands.

Social risk factors (SRFs) continue to play a significant role in TB epidemiology; 13.6% of individuals aged 15 years or older reported at least one SRF, with current asylum seeker status and drug misuse the most common. SRFs were more prevalent among UK‑born individuals and males, consistent with national patterns. Notably, TB rates were highest in the most deprived IMD deciles, demonstrating the strong, persistent association between deprivation and TB incidence. These findings indicate continued need for targeted outreach, improved access to early diagnosis, and holistic case support addressing social need.

Over half of all cases had pulmonary TB, underscoring the ongoing risk of transmission. Culture confirmation of pulmonary cases increased in 2024, but remained below the national target of 80%, which limits the ability to detect drug resistance and identify clusters through WGS. This potentially slows effective treatment regimens being put in place, plus outbreak detection and response.

Initial resistance to first‑line drugs increased compared with the previous year, and over one‑third of culture‑confirmed cases were part of a WGS cluster, suggesting ongoing recent transmission. These findings emphasise the importance of strengthening early case detection, laboratory capacity, and rapid molecular diagnostics.

There has been an increase in TB cases in children in the West Midlands, including UK-born children, which is an important indicator of recent transmission. The presence of TB in children underscores the need for strengthened contact tracing, improved early case finding, and timely BCG vaccination in eligible groups.

Treatment delays remain a substantial challenge to TB control; approximately 60% of pulmonary TB cases experienced delays of over 2 months from symptom onset to treatment start, the median delay has increased in 2024 and is not on track to meet the 2027 target. Delays potentially prolong infectiousness, increase risk of complications and mortality, and reflect unmet needs in diagnostic pathways and healthcare access. Strengthened awareness, better access to services, and culturally appropriate communication are therefore essential.

TB treatment completion for drug-sensitive patients within 12 months has remained stable for those notified in 2023 but is below the 90% treatment target. The most common reason for treatment non-completion was that the case had died, followed by the TB case had stopped treatment.

There has been a decline in 2024 in the proportion of TB contacts screened for active and latent TB. Contact tracing is important for preventing further cases, through identifying those at highest risk of exposure, finding people with disease earlier and treating latent infection. Sufficient capacity is required for these activities to streamline referral, initiation and adherence support for LTBI therapy.

The 2024 findings show a region experiencing an accelerating TB burden, driven by multiple overlapping determinants: migration, deprivation, comorbidity, social risk factors, and diagnostic delays. The rise in TB reflects both recent transmission and reactivation of disease, with clear evidence that structural inequalities continue to shape risk. Longstanding challenges remain in treatment timeliness, completion rates and contact tracing.

TB must remain a health priority for partners in the West Midlands region. To reverse current trends, the West Midlands requires sustained efforts in TB diagnosis and management, including culturally competent outreach, improved primary care engagement, faster diagnostic pathways, integrated management of social risk factors and comorbidities, and strengthened contact tracing capacity. 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. Collaboration between NHS services, public health teams, community organisations and local authorities will be critical to delivering these goals.

Recommendations

To reverse the increasing trend in TB, important themes to focus on are summarised in the following recommendations, linked to the 5 priority areas in the Tuberculosis: 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, prioritising regional forums, such as the West Midlands TB Control Board, and the Midlands TB Regional Strategic Oversight Group (RSOG).

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 to formalise reporting and governance arrangements to support local risk escalation. 

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.

TB services and commissioners should identify areas for improving and expanding new migrant LTBI screening where there is a need.

Provide targeted training on TB signs and symptoms for professional groups, including large employers, to increase awareness of TB and promote early diagnosis.

Improve screening opportunities for contacts of pulmonary TB cases, to increase the proportion that are screened for active and latent TB. 

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 barriers 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 with aim of improving treatment completion rates for TB drug-sensitive cases and meeting the 90% target.

5. Workforce

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

Methods and acknowledgements

Methods

Full details of the data sources and methodologies used in this report, including definitions, are available in:

• Tuberculosis in England 2025 report
• Methodology and definitions

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.

References 

1. UKHSA (2024). Tuberculosis in England, 2025 report (presenting data to end of 2024)

2. WHO (2015). The End TB strategy

3. UKHSA (2021). UK pre-entry tuberculosis screening report 2020

4. WHO (2025). WHO consolidated guidelines on tuberculosis. Module 4: treatment and care

5. Joint Formulary Committee. British National Formulary 2018 3 October 2018

6. WHO (2013). Definitions and reporting framework for tuberculosis – 2013 revision

7. UKHSA (2021). TB Action Plan for England, 2021 to 2026

8. UKHSA (2021). BCG vaccination programme