Official Statistics

National quarterly report of tuberculosis in England: Quarter 1, 2023 provisional data

Updated 25 April 2024

Applies to England

Main messages

Provisional data indicates no notable changes in the numbers, basic demographic and clinical characteristics between notifications in 2022 compared with 2021, or between the first quarter of 2023 with the first quarter of 2022.

The proportion of people notified with culture confirmation remains under the target of 80% for those notified with infectious pulmonary tuberculosis (TB).

The number of people notified with multi-drug resistant (MDR) or rifampicin resistant (RR) TB is higher in the first quarter of 2023 compared with the same quarter in 2022 (13 versus 5), but so far the total for the last 4 quarters is similar to the previous 4 quarters.

No consistent improvement in the proportion of people with more than 4 months delay from reported symptom onset to start of treatment is observed over the reporting period (quarter 2 (April to June) 2021 to quarter 3 (July to September) 2023).

No notable improvement is observed in the proportion of people completing TB treatment within the expected 12-month duration over the reporting period (TB notifications from quarter 2 2020 to quarter 1 2022).

Overall numbers and geographical distribution

The number of notifications per quarter for England are shown in Figure 1 and by the UK Health Security Agency (UKHSA) centres in Figures 2a and 2b. Exact numbers per quarter by UKHSA centre and in total are shown in Table 1. Due to the seasonality of TB notifications, the most recent quarter is compared with the same quarter in the previous year rather than with the previous quarter.

For England in quarter 1 2023, 1,069 people were notified with TB in England. This is similar to quarter 1 2022 (1,060). Provisional data for England suggests no change in total notifications in 2022 compared with 2021.

Figure 1. Number of TB notifications in England, quarter 1 (January to March) 2021 to quarter 1 2023

By UKHSA centre, in quarter 1 2023 compared with quarter 1 2022 the number of TB notifications:

• increased in the North East (increase of 135.7%, 33 people compared with 14 people), North West (increase of 13.2%) and South West (increase of 76.7%)
• remained within 5% in the East Midlands (decrease of 4.4%), East of England (increase of 4.1%), South East (increase of 2.8%) and Yorkshire and the Humber (increase of 4.3%)
• decreased in London (decrease of 6.1%) and West Midlands (decrease of 21.0%)

Figure 2a. Number of TB notifications in London, England, quarter 1 (January to March) 2021 to quarter 1 2023

Figure 2b. Number of TB notifications in UKHSA centre, England, quarter 1 (January to March) 2021 to quarter 1 2023

Note: The axes on the London figure are different to that of the other regions due to the higher number of TB notifications in London.

Table 1. Number of TB notifications by UKHSA centre, England, quarter 1 (January to March) 2020 to quarter 1 2023

UKHSA centre	2020 Q1	2020 Q2	2020 Q3	2020 Q4	2020 Total	2021 Q1	2021 Q2	2021 Q3	2021 Q4	2021 Total	2022 Q1	2022 Q2	2022 Q3	2022 Q4	2022 Total	2023 Q1	2023 Total
London	381	335	382	365	1,463	356	422	430	360	1,568	394	429	408	367	1,598	370 (- 24)	370
North West	120	101	123	111	455	135	122	126	98	481	114	135	134	121	504	129 (-15)	129
West Midlands	146	138	126	131	541	128	159	150	131	568	143	158	114	125	540	113 (-30)	113
South East	106	99	118	119	442	112	136	134	128	510	107	127	144	102	480	110 (+3)	110
East of England	104	99	85	83	371	89	106	88	92	375	98	94	97	81	370	102 (+4)	102
East Midlands	88	68	80	78	314	74	109	98	68	349	90	106	92	98	386	86 (-4)	86
Yorkshire and the Humber	81	64	71	69	285	81	95	76	77	329	70	83	73	79	305	73 (+3)	73
South West	57	37	40	33	167	35	46	36	45	162	30	43	51	42	166	53 (+23)	53
North East	24	24	17	19	84	19	23	17	22	81	14	25	21	14	74	33 (+19)	33
Total	1,107	965	1,042	1,008	4,122	1,029	1,218	1,155	1,021	4,423	1,060	1,200	1,134	1,029	4,423	1,069 (+9)	1,069

Notes:
1. Ordered by decreasing total number of TB notifications in quarter 1 2023.
2. Number in brackets for quarter 1 2023 is the number difference from the same quarter in 2022.

Demographic and clinical characteristics

The number of TB notifications by where a person is born (where known) is shown in Figure 3, sub-divided by whether the disease is pulmonary or non-pulmonary (site of disease). Pulmonary disease is defined here as disease affecting the lungs and non-pulmonary disease notifications are those without any pulmonary involvement. Note that those with pulmonary disease may also have other sites of disease outside of the lungs.

Figure 3. Number of TB notifications by place of birth and site of disease, England, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 1 of the supplementary data set)

Place of birth was not known for 3 notifications in quarter 1 2023 and one notification in quarter 1 2022. Missing data may reflect difficulties in obtaining data (for example, patient died or language barriers). In quarter 1 2023, the number of people born outside of the UK accounted for 75.9% of notifications (809 out of 1,066), a small change in proportion compared with quarter 1 2022 (77.7%, 823 out of 1,059).

There was no missing data for pulmonary versus non-pulmonary disease. In quarter 1 2023, the number of people with pulmonary TB accounted for 53.6% (573 of 1,069) of all people with TB, consistent with 54.1% in quarter 1 2022 (573 of 1,060). In quarter 1 2023 for those born outside the UK, pulmonary disease accounted for 49.4% (400 of 809) of all notifications in quarter 1 2023 compared with 66.9% (172 of 257) for those born in the UK. This pattern of pulmonary disease being more common in UK-born people is seen for all quarters.

Culture confirmation

The TB Action Plan 2021 to 2026 Priority 3 workplan (Action 3.3) aims to increase culture confirmation rates by 5% per year with a specific target within the workplan (3.3.2a) to reach the European standard of 80% culture confirmation for pulmonary disease.

Figure 4 shows the proportion of culture confirmed notifications received by the number of culture-confirmed notifications by disease site (pulmonary or non-pulmonary) by quarter and year.

In 2022, preliminary data shows the proportion of culture confirmed notifications is 61.7% (2,730 of 4,423). When limited to those with pulmonary disease, the proportion that are culture confirmed increases to 74.0% (1,742 of 2,355). In quarter 1 2023, 46.8% (500 of 1,069) of notifications are culture confirmed. This increases to 60.6% (347 of 573), when limited to those with pulmonary disease. These numbers will increase as laboratory results are confirmed.

Figure 4. Proportion of culture confirmation among TB notifications by site of disease, England, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 2 of the supplementary data set)

Figure 5 shows the proportions of culture confirmation for pulmonary and non-pulmonary TB disease notifications by UKSHA centres. No UKSHA centres were consistent in achieving the 80% target of culture confirmation for pulmonary disease notifications. The North East consistently achieved the highest proportions for both pulmonary and non-pulmonary disease notifications.

Please note, in the following comparisons, we are comparing quarter 4 (October to December) 2022 with the same quarter in 2021, due to incomplete culture results data for the latest quarter.

In quarter 4 2022 compared with quarter 4 2021 the largest changes in culture confirmation for pulmonary TB are seen for:

• North West and Yorkshire and the Humber, which all decreased
• East of England, North East, South East and South West, which all increased

In quarter 4 2022 compared with quarter 4 2021 the largest changes in culture confirmation for non-pulmonary TB are seen for:

• East of England, North East and South East, which all decreased
• East Midlands, North West and Yorkshire and the Humber, which all increased

Figure 5a. Proportion of culture confirmation among TB notifications in London by site of disease, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 3 of the supplementary data set)

Figure 5b. Proportion of culture confirmation among TB notifications by site of disease and UKHSA centre, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 4 of the supplementary data set)

Multi-drug resistant or rifampicin resistant TB

Resistance to antimicrobial therapy is a major concern for treatment of TB, requiring extended therapy of between 12 and 24 months. All notifications with a positive culture are tested for antimicrobial susceptibility using whole genome sequencing. If a notification does not have a positive culture, no resistance results are available.

This report uses the World Health Organization (WHO) guidance of classification of MDR or RR TB. Multidrug resistance is classified as resistance to at least isoniazid and rifampicin. Figure 6 shows the number of culture confirmed notifications that are MDR or RR resistant by quarter.

Figure 6. Number of culture confirmed TB notifications with MDR or RR TB at diagnosis, England, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 5 of the supplementary data set)

Note: This figure displays numbers rather than proportions due to low number of MDR or RR TB notifications.

Numbers of TB notifications with culture confirmed MDR or RR TB in quarter 1 2023 were higher than the same quarter in 2022 and may increase further as laboratory results are finalised. However, provisional data indicates a similar number of people notified with MDR or RR TB (51 people) in the most recent 4 quarters (quarter 2 2022 to quarter 1 2023) compared with the previous 4 quarters (49 people, quarter 2 2021 to quarter 1 2022).

Treatment delays

Treatment delay is the time between the reported symptom onset date and treatment start date. It reflects either delays in patients seeking healthcare or delays in diagnosis after presentation, or both. Treatment delays are reported here only for potentially infectious pulmonary TB (Figures 7 and 8) due to the risk that extended treatment delays may increase transmission within communities. Analysis excludes notifications with a diagnosis made after death (post-mortem).

The joint UKHSA NHS England 2021 to 2026 TB Action Plan has a target of a 5% reduction per year in the proportion of people with a treatment delay of 4 months or more compared with that in 2021 and 2022 (Action plan 3.1 and 3.2).

Figure 7. Proportion of pulmonary TB notifications starting treatment within 4 months (symptom onset to treatment start), England, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 6 of the supplementary data set)

Data was missing for a considerable proportion of people due to missing date of onset of symptoms or treatment start date. In quarter 1 of 2023, this was missing for 352 people (33%) compared with 243 (23%) for quarter 1 in 2022. In quarter 4 of 2022 it was missing for 329 (32%) compared with 277 (27%) for quarter 4 in 2021.

In quarter 1 2023, 69.5% of people with pulmonary TB started treatment within 4 months of symptom onset, compared with 68.9% in quarter 1 2022. This proportion may change due to incomplete data in the latest quarter. As a result, quarter 4 2022 is compared with quarter 4 2021.

Figures 8a and 8b show the proportion of people starting treatment within 4 months by UKHSA centre and quarter. In quarter 4 2022 compared with quarter 4 2021, the proportion of people with TB who started treatment within 4 months of symptom onset is:

• higher for the East Midlands and London
• lower for the East of England, North East, South East and South West
• similar for the North West, West Midlands and Yorkshire and the Humber

Figure 8a. Proportion of pulmonary TB notifications in London starting treatment within 4 months (symptom onset to treatment start), quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 7 of the supplementary data set)

Figure 8b. Proportion of pulmonary TB notifications starting treatment within 4 months (symptom onset to treatment start) by UKHSA centre, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 8 of the supplementary data set)

Treatment outcomes

Treatment outcomes at or before 12 months from start of treatment are reported for persons notified up to quarter 1 2022 with known or assumed drug sensitive TB, the majority of whom should have completed treatment within 12 months of treatment start. Data is not presented for those notified after quarter 1 2022 as many are not expected to have completed treatment. The data excludes people in the drug resistant cohort and those with central nervous system (CNS), spinal, miliary or cryptic disseminated TB as treatment time for these groups usually exceeds 12 months.

The joint UKHSA NHS England 2021 to 2026 TB Action Plan has a target of 90% treatment completion at 12 months by 2026 (Action plan 4.1) in those treated for drug sensitive TB and expected to complete within 12 months.

Where treatment outcome is reported as not known or transferred to a different country, data is included in the not evaluated group. Figure 9a shows outcomes for notifications where treatment is complete, not evaluated or other (proportion shown in bars). The category ‘other’ comprises those who died, were lost to follow-up, are still on treatment (treatment period may be extended beyond 12 months in some notifications) or where the treatment was stopped, the proportion of each of these is shown in Figure 9b.

The proportion of people with drug sensitive TB (with an expected treatment duration of less than 12 months) who completed treatment at 12 months was 70.0% for people notified in quarter 1 2022 compared with 84.7% in quarter 1 2021.

Please note: the latest 4 quarters evaluated tend to show a high proportion of people with treatment outcomes recorded as ‘not evaluated’ despite having started at least 12 months previously. This reflects a delay in reporting the final outcome. The proportion not evaluated is expected to decrease with time. For those notified between quarter 2 2020 and quarter 1 2021, the highest proportion of treatment completed was observed in quarter 2 2020 at 84.9%.

Figures 9a and 9b. Outcomes at 12 months for people treated for drug sensitive TB with expected treatment duration under 12 months, England, quarter 2 (April to June) 2020 to quarter 1 (January to March) 2022 (Tables 9 and 10 of the supplementary data set)

Figure 9a

Figure 9b

Notes:
1. Excludes people in the drug resistant cohort and those with CNS, spinal, miliary or cryptic disseminated TB. Persons included here as drug sensitive TB notifications include those with known drug sensitivities and those with no information on drug sensitivity or not known to be high-risk for MDR or RR TB and who were therefore not treated as MDR or RR notifications.
2. Not evaluated includes unknown and transferred out.

Social risk factors

Social risk factors (SRFs) are reported as categorical yes or no variables with current or past history recorded as yes. Information on these social risk factors is collected through the routine surveillance system via interviews by the clinical team. Social risk factors that are recorded include current or history of prison or homelessness or drug misuse, current alcohol misuse, current mental health needs and asylum seeker status. Data reported is for persons aged 15 years and over due to low numbers in young children. Note that asylum seeker status is a newly recorded variable and there is currently not enough data available to accurately report on historic values of this SRF.

Figure 10a. Proportion of TB notifications with at least one social risk factor, England, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 11 of the supplementary data set)

Note: The axes on the figure for people with at least one SRF (Figure 10a) are different to that for individual SRFs (Figure 10b) due to the higher proportion of people with at least one SRF.

In quarter 1 2023, 16.0% of people with TB aged 15 years and over had at least one SRF. This is similar to quarter 1 2022 (15.9%).

For single risk factors (shown in Figure 10b), the proportion of people with TB in quarter 1 2023 with:

• current alcohol misuse was similar to quarter 1 2022
• current or a history of drug misuse was similar to quarter 1 2022
• current or a history of homelessness was similar to quarter 1 2022
• mental health needs was similar to quarter 1 2022
• current or history of imprisonment was similar to quarter 1 2022

Figure 10b. Proportion of TB notifications by social risk factor, England, quarter 2 (April to June) 2021 to quarter 1 (January to March) 2023 (Table 11 of the supplementary data set)

Background

This report aims to provide timely and up-to-date figures of important epidemiological indicators to inform ongoing TB control efforts in England.

Please note data for 2022 and 2023 is provisional and subject to validation and should be interpreted with caution. The data used for this report was extracted on 11 April 2023.

This report presents quarterly data on people with tuberculosis (TB) disease notified to the National TB surveillance system (NTBS) in England. Notifications include patients with culture confirmed TB or if a patient has started treatment for TB based on their clinical presentation. It is mandatory to notify TB notifications in the UK within 3 working days of making or suspecting a diagnosis of TB. You can find more details about notification of TB online. Most health protection functions are devolved to the other UK nations’ public health teams in the UK, so this report only covers TB notifications and data from England.

Detailed results for data up to the end of 2021 are published in the annual report.

This report aims to provide timely and up-to-date figures of important epidemiological indicators to inform ongoing TB control efforts in England.

Methodology

TB notifications

People who are diagnosed with TB in England, Wales and Northern Ireland must be notified through NTBS. This report only includes data for individuals with TB who are resident in England or are treated in England (including individuals who are homeless or visiting from abroad). Individuals with TB are reported by area of residence and by calendar year quarter of notification. UKHSA centre was derived from UKHSA region of residence based on individual’s residential postcode. If missing, UKHSA centre in which treatment occurred was used, for example if a person had no fixed abode. Data from quarter 1 2022 onwards is provisional and is provisional for treatment outcomes for those notified from quarter 1 of 2021 onwards. Verification and data cleaning and recoding, as conducted for the annual TB report data set, are not yet complete for provisional data.

Culture confirmation

Microbiological culture from biological specimens from persons with suspected disease confirms diagnosis and provides valuable information on antimicrobial susceptibility of TB and possible transmission events between persons notified with TB. It is noted that suitable specimens from children and from non-pulmonary sites are harder to obtain and culture due to lower numbers of viable bacteria.

Site of disease

Site of disease is classified as pulmonary and therefore potentially infectious through airborne transmission if disease was recorded in the lungs, larynx or was recorded as miliary (for example. disseminated TB). If none of these sites were recorded, disease is classified as non-pulmonary disease. People can have multiple sites of disease and have pulmonary and non-pulmonary disease sites.

Social risk factors including prison and asylum status

People with TB are reported as having at least one social risk factor (SRF) (‘yes’) if any of the 6 SRFs had ‘yes’ recorded. The 6 SRFs are:

• current alcohol misuse
• current or a history of homelessness
• current or a history of imprisonment
• current or a history of drug misuse
• asylum seeker status
• mental health needs

As a result, the denominator is all notifications. This assumes that people for whom no data was recorded for individual SRFs were a ‘no’ and may result in under-estimation. Data for individual social risk factors reported are limited to those with recorded data, for example a ‘yes’ or a ‘no’. As a result, the denominators for these are smaller than all notifications due to missing data. If there is significant under-reporting of SRFs in those with missing data, this should result in a better estimate of the true proportion of the people with each SRF. However, if data is more likely to be recorded if the response is a ‘yes’, this could result in an over-estimate. This may be the case for the asylum seeker SRF.

Mental health need is recorded by TB case managers and is based on their judgement if mental health concerns are likely to affect the person’s ability to adhere to treatment.

Alcohol misuse is as recorded by case managers and is based on their judgement if current alcohol misuse is likely to affect adherence to treatment.

History of drug misuse, homelessness and prison are self-reported by individuals and are first asked as a ‘yes’ or ‘no’ response and then with additional information on duration, as current, within last 5 years, or more than 5 years ago. Unless indicated otherwise, analyses here present these SRFs as ‘yes’ if either history of, or a duration value, was recorded.

Data for SRFs is reported only for people aged 15 years or over due to low numbers in young children.

Treatment delay

Treatment delay is calculated as the days difference between self-reported date of symptom onset and the date treatment started. People with either a missing symptom onset date or treatment start date have no value calculated for treatment delay and are not included in the denominator for the proportion of people with treatment delay.

Treatment outcome

For people in the cohort expected to complete treatment in 12 months, if no treatment outcome at 12 months was recorded this was recoded as ‘not evaluated’. Hence, the denominator for the proportion of people completing treatment in 12 months includes all people in this cohort.