Official Statistics

National quarterly report of tuberculosis in England: Quarter 2, 2023 provisional data

Updated 25 April 2024

Applies to England

Main messages

In the first half of 2023, there was a 7% increase in TB notifications compared with the first half of 2022 (2,408 versus 2,251).

Compared with the same quarter in 2022, there was a 10% increase in the number of people notified with TB; this increase was not uniform across regions with large increases in some typically low incidence areas.

As in all recent years except 2020, there was a seasonal increase in notifications in the second quarter compared to the first quarter of the year. This year, that increase was slightly larger at a 21% increase compared with 18% in 2021 and 13% in 2022.

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

The number of people notified with multi-drug resistant (MDR), or rifampicin resistant (RR) TB is lower in the second quarter of 2023 compared with the same quarter in 2022 (11 versus 17); but has increased over the first half of 2023 compared with the first half of 2022 (30 versus 23).

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

No notable improvement was 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 of the supplementary data set. 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 2 2023, 1,320 people were notified with TB in England. This is higher than the same quarter in 2022 (1,195), an increase of 10.5%. The number of notifications in quarter 1 of 2023 was also increased compared with quarter 1 of 2022, representing a 7% increase for the first half of 2023 compared with the same period in 2022.

As in all recent years except 2020 there was a seasonal increase in notifications in the second quarter compared to the first quarter of the year. This year that increase was slightly larger at 21% increase compared with 18% in 2021 and 13% in 2022.

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

(Table 1 of the supplementary data set)

By UKHSA centre, in quarter 2 2023 compared with quarter 2 2022 the number of people notified with TB:

• increased in London (10.0% increase), North East (8.0% increase), North West (23.1% increase), South East (20.3% increase), South West (42.9% increase) and West Midlands (6.9% increase)
• were unchanged in the East Midlands (0.0%) and East of England (0.0%)
• decreased in Yorkshire and the Humber (6.0% decrease)

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

(Table 1 of the supplementary data set)

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

(Table 1 of the supplementary data set)

Notes:

1. The axes on the London figure are different to that of the other regions due to the higher number of TB notifications in London.
2. Charts in Figure 2b are ordered by decreasing total number of people with TB in quarter 2 2023.

Demographic and clinical characteristics

The number of TB notifications by place of birth (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 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 2 of the supplementary data set)

Place of birth was not known for 13 notifications in quarter 2 2023 and 2 notifications in quarter 2 2022. Missing data may reflect difficulties in obtaining data (for example, if the patient died or language barriers). In quarter 2 2023, people born outside of the UK accounted for 80.3% of notifications, a small change in proportion compared with quarter 2 2022 (78.4%). Note that the numbers do not correspond to the total number of notifications due to missing data.

There was no missing data for pulmonary versus non-pulmonary disease. In quarter 2 2023, the number of people with pulmonary TB accounted for 52.8% of all people with TB, consistent with 53.3% in quarter 2 2022. For those born outside the UK, pulmonary disease accounted for 48.6% of all notifications in quarter 2 2023 compared with 70.2% 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 by disease site (pulmonary or non-pulmonary) by quarter.

In Q2 2023, 48.0% of notifications were culture confirmed. This increased to 56.0% in those with pulmonary disease. These numbers will increase as laboratory results become available for the most recent notifications in the current quarter which are not yet expected.

Thus, further comparisons by quarter are made for quarter 1 2023 versus quarter 1 2022. The 80% target of culture confirmation for pulmonary TB disease was reached in 0 of the last 8 quarters with little change over time for culture confirmation in people notified with pulmonary disease and lower in 2023 in people notified with non-pulmonary disease compared with earlier quarters.

Figure 4. Proportion of culture confirmation among TB notifications by site of disease, England, quarter 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 3 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 have been 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.

In quarter 1 2023 compared with quarter 1 2022 the largest changes in culture confirmation for pulmonary TB were seen for:

• London and South West, which both decreased
• East Midlands, North East, North West and South East, which all increased

In quarter 1 2023 compared with quarter 1 2022 the largest changes in culture confirmation for non-pulmonary TB were seen for:

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

Figure 5a. Proportion of culture confirmation among TB notifications in London by site of disease, quarter 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 4 of the supplementary data set)

Figure 5b. Proportion of culture confirmation among TB notifications by site of disease and UKHSA centre, quarter 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 5 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 to 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. MDR is classified as resistance to isoniazid and rifampicin. Figure 6 shows the number of culture confirmed notifications that are MDR or RR by quarter.

Figure 6. Number of culture confirmed TB notifications with MDR or RR TB at diagnosis, England, quarter 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 6 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 2 2023 were lower than the same quarter in 2022 but may increase as laboratory results are finalised. However, provisional data indicates a similar number of people were notified with MDR or RR TB (52 people) in the most recent 4 quarters (quarter 3 2022 to quarter 2 2023) compared with the previous 4 quarters (51 people from quarter 3 2021 to quarter 2 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 only for pulmonary TB (Figure 7) 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 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 7 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 2 of 2023 this was missing for 195 people (28.3%) compared with 114 (18.1%) for quarter 2 in 2022. In quarter 1 of 2023 it was missing for 144 (25.0%) compared with 96 (17.0%) for quarter 1 in 2022.

In quarter 2 2023, 71.3% of people with pulmonary TB started treatment within 4 months of symptom onset, compared to 70.3% in quarter 2 2022. This proportion may change due to incomplete data in the latest quarter. As a result, quarter 1 2023 is compared with quarter 1 2022.

Figures 8a and 8b show the proportion of people starting treatment within 4 months by UKHSA centre and quarter. In quarter 1 2023 compared with quarter 1 2022, the proportion of people with TB who started treatment within 4 months of symptom onset is:

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

Figure 8a. Proportion of pulmonary TB notifications in London starting treatment within 4 months (symptom onset to treatment start), quarter 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 8 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 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 9 of the supplementary data set)

Treatment outcomes

Treatment outcomes at or before 12 months from start of treatment are reported for people notified up to quarter 2 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 2 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 may exceed 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 cases) 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 71.3% for people notified in quarter 2 2022 compared with 83.5% in quarter 2 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 3 2020 and quarter 2 2021 the highest proportion of treatment completed was observed in quarter 1 2021 at 84.8%.

Figures 9a and 9b. Outcomes at 12 months for people treated for drug sensitive TB with expected treatment duration under 12 months, England, quarter 3 (July to September) 2020 to quarter 2 (April to June) 2022

(Tables 10 and 11 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. People 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) recorded include current or history of prison, homelessness drug misuse, current alcohol misuse, mental health needs and asylum seeker status. Data reported is only for people aged over 15 years due to low numbers in young children.

Figure 10a. Proportion of TB notifications (15 years or older) with at least one social risk factor (SRF) recorded, England, quarter 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 12 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 2 2023, 15.5% of people with TB aged 15 years and older had at least one SRF. This is similar compared with quarter 2 2022 (16.1%).

The most common SRF in the latest quarter was being an asylum seeker at 6.4% of adults (aged 15 years or older) notified with TB and information recorded for this SRF. Homelessness was 6.3%. Data on asylum seeker status was missing in 14.9% of notifications. Data on prison status was missing in 18.4% of notifications. It should be noted that asylum seeker status had high levels of missing data in the first 2 quarters reported here and comparisons with these quarters should be interpreted with caution.

For single risk factors, shown in Figure 10b, the proportion of people with TB in Q2 2023 with:

• current alcohol misuse was lower than quarter 2 2022
• current asylum seeker status was higher than quarter 2 2022
• current or a history of drug misuse was slightly lower than quarter 2 2022
• current or a history of homelessness was similar to quarter 2 2022
• current mental health needs was similar to quarter 2 2022
• current or history of imprisonment was higher than quarter 2 2022

Note that some people will have more than one SRF.

Figure 10b. Proportion of TB notifications (15 years or older) by social risk factor, England, quarter 3 (July to September) 2021 to quarter 2 (April to June) 2023

(Table 12 of the supplementary data set)

Note: Percentages in the above figure are calculated from notifications with information recorded for each SRF (please see the methodology section).

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 4 July 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 cases of TB 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.

For more information on the data and methods used for this report, see the accompanying quality and methodology information document.

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. The UKHSA centre was derived from the UKHSA region of residence based on an individual’s residential postcode. If missing, the 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.

Please note that the total number of notifications in 2021 is different (minus 2) from the published 2021 annual report due to subsequent changes in notification date from 2021 to 2022.

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 from 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 (disseminated TB). If none of these sites was recorded, disease is classified as non-pulmonary disease. People can have multiple sites of disease and have pulmonary and extra-pulmonary disease sites.

Social risk factors

People with TB are reported as having at least one SRF (‘yes’) if any of the 6 social risk factors 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
• current asylum seeker status
• current 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 is 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 over-estimates. This may be the case for the asylum seeker SRF.

Mental health needs 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 are reported only for people aged over 15 years 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.