Official Statistics

National quarterly report of tuberculosis in England: Quarter 3, 2023 provisional data

Updated 25 April 2024

Applies to England

Main messages 

In the first 3 quarters of 2023, there was an 8.1% increase in tuberculosis (TB) notifications compared with the same period in 2022 (3,628 versus 3,402). The cumulative number of notifications in 2023 most closely matches that observed in the pre-COVID-19 pandemic year of 2019, with lower total notifications in 2021 and 2022. 

In quarter 3 of 2023 there was a similar number of people (54 additional people, 5% increase) notified with TB compared with the same quarter in 2022 (1,175 versus 1,121). This compares with a rise of 14% for quarter 2 of 2023 versus the equivalent quarter in 2022 (1,353 versus 1,191). 

In quarter 3 2023, the greatest number of TB notifications continued to be in London. Notifications were not stable across regions, with the largest increases compared with the same quarter in 2022 in the North East, Yorkshire and the Humber, and West Midlands.  

The proportion of people notified with pulmonary disease that is confirmed by culture in the last 4 reporting quarters remains below the European standard and target of 80%. The 5% increase in rate per year outlined in the joint UK Health Security Agency (UKHSA) and NHS England TB action plan for England, 2021 to 2026 has not been achieved over the last 24 months.  

Over the last 4 quarters (quarter 4 2022 to quarter 3 2023) the number of people notified with multi-drug resistant (MDR), or rifampicin resistant (RR) TB is the same compared with the preceding 4 quarters (52 people in both periods). 

Over the last 8 quarters, the proportion of people experiencing delay between reported symptom onset and start of treatment of more than 4 months (30%) and the proportion completing TB treatment within the expected 12-month duration (80%) remains static with no evidence of improvement towards TB action plan targets.

In quarter 3 2023, a similar proportion of people with TB aged 15 years and over had at least one social risk factor (SRF) (such as alcohol and/or drug misuse, asylum seeker, homelessness, mental health need, and/or imprisonment) compared with the same quarter in 2022 (15.2% versus 18.5%).

Overall numbers and geographical distribution 

The number of notifications per quarter for England are shown in Figure 1a and cumulative number of notifications by month for 2019, in Figure 1b. The number of notifications per quarter by UKHSA regions are shown in Figures 2a and 2b. Exact numbers per quarter by UKHSA region 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 3 2023, 1,175 people were notified with TB. This is similar (4.8% increase) to quarter 3 2022 (1,121). In 2023, the greatest year-on-year percentage rise in notified cases between equivalent quarters was in the second quarter, with a 14% increase (1,353 versus 1,191). 

Figure 1a. Number of TB notifications in England, quarter 1 (January to March) 2020 to quarter 3 (July to September) 2023 (Table 1 of the supplementary data set)

When comparing the cumulative number of cases by month (Figure 1b), the pre-pandemic year of 2019 is included for reference and the peak COVID-19 pandemic year of 2020 excluded to allow comparison with the years since (Figure 1b). In 2023 so far (January to September), there have been 3,628 notifications, which most closely matches the pre-pandemic year of 2019 and is an 8.1% increase compared with the same period in 2022 (3,402 notifications) and 6.6% increase compared with 2021.   

Figure 1b. Monthly cumulative number of TB notifications, England. Data from pre-pandemic year, 2019, and between January 2021 to quarter 3 (July to September) 2023 (Table 1 of the supplementary data set)

Over the last 4 quarters (quarter 4 2022 to quarter 3 2023) there has been an increased number of TB notifications compared with the preceding 4 quarters (quarter 4 2021 to quarter 3 2022) with 4,651 people notified compared with 4,378 people, a 6.2% increase.  

Provisional data so far suggest an increase in TB notifications compared with the previous 2 years up to a level seen before the COVID-19 pandemic. Similar patterns have been observed in many other countries as seen in the World Health Organization (WHO) Global Tuberculosis Report.  

By UKHSA region, in quarter 3 2023 compared with quarter 3 2022 the number of people notified with TB: 

• increased in London (6.5% increase), North East (23.8% increase), North West (10.6% increase), West Midlands (11.4% increase) and Yorkshire and the Humber (15.5% increase) 
• remained similar in the East of England (2.0% increase), South East (3.5% decrease) and South West (4.0% decrease) 
• decreased in the East Midlands (10.9% decrease) 

Figure 2a. Number of TB notifications in London, England, quarter 1 (January to March) 2020 to quarter 3 (July to September) 2023 (Table 1 of the supplementary data set) [note 1]

[note 1] The axes on the London figure are different from those of the other regions due to the higher number of TB notifications in London. 

Figure 2b. Number of TB notifications in UKHSA centre, England, quarter 1 (January to March) 2020 to quarter 3 (July to September) 2023 (Table 1 of the supplementary data set) [note 2]

[note 2] Charts in Figure 2b are ordered by decreasing total number of people with TB in quarter 3 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 (and therefore potentially airborne and infectious) or non-pulmonary (site of disease). 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 4 (October to December) 2021 to quarter 3 (July to September) 2023 (Table 2 of the supplementary data set)

Place of birth was not known for 11 notifications in quarter 3 2023 and 5 notifications in quarter 3 2022. Missing data may reflect difficulties in obtaining data (for example, if the patient died or language barriers). In quarter 3 2023, people born outside of the UK accounted for 80.9% of notifications (942 out of 1,164), a small change in proportion compared with quarter 3 2022 (80.1% (894 out of 1,116)). 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 3 2023 people with pulmonary TB accounted for 51.5% (605 of 1,175) of all notifications, consistent with 52.3% in quarter 3 2022 (586 of 1,121).  

For those born outside the UK, pulmonary disease accounted for 48.3% (455 of 942) of all notifications in quarter 3 2023 compared with 64.4% (143 of 222) 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 for England, 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 quarter 3 2023, 42.8% (503 of 1,175) of notifications are culture confirmed. This increases to 49.6% (300 of 605), 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 2 2023 versus quarter 2 2022. The 80% target of culture confirmation for pulmonary TB disease was reached in 0 of the last 8 quarters. 

Figure 4. Proportion of culture confirmation among TB notifications by site of disease, England, quarter 4 (October to December) 2021 to quarter 3 (July to September) 2023 (Table 3 of the supplementary data set)

Figure 5a and Figure 5b show the proportions of culture confirmation for pulmonary and non-pulmonary TB disease notifications by UKHSA regions. No UKHSA regions 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. 

In quarter 2 2023 compared with quarter 2 2022 the largest changes in culture confirmation for non-pulmonary TB are seen for: 

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

In quarter 2 2023 compared with quarter 2 2022 the largest changes in culture confirmation for non-pulmonary TB are seen for: 

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

Figure 5a. Proportion of culture confirmation among TB notifications in London by site of disease, quarter 4 (October to December) 2021 to quarter 3 (July to September) 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 4 (October to December) 2021 to quarter 3 (July to September) 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. 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 WHO guidance of classification of multidrug or rifampicin resistance (MDR or RR). Multidrug resistance 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 4 (October to December) 2021 to quarter 3 (July to September) 2023 (Table 6 of the supplementary data set) [note 3]

[note 3] Figure 6 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 in quarter 3 2023 were slightly 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 2022 to quarter 2023) compared with the previous 4 quarters (52 people from quarter 2021 to quarter 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 and commencement of anti-tubercular therapy 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 TB action plan for England, 2021 to 2026 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 1 (January to March) 2020 to quarter 3 (July to September) 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 3 of 2023 symptom onset date was missing for 168 people (28.0%) compared with 113 (19.7%) for quarter 3 in 2022 and treatment start date missing for 179 (25.3%) compared with 111 (17.7%). 

In quarter 3 2023, 69.1% of people with pulmonary TB started treatment within 4 months of symptom onset, compared with 67.9% in quarter 3 2022. This proportion may change due to incomplete data in the latest quarter. As a result, comparisons are made for the quarter preceding the most current.  

In England the proportion of people starting treatment within 4 months in quarter 2 2023 compared with quarter 2 in the preceding year was 71.8% versus 70.3%.  

Figures 8a and 8b show the proportion of people starting treatment within 4 months by UKHSA centre and quarter. In quarter 2 2023 compared with quarter 2 2022, the proportion of people with TB who started treatment within 4 months of symptom onset is: 

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

Figure 8a. Proportion of pulmonary TB notifications in London starting treatment within 4 months (symptom onset to treatment start), quarter 4 (October to December) 2021 to quarter 3 (July to September) 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 4 (October to December) 2021 to quarter 3 (July to September) 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 3 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 3 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 TB action plan for England, 2021 to 2026 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. 

For those notified between quarter 4 2020 and quarter 3 2022 the highest proportion of treatment completed was observed in quarter 1 2021 at 85.0%. 

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.  

Figures 9a and 9b. Outcomes at 12 months for people treated for drug sensitive TB with expected treatment duration under 12 months, England, quarter 1 (January to March) 2020 to quarter 3 (July to September) 2022 (Table 10 of the supplementary data set) 

Figure 9a [note 4] [note 5]

Figure 9b [note 4] [note 6]

[note 4] 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. 

[note 5] Not evaluated includes unknown and transferred out. 

[note 6] 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, drug and alcohol misuse, homelessness, 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 (aged 15 years and over) with at least one social risk factor (SRF), England, quarter 4 (October to December) 2021 to quarter 3 (July to September) 2023 (Table 11 of the supplementary data set) [note 7]

[note 7] The axes on the figure for people with at least one SRF (Figure 10a) are different from those for individual SRFs (Figure 10b) due to the higher proportion of people with at least one SRF. 

In quarter 3 2023, 15.2% of people with TB aged 15 years and older had at least one SRF. This is similar compared with quarter 3 2022 (18.5%). 

For single risk factors, shown in Figure 10b, the proportion of people with TB in quarter 3 2023 with: 

• alcohol misuse was slightly lower than quarter 3 2022 
• asylum seeker status was lower than quarter 3 2022 
• current or a history of drug misuse was slightly higher than quarter 3 2022 
• current or a history of homelessness was lower than quarter 3 2022 
• mental health needs was lower than quarter 3 2022 
• current or history of imprisonment was lower than quarter 3 2022 

Figure 10b. Proportion of TB notifications (aged 15 years and over) by social risk factor, England, quarter 4 (October to December) 2021 to quarter 3 (July to September) 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 2 October 2023. 

This report presents quarterly data on people with 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. 

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 are provisional and are 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 is 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 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 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 has ‘yes’ recorded. As a result, the denominator is all notifications. This assumes that people for whom no data were recorded for individual SRFs were a ‘no’ and may result in under-estimation. The 6 SRFs are: 

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

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 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 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. 

Statements 

Our statistical practice is regulated by the Office for Statistics Regulation (OSR). OSR sets the standards of trustworthiness, quality and value in the Code of Practice for Statistics that all producers of official statistics should adhere to. You are welcome to contact us directly by emailing tbunit@ukhsa.gov.uk with any comments about how we meet these standards. Alternatively, you can contact OSR by emailing regulation@statistics.gov.uk or via the OSR website. 

UKHSA is committed to ensuring that these statistics comply with the Code of Practice for Statistics. This means users can have confidence in the people who produce UKHSA statistics because our statistics are robust, reliable and accurate. Our statistics are regularly reviewed to ensure they support the needs of society for information. They were last formally reviewed internally in spring 2023. Actions following this review have continued to improve the trustworthiness, quality and value of the statistics, including:   

• automation of data processing to improve the accuracy of the statistics 

• improved transparency of assessment of data, methods and quality assurance via publication of the accompanying quality and methodology information report 

• simplified commentary to better enable users to understand the key messages 

• clearer advice on appropriate use of the statistics, including consideration of seasonal trends in the data