Official Statistics

National quarterly report of tuberculosis in England: Quarter 4, 2022 provisional data

Updated 25 April 2024

Applies to England

Background

This report presents quarterly data on tuberculosis (TB) case notifications in England. Notifications include patients with culture confirmed TB or if a patient has started treatment for TB based on the 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.

Detailed results for data up to the end of 2020 are published on GOV.UK.

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 is provisional and subject to validation and should be interpreted with caution. The data used for this report was extracted on 10 January 2023.

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 4 (October to December) 2022, 987 people were notified with TB in England. This is slightly lower than quarter 4 2021 (1,021).

Figure 1. Number of TB notifications in England, quarter 1 (January to March) 2021 to quarter 4 (October to December) 2022

By UKHSA centre, in quarter 4 2022 compared with quarter 4 2021, the number of people notified with TB:

• increased in the East Midlands (up 18.8%) and North West (up 15.5%)
• remained similar in the London and Yorkshire and the Humber
• decreased in the North East (down 45.5%), South East (down 20.2%), East of England (down 15.2%), South West (down 9.3%) and the West Midlands (down 7.0%)

Figure 2a. Number of TB notifications in London, England, quarter 1 2021 to quarter 4 2022

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

Figure 2b. Number of TB notifications by UKHSA Centre, England, quarter 1 2021 to quarter 4 2022

Table 1. Number of TB notifications by UKHSA Centre, England, quarter 1 2020 to quarter 4 2022

	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
London	379	333	382	370	1,464	358	424	432	359	1,573	391	433	409	358 (-1)	1,591
North West	122	102	120	111	455	135	122	126	103	486	116	135	134	119 (+16)	504
West Midlands	146	141	127	134	548	126	159	150	128	563	143	161	112	119 (-9)	535
South East	109	101	121	125	456	113	136	132	129	510	109	127	142	103 (-26)	481
East Midlands	89	67	79	75	310	74	109	99	69	351	88	106	88	82 (+13)	364
East of England	104	102	83	82	371	88	105	86	92	371	96	92	92	78 (-14)	358
Yorkshire and the Humber	81	63	64	62	270	81	95	75	76	327	71	84	70	77 (+1)	302
South West	57	41	39	30	167	35	46	35	43	159	29	43	50	39 (-4)	161
North East	24	24	17	19	84	19	23	17	22	81	14	24	21	12 (-10)	71
Total	1,111	974	1,032	1,008	4,125	1,029	1,219	1,152	1,021	4,421	1,057	1,205	1,118	987 (-34)	4,367

Ordered by decreasing total number of people with TB in quarter 4 2022.

For all UKHSA centres in England combined, provisional data suggest a decreased number of notifications for 2022 compared with 2021 (1.2% decrease) and an increase in 2021 compared with 2020 (7.2% increase).

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 extra-pulmonary (site of disease). Pulmonary disease is defined here as disease affecting the lungs and extra-pulmonary disease cases 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 1 2021 to quarter 4 2022

Place of birth was not known for 19 notifications in quarter 4 2022 and 5 notifications in quarter 4 2021. Missing data may reflect difficulties in obtaining data (for example, patient died or language barriers). In quarter 4 2022, the number of people born outside of the UK accounted for 78.5% of notifications (n equals 760 divided by 968), a small increase in proportion compared with quarter 4 2021 (76.9%, n equals 781 divided by 1016). 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 4 2022, the number of people with pulmonary TB accounted for 53.9% (532 of 987) of all people with TB, consistent with 54.0% in quarter 4 2021 (551 of 1,021). For those born outside the UK, pulmonary disease accounted for 51.2% (389 of 760) of all cases in quarter 4 2022 compared with 61.5% (128 of 208) 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

Microbiological culture of TB from patients with suspected disease confirms diagnosis and provides valuable information on antimicrobial susceptibility of TB and possible transmission events between persons notified with TB. The difficulty of obtaining cultures from some patients, especially children, and non-pulmonary sites of disease is acknowledged. However, 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 extra-pulmonary) by quarter or year.

In 2021, preliminary data show the number of culture-confirmed cases are 60.9% (2,693 of 4,421). When limited to those with pulmonary disease, the proportion that are culture confirmed increases to 74.4% (1,690 of 2,271), still short of the 80% target. In quarter 4 2022, 47.8% (472 of 987) of notifications are culture confirmed. This increases to 57.9% (308 of 532) when limited to those with pulmonary disease. These numbers will increase as laboratory results are confirmed. Thus, comparisons by quarter are made for quarter 3 (July to September) 2022 versus quarter 3 2021. Only in quarter 1 (January to March) 2021 was the target of 80% of all pulmonary disease notifications reached, in which there was also the largest difference in culture confirmation between pulmonary and extra-pulmonary disease.

Figure 4. Proportion of culture confirmation among TB notifications by site of disease, England, quarter 1 2021 to quarter 4 2022

Figure 5 shows the proportions of culture confirmation for pulmonary and extra-pulmonary TB disease notifications by UKHSA centres. No UKHSA 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.

In quarter 3 2022 compared with quarter 3 2021, the largest changes in culture confirmation for pulmonary TB are seen for:

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

In quarter 3 2022 compared with quarter 3 2021, the largest changes in culture confirmation for pulmonary TB are seen for:

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

Figure 5a. Proportion of culture confirmation among TB notifications in London by site of disease, quarter 1 2021 to quarter 4 2022

Figure 5b. Proportion of culture confirmation among TB notifications by site of disease and UKHSA Centre, quarter 1 2021 to quarter 4 2022

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 multidrug or rifampicin resistance (MDR/RR). Multidrug resistance is classified as resistance to at least isoniazid and rifampicin. Figure 6 shows the number of culture confirmed notifications that are MDR/RR resistant by quarter.

Figure 6. Number of culture confirmed TB notifications with MDR/RR TB, England, quarter 1 2021 to quarter 4 2022

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

Numbers of TB notifications with culture confirmed MDR/RR in quarter 4 of 2022 are expected to increase as laboratory results are finalised. Provisional data show 38 people were notified with MDR/RR TB between quarter 1 and quarter 4 2022, compared with 55 from quarter 1 to quarter 4 2021.

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).

Figure 7. Proportion of pulmonary TB notifications starting treatment within 4 months (symptom onset to treatment start), England, quarter 1 2021 to quarter 4 2022

In quarter 4 2022, 64.6% of people with pulmonary TB started treatment within 4 months of symptom onset, compared with 66.3% in quarter 4 2021. This proportion will likely increase as some people in the most recent quarter are yet to begin treatment. Thus, quarter 3 2022 is compared with quarter 3 2021.

Figure 8 shows the proportion of people starting treatment within 4 months by UKHSA centre and quarter. In quarter 3 2022 compared with quarter 3 2021, the proportion of people with TB who started treatment within 4 months of symptom onset is:

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

Figure 8a. Proportion of pulmonary TB notifications in London starting treatment within 4 months (symptom onset to treatment start), quarter 1 2021 to quarter 4 2022

Figure 8b. Proportion of pulmonary TB notifications starting treatment within 4 months (symptom onset to treatment start) by UKHSA centre, quarter 1 2021 to quarter 4 2022

Treatment outcomes

Treatment outcomes at or before 12 months from start of treatment are reported for persons notified up to quarter 4 2021 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 4 2021 as many are not expected to have completed treatment. The data excludes people in the drug resistant cohort and those with CNS, spinal, miliary or cryptic disseminated TB as treatment time for these groups usually exceeds 12 months. Where a 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 69.9% for people notified in quarter 4 2021 compared with 79.5% in quarter 4 2020.

Please note: the latest 3 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 in 2020, the highest proportion of treatment completed was observed in quarter 1 at 85.2%.

Figures 9a and 9b. Outcomes at 12 months for people with drug sensitive TB with expected treatment duration of less than 12 months*, ** England, quarter 1 2020 to quarter 4 2021

Figure 9a

Figure 9b

*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/RR TB and who were therefore not treated as MDR/RR cases.

** Not evaluated includes unknown and transferred out.

Social risk factors

Social risk factors are reported as categorical yes or no variables with current or past history recorded as yes. Information on these social risk factors is collected though the routine surveillance system via interviews by the clinical team. Social risk factors that are recorded are current or history of prison, drug and alcohol use and homelessness. Data reported is for persons 15 years and over due to low numbers in young children.

Figure 10a. Proportion of TB notifications (persons 15 years or over) with social risk factors (SRF)*, England, quarter 1 2021 to quarter 4 2022

*Note: the axes on the figure for people with at least one SRF are different to that for individual SRFs due to the higher proportion of people with at least one SRF.

In quarter 4 2022, 13.0% of people with TB aged 15 years and over had at least one SRF. This is slightly higher than in quarter 4 2021 (11.2%).

For single risk factors, shown in Figure 10b, the proportions in quarter 4 2022 compared with quarter 4 2021 are:

• current or a history of drug misuse - lower
• alcohol misuse – higher
• current or a history of homelessness – higher
• imprisonment – lower

Figure 10b. Proportion of TB notifications (persons 15 years or over) with social risk factors, England, quarter 1 2021 to quarter 4 2022