Official Statistics

National quarterly report of tuberculosis in England: quarter 4 2023, provisional data

Updated 25 April 2024

Applies to England

Main points

Provisional data in 2023 shows that:

• tuberculosis (TB) notifications increased in quarter 4 2023 compared with quarter 4 2022, and for the whole year, notifications increased by 10.7% to 4,850; a rebound to above the pre-COVID-19-pandemic numbers in 2019
• this takes England further from the trajectory required to meet World Health Organisation (WHO) elimination targets
• numbers increased in 2023 nearly equally in both UK-born and non-UK born individuals (9.1% and 10.8%, respectively)
• the increase in notifications in 2023 compared with 2022 was seen across all regions in England, and was highest in the low incidence regions of the North East (50.0% increase) and the South West (30.4% increase)
• the number of individuals with culture-confirmed rifampicin-resistant (RR) or multidrug-resistant (MDR) TB increased by 53% to 66 individuals in 2023 compared with 2022, after remaining stable since 2017

Overall numbers and geographical distribution

The number of notifications per quarter for England are shown in Figure 1a and the cumulative number of notifications by month from 2019, in Figure 1b. The number of notifications per quarter by UKHSA regions are showing 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. Because of 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 2023, 1,175 people were notified with TB in England. This is higher than quarter 4 2022 (1,025).

Figure 1a. Number of TB notifications in England, quarter 1 (January to March) 2021 to quarter 4 (October to December) 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 pandemic year of 2020 is excluded to allow comparison with the years since (Figure 1b).

Figure 1b. Monthly cumulative number of TB notifications, England. Data from pre-pandemic year, 2019, and between January 2021 to quarter 4 (October to December) 2023 (Table 2 of the supplementary data set)

Provisional data for the last 4 quarters indicates that the cumulative number of notifications is higher this year at 4,850 than the same quarters in the pre-pandemic year of 2019 (in which there were 4,704 notifications).

By UKHSA region, in quarter 4 2023 compared with quarter 4 2022, the number of people notified with TB:

• increased in the East of England (6.0% increase), London (9.7% increase), North East (85.7% increase), North West (23.3% increase), South East (25.5% increase), West Midlands (24.0% increase) and Yorkshire and the Humber (28.9% increase)
• remained similar in the South West (4.8% increase)
• decreased in the East Midlands (11.2% decrease)

Figure 2a. Number of TB notifications in London, England, quarter 1 (January to March) 2021 to quarter 4 (October to December) 2023 (Table 1 of the supplementary data set)

Figure 2b. Number of TB notifications in UKHSA region, England, quarter 1 (January to March) 2021 to quarter 4 (October to December) 2023 (Table 1 of the supplementary data set)

Notes:

1. The axes on the London figure are different to that of the other regions because of the higher number of TB notifications in London.
2. Ordered by decreasing total number of people with TB in quarter 4 2023.

Provisional data for the last 4 quarters of 2023 compared with the same period in 2022 suggests that the cumulative total of notifications has increased for all regions, with the greatest increase in numbers in London (103 extra) but the highest percentage increases in the North East (50.0%) and the South West (30.4%) (Table 1 of the supplementary data set)

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 1 (January to March) 2022 to quarter 4 (October to December) 2023 (Table 3 of the supplementary data set)

Place of birth was not known for 13 notifications in quarter 4 2023 and 8 notifications in quarter 4 2022. Missing data may reflect difficulties in obtaining data (for example, if the patient died or language barriers). In quarter 4 2023, people born outside of the UK accounted for 77.8% of notifications (904 out of 1,162), a decrease in proportion compared with quarter 4 2022 (80.2% (816 out of 1,017)). Note that the numbers do not correspond to the total number of notifications because of missing data. For the last 4 quarters in 2023, the total number of notifications in individuals born outside of the UK increased by 10.8% compared with the same period in 2022 and by 9.1% in UK-born individuals (Table 3 of the supplementary data set).  

There was no missing data for pulmonary versus non-pulmonary disease. In quarter 4 2023, the number of people with pulmonary TB accounted for 54.7% (643 of 1,175) of all people with TB, consistent with 55.3% in quarter 4 2022 (567 of 1,025). For those born outside the UK, pulmonary disease accounted for 48.7% (440 of 904) of all notifications in quarter 4 2023 compared with 76.4% (197 of 258) 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 quarter 4 2023, 45.7% (537 of 1,175) of notifications are culture confirmed. This increases to 56.1% (361 of 643) 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 3 2023 versus quarter 3 2023. 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 1 (January to March) 2022 to quarter 4 (October to December) 2023 (Table 4 of the supplementary data set](https://www.gov.uk/government/statistics/tuberculosis-in-england-national-quarterly-reports))

In quarter 3 2023 compared with quarter 3 2022 the largest changes in culture confirmation for pulmonary TB are seen for:

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

Figure 5 shows the proportions of culture confirmation for pulmonary and non-pulmonary TB disease notifications by UKSHA regions. No UKSHA 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 3 2023 compared with quarter 3 2022, the largest changes in culture confirmation for non-pulmonary TB are seen for:

• North West, South East and South West, which all decreased
• East Midlands, East of England, London, 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 1 (January to March) 2022 to quarter 4 (October to December) 2023 (Table 5 of the supplementary data set)

Figure 5b. Proportion of culture confirmation among TB notifications by site of disease and UKHSA region, quarter 1 (January to March) 2022 to quarter 4 (October to December) 2023 (Table 5 of the supplementary data set)

Multidrug-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 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 multidrug or rifampicin resistant by quarter.

Figure 6. Number of culture confirmed TB notifications with MDR or RR TB at diagnosis, England, quarter 1 (January to March) 2022 to quarter 4 (October to December) 2023 (Table 6 of the supplementary data set)

Note: this figure displays numbers rather than proportions because of a low number of MDR or RR TB notifications.

Numbers of TB notifications with culture-confirmed MDR or RR in quarter 4 2023 were higher than the same quarter in 2022 and may increase further as laboratory results are finalised. Additionally, provisional data indicates a higher number of people were notified with MDR or RR TB (66 people) in the most recent 4 quarters compared with the previous 4 quarters (43 people).

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) because of 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 1 (January to March) 2022 to quarter 4 (October to December) 2023 (Table 7 of the supplementary data set)

Data was missing for a considerable proportion of people because there was a missing date of onset of symptoms or treatment start date. In quarter 4 of 2023, this was missing for 212 people (33.0%) compared with 124 (21.9%) for quarter 4 in 2022. In quarter 3 of 2023, it was missing for 156 (25.3%) compared with 134 (22.3%) for quarter 3 in 2022.

In quarter 4 2023, 65.7% of people with pulmonary TB started treatment within 4 months of symptom onset, compared with 67.3% in quarter 4 2022. This proportion may change because of incomplete data in the latest quarter. As a result, quarter 3 2023 is compared with quarter 3 2022.

Figures 8a and 8b show the proportion of people starting treatment within 4 months by UKHSA region and quarter. In quarter 3 2023, when compared with quarter 3 2022, the proportion of people with TB who started treatment within 4 months of symptom onset is:

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

Figure 8a. Proportion of pulmonary TB notifications in London starting treatment within 4 months (symptom onset to treatment start), quarter 1 (January to March) 2022 to quarter 4 (October to December) 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 region, quarter 1 (January to March) 2022 to quarter 4 (October to December) 2023 (Table 8 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 4 2022 with known or assumed drug-sensitive TB. The majority of these people should have completed treatment within 12 months of treatment start. Data is not presented for those notified after quarter 4 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 cases) or where the treatment was stopped. The proportion of each of these cases in the ‘other’ category 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 70.3% for people notified in quarter 4 2022 compared with 81.4% in quarter 4 2021.

Please note: the latest 4 quarters evaluated tend to show a high proportion of people with treatment outcomes recorded as ‘not evaluated’ despite their 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 1 2021 and quarter 4 2022, the highest proportion of treatment completed was observed in quarter 1 2021, at 85.2%.

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) 2021 to quarter 4 (October to December) 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. 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) 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 because of low numbers in young children.

Figure 10a. Proportion of TB notifications (15 years or older) with at least one SRF, England, quarter 1 (January to March) 2022 to quarter 4 (October to December) 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) because of the higher proportion of people with at least one SRF.

In quarter 4 2023, 14.8% of people with TB who are aged 15 years and older had at least one SRF. This is similar when compared with quarter 4 2022 (16.7%).

For SRFs, shown in Figure 10b, the proportion of people with TB in quarter 4 2023 with:

• alcohol misuse was similar to quarter 4 2022
• asylum seeker status was similar to quarter 4 2022
• current or a history of drug misuse was lower than quarter 4 2022
• current or a history of homelessness was slightly lower than quarter 4 2022
• mental health needs was slightly lower than quarter 4 2022
• current history of imprisonment was lower than quarter 4 2022

In the most recent 4 quarters, a similar proportion of people were notified, with at least one SRF (16.2%) compared with the previous 4 quarters (17.0%).

Figure 10b. Proportion of TB notifications (15 years or older) by social risk factor, England, quarter 1 (January to March) 2022 to quarter 4 (October to December) 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 2023 is provisional and subject to validation and should be interpreted with caution. The data used for this report was extracted on 11 January 2024.

This report presents quarterly data on people with tuberculosis 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

Detailed methods and data sources are available in our quality and methodology information for TB in England national reports

TB notifications

People who are diagnosed with TB in England, Wales and Northern Ireland must be notified through the 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 region was derived from UKHSA region of residence based on an individual’s residential postcode. If missing, UKHSA region in which treatment occurred was used, for example if a person had no fixed abode. Data from quarter 1 2023 onwards is provisional and is provisional for treatment outcomes for those notified from quarter 1 of 2022 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 (such as 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 (SRFs) including prison and asylum status

People with TB are reported as having at least one SRF (‘yes’) if any of the 6 SRFs have yes recorded. 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. 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-estimates. This may be the case for the asylum seeker SRF.

Mental health needs are recorded by TB case managers and is based on their judgement as to whether 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 as to whether 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: ‘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 because of 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 then recorded as ‘not evaluated’. This means that the denominator for the proportion of people completing treatment in 12 months includes all people in this cohort.