Title page
Contents
Summary 3
Key points 5
Acknowledgements 8
Notes on the report 9
Background and context 11
1. TB notifications and incidence 15
Key messages 15
Overall numbers, rates and geographical distribution 15
Demographic characteristics 22
Occupation 30
Clinical characteristics 30
Co-morbidities 32
Travel and visitor risk factors 32
2. Laboratory confirmation among people notified with TB 34
Key messages 34
Laboratory tests data collection 34
Culture confirmation 34
Sputum smear test results 35
Other laboratory test results 35
TB isolates not matched to a TB notification 36
3. TB transmission 38
Key messages 38
Genotyping methods used to determine clustering 38
MIRU-VNTR strain typing in the South of England 39
Whole genome sequencing in North and Central England 40
Rate of TB in children born in the UK 41
Summary of TB transmission 42
4. Delay from symptom onset to treatment start 43
Key messages 43
Time from symptom onset to treatment start for people with pulmonary TB 43
Geographical distribution 46
5. TB outcomes in the drug sensitive cohort 48
Key messages 48
Drug sensitive cohort, 2007-2016 48
TB outcomes for the drug sensitive cohort with expected treatment duration of less than 12 months 49
TB outcomes for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB 52
TB outcomes in the entire drug sensitive cohort 52
6. Drug resistant TB and outcomes in the drug resistant cohort 55
Key messages 55
Identification and classification of drug resistance 55
Initial first line drug resistance 56
Isoniazid resistance without MDR-TB 56
Drug resistant cohort 59
Multi-drug resistant/rifampicin resistant (MDR/RR) TB 59
Second line drug resistance and Extensively Drug Resistant (XDR) TB 61
Acquired drug resistance on repeat culture 62
TB outcomes for the drug resistant cohort 63
7. TB in under-served populations 65
Key messages 65
Social risk factors 65
Demographic characteristics 66
Clinical characteristics 70
8. TB-HIV co-infection and HIV testing 73
Key messages 73
TB-HIV co-infection 73
Testing for HIV in people notified with TB 75
9. BCG vaccination 77
Key messages 77
BCG vaccine coverage data 77
Annual universal BCG programme vaccine coverage data 78
10. Latent TB infection testing and treatment 79
Key messages 79
Implementing and monitoring systematic LTBI testing and treatment in England 79
Programme coverage 80
Data in this chapter 80
Number of tests 80
Demographic characteristics 82
LTBI testing acceptance 84
IGRA test performance and LTBI positivity 85
Treatment for LTBI 87
11. UK tuberculosis pre-entry screening programme 90
Key messages 90
Drug susceptibility testing of positive TB cultures 92
12. Conclusions 94
13. Recommendations 97
To improve access to services and ensure early diagnosis (AfA1) 97
To provide universal access to high quality diagnostics (AfA2) 97
To improve treatment and care services (AfA3) 98
To reduce drug-resistant TB (AfA6) 98
To tackle TB in under-served populations (USPs) (AfA7) 99
To implement new entrant latent TB screening (AfA8) 99
References 101
Appendix I. Supplementary tables 103
Appendix II. Supplementary tables of local level data 173
Appendix III. Methods 188
Appendix IV. Surveillance data quality 198
Appendix V. National level data for TB strategy monitoring indicators, England, 2000-2017 206
List of acronyms 214
Glossary 216
Table 1.1. Most frequent countries of birth for people with TB and time between entry to the UK and TB notification, England, 2017 27
Table 1.2. Number of people with TB by site of disease, England, 2017 31
Table 1.3. Number of people with TB by co-morbidity status, England, 2017 32
Table 1.4. Number and proportion of people with TB with history of travel to and visitors received from a country outside the UK in the last two year prior to diagnosis, England, 2017 33
Table 2.1. Number and proportion of people without culture confirmed TB by alternative method of confirmation, England, 2017 36
Table 2.2. Unmatched isolates by specimen year, England, 2008-2017 37
Table 3.1. Number and proportion of people with TB clustered using MIRU-VNTR by place of birth and year and number of new clusters by year, South of England, 2010-2017 40
Table 3.2. Number and proportion of people with TB clustered using WGS by place of birth and number of new clusters, North and Central England, 2017 41
Table 4.1. Number and proportion of people with pulmonary TB by time from symptom onset to treatment start, England, 2011-2017 44
Table 4.2. Number and proportion of people with pulmonary TB by time from symptom onset to treatment start by age group, England, 2017 44
Table 4.3. Number and proportion of people with pulmonary TB who experienced a delay of more than four months between symptom onset and treatment start by age group and sex, England, 2017 45
Table 5.1. Outcome at 12 months for people with drug sensitive TB with expected treatment duration 〈12 months, England, 2016 49
Table 5.2. Last recorded TB outcome for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB, England, 2016 52
Table 5.3. Last recorded TB outcome for the entire drug sensitive cohort, England, 2016 53
Table 6.1. Number and proportion of people with drug resistant TB by characteristic, England, 2017 58
Table 6.2. Number of people with TB in the drug resistant cohort, England, 2000-2017 60
Table 6.3. Number of people with TB with initial and amplified XDR-TB, England, 2000-2017 61
Table 6.4. 24-month and last recorded TB outcomes for the drug resistant cohort, England, 2015 63
Table 7.1. Number and proportion of people with TB (≥15 years) with a social risk factor (SRF) by demographic characteristic, England, 2017 68
Table 7.2. Last recorded TB outcome for the entire drug sensitive cohort by social risk factor, England, 2016 71
Table 8.1. HIV testing in people notified with TB, England, 2012-2017 76
Table 8.2. HIV testing in people with notified TB by age group, England, 2017 76
Table 9.1. Annual BCG vaccine coverage at 12 months in English local authorities with TB incidence ≥40 per 100,000. April 2017 to March 2018 78
Table 10.1. People who were tested for LTBI as a proportion of total number of those offered a test as part of the LTBI, by CCG, 2016-2017 84
Table 10.2. Treatment acceptance and completion by for individuals tested positive for LTBI by CCG, 2016-2017 88
Figure A. TB notifications and rates, England, 1971-2017 12
Figure B. Observed and projected rate of TB notifications, England, 2010-2035 12
Figure 1.1. Number of TB notifications and rates, England, 2000-2017 16
Figure 1.2. Number TB notifications and rates by TB Control Board, England, 2017 17
Figure 1.3. Number of TB notifications and rates by PHE Centre, 2000-2017 18
Figure 1.4. Three-year average TB rates by clinical commissioning group (CCG), England, 2015-2017 (box shows enlarged map of London area) 20
Figure 1.5. Three-year average TB rates by local authority district, England, 2015-2017 (box shows enlarged map of London area) 21
Figure 1.6. Number of TB notifications and rates by place of birth, England, 2000-2017 23
Figure 1.7. Number of TB notifications and rates by age group and place of birth, England, 2017 23
Figure 1.8. Number of TB notifications and rates by PHE Centre and place of birth, 2000-2017 24
Figure 1.9. Trend in the number of people with TB for the top five countries of birth for those born outside the UK, England, 2008-2017 26
Figure 1.10. Time between entry to the UK and TB notification for people born outside the UK, England, 2008-2017 28
Figure 1.11. Number of people with TB born in the UK by ethnic group, England, 2000-2017 29
Figure 1.12. Number of TB notifications and rates by place of birth and ethnic group, England, 2017 30
Figure 3.1. Rate of TB in children (〈15 years) born in the UK, England, 2000-2017 42
Figure 4.1. Proportion of people with pulmonary TB by time from symptom onset to treatment start by place of birth, England, 2013-2017 46
Figure 4.2. Proportion of people with pulmonary TB with a delay of more than four months between symptom onset and treatment start by PHE Centre, England, 2013-2017 46
Figure 4.3. Proportion of people with pulmonary TB who experienced a delay of more than four months between symptom onset date and treatment start by local authority district, England, 2015-2017 (box shows enlarged map of London area) 47
Figure 5.1. Outcomes at 12 months for people with drug sensitive TB with expected treatment duration 〈12 months, England, 2007-2016 50
Figure 5.2. Outcomes at 12 months by age group for people with drug sensitive TB with expected treatment duration 〈12 months, by sex and age group, England, 2016 51
Figure 6.1. Number and proportion of people notified with TB with initial drug resistance, England, 2000-2017 57
Figure 6.2. Number and proportion of people with MDR/RR-TB by full resistance profile by most frequent country of birth, England, 2013-2017 62
Figure 6.3. Treatment completion for the drug resistant cohort, England, 2006-2015 64
Figure 7.1. Proportion of people with TB (≥15 years) with at least one social risk factor (SRF), England, 2013-2017 66
Figure 7.2. Proportion of people with TB (≥15 years) with social risk factors by place of birth, England, 2017 67
Figure 7.3. Number and proportion of people with TB (≥15 years) with at least one SRF by local authority, England, 2010-2017 (boxes shows enlarged map of London area) 69
Figure 7.4. Proportion of people with TB (≥15 years) with at least one social risk factor by PHE Centre, England, 2013-2017 70
Figure 7.5. Rate of TB by deprivation decile, England, 2017 72
Figure 8.1. Number and proportion of people with TB who have HIV co-infection, England, 2001-2017 74
Figure 8.2. Number of people notified with TB-HIV co-infection by age group, England, 2001-2017 75
Figure 10.1. Number of LTBI tests by CCG and year, England, 2016-2017 (box shows enlarged map of London area) 81
Figure 10.2. Number of LTBI tests by TB control board and year, 2016-2017 82
Figure 10.3. Number of people tested for LTBI by sex and age group, 2016-2017 83
Figure 10.4. Number and proportion of LTBI tests by country of birth, 2016-2017 83
Figure 10.5. Proportion of people that tested positive for LTBI by sex and age group, 2016-2017 85
Figure 10.6. Proportion of people that tested positive for LTBI by CCG and year, 2016-2017 (box shows enlarged map of London area) 86
Figure 10.7. Number and proportion of people reporting adverse treatment effects following LTBI treatment, 2016-2017 89
Figure 11.1. Number and rate of people with TB detected in high incidence countries through the UK pre-entry screening programme, 2006 to 2017 91
Figure 11.2. Number of people with TB detected by pre-entry screening in the 101 programme countries and those identified within one year of UK entrya, 2006 to 2017 92
Figure 11.3. Summary of drug susceptibility pattern for the 702 positive TB cultures that underwent DST, 2007 to 2017 93
Table Ai.A. Number of TB notifications, rates and annual percentage change, England, 1960-2017 103
Table Ai.1.1. Number of TB notifications, rates and annual percentage change, England, 2000-2017 105
Table Ai.1.2. Number of TB notifications and rates by PHE Centre, England, 2000-2017 106
Table Ai.1.3. Number of TB notifications and rates by age group and place of birth, England, 2017 108
Table Ai.1.4. Number of TB notifications, rates and annual percentage change by place of birth, England, 2000-2017 109
Table Ai.1.5. Number of TB notifications and rates by place of birth and PHE Centre, England, 2000-2017 110
Table Ai.1.6. Number and proportion of people with TB by most frequent country of birth for those born outside the UK, England, 2000-2017 113
Table Ai.1.7. Time between entry to the UK and TB notification for people with TB born outside the UK by year, England, 2008-2017 115
Table Ai.1.8. Number of TB notifications and rates by ethnic group and place of birth, England, 2017 116
Table Ai.1.9. Number of people with TB born in the UK over time by ethnic group, England, 2000-2017 117
Table Ai.1.10. Number and proportion of people with TB by site of disease and place of birth, England, 2008-2017 118
Table Ai.1.11. Number of people with TB receiving directly observed therapy (DOT) by age group, England, 2008-2017 119
Table Ai.2.1. Number and proportion of all people with TB who were culture confirmed by PHE Centre, England, 2008-2017 120
Table Ai.2.2. Species identification for people with culture confirmed TB, England, 2009-2017 121
Table Ai.2.3. Number and proportion of people with pulmonary TB who were culture confirmed by PHE Centre, England, 2008-2017 122
Table Ai.3.1. Numbers and rate of TB in children (〈15 years) born in the UK, England, 2000-2017 123
Table Ai.4.1. Number and proportion of people with pulmonary TB by time from symptom onset to treatment start and place of birth, England, 2011-2017 124
Table Ai.4.2. Number and proportion of people with pulmonary TB by time from symptom onset to treatment start and PHE Centre, England, 2011-2017 125
Table Ai.5.1. TB outcome at 12 months for people with drug sensitive TB with expected treatment duration 〈12months, England, 2007-2016 127
Table Ai.5.2. Last recorded TB outcome for people with drug sensitive TB with expected treatment duration 〈12months, England, 2007-2016 128
Table Ai.5.3. Time to treatment completion for people with drug sensitive TB with expected treatment duration 〈12months, England, 2007-2016 129
Table Ai.5.4. Treatment completion at 12 months by age group for people with drug sensitive TB with expected treatment duration 〈12months, England, 2007-2016 130
Table Ai.5.5. TB outcome at 12 months for people with drug sensitive TB with expected treatment duration 〈12 months by age and sex, England, 2016 131
Table Ai.5.6. Last recorded TB outcome for the entire drug sensitive cohort by site of disease, 2016 132
Table Ai.5.7. TB outcome at 12 months for people with drug sensitive TB with expected treatment duration 〈12 months by PHE Centre, England, 2016 133
Table Ai.5.8. Treatment completion at 12 months for people with drug sensitive TB with expected treatment duration 〈12months by PHE Centre, England, 2007-2016 134
Table Ai.5.9. Last recorded TB outcome by end of follow-up period for people with drug sensitive CNS, spinal, miliary or cryptic disseminated TB, England, 2007-2016 135
Table Ai.5.10. Last recorded TB outcome by end of follow-up period for the entire drug sensitive cohort, England, 2007-2016 136
Table Ai.5.11. Relationship with TB for people in the entire drug sensitive cohort who died at last recorded outcome, England, 2007-2016 137
Table Ai.5.12. Last recorded TB outcome for the entire drug sensitive cohort by PHE Centre, England, 2016 138
Table Ai.6.1. Number and proportion of people with TB with first line drug results, England, 2000-2017 139
Table Ai.6.2. Number and proportion of people with TB with first line drug resistance, England, 2000-2017 140
Table Ai.6.3. Number and proportion of people with TB with initial drug resistance, England, 2000-2017 141
Table Ai.6.4. Number and proportion of people with TB with drug resistance by Public Health England Centre, England, 2013-2017 142
Table Ai.6.5. Number and proportion of people with MDR/RR-TB with resistance to an injectable agent or a fluoroquinolone, England, 2000-2017 143
Table Ai.6.6. The number and proportion of people with MDR/RR-TB resistant to at least one injectable agent or at least one fluoroquinolone by most frequent country of birth, England, 2013-2017 144
Table Ai.6.7. TB outcome at 24 months after treatment start for the drug resistant cohort, England, 2006-2015 145
Table Ai.6.8. Last recorded TB outcome for the drug resistant cohort, England, 2006-2015 146
Table Ai.6.9. Time to TB treatment completion for the drug resistant cohort, England, 2006-2015 147
Table Ai.7.1. Number and proportion of people with TB (≥15 years) with a social risk factor (SRF) by place of birth, England, 2010-2017 148
Table Ai.7.2. Number and proportion of people with TB (≥15 years) with a social risk factor (SRF), by ethnicity and country of birth, England, 2013-2017 149
Table Ai.7.3. Number and proportion of people with TB (≥15 years) with social risk factors (SRF) by PHE Centre, England, 2017 150
Table Ai.7.4. Number and proportion of people with TB (≥15 years) with a social risk factor by PHE Centre, England, 2010-2017 151
Table Ai.7.5. Number and proportion of people with TB (≥15 years) with specific clinical and disease characteristics, according to the presence of social risk factors (SRF), England, 2017 152
Table Ai.7.6. TB notifications and rates by deprivation decile, England, 2017 153
Table Ai.8.1. Number and proportion of people (notified and un-notified) with TB-HIV co-infection, England, 2001-2017 154
Table Ai.8.2. Number and proportion of people (notified and un-notified) with TB-HIV co-infection by PHE Centre, England, 2001-2017 155
Table Ai 8.3. Number and proportion of people notified with TB who had HIV co-infection by age group, England, 2001-2017 156
Table Ai.8.4. HIV testing in people notified with TB by PHE Centre, England, 2017 157
Table Ai 9.1. Number of children vaccinated with BCG at 12 months of age, by upper tier local authority, financial years 2016-2017 and 2017-2018 158
Table Ai.10.1. Availability of data by source and CCG for latent TB testing 162
Table Ai.10.2. Number of LTBI tests by CCG and year, 2016-2017 164
Table Ai.10.3. Number and proportion of people tested for LTBI by country of birth, 2016-June 2017 166
Table Ai.10.4. Number and proportion of people that tested positive for LTBI by CCG and year, 2016-2017 167
Table Ai.11.1. Number and rate of people with TB detected in high incidence countries through the UK pre-entry screening programme, 2006 to 2017 170
Table Ai.11.2. Number of people with pulmonary TB detected by pre-entry screening and those identified within one year of UK entry, 2006 to 2017 171
Table Ai.11.3. Drug susceptibility testing of sputum cultures from people detected with TB, 2006 to 2017 172
Table Aii.1.1. Three year average number of people with TB and rates by upper tier local authority and local authority district, England, 2015-2017 173
Table Aii.1.2. Three-year average number of people with TB and rates by clinical commissioning group (CCG), England, 2015-2017 183
Table Aiv.1. Percentage completeness of key data fields in ETS by PHE Centre, England, 2017 202
Table Aiv.2. Percentage difference in completeness of key fields in ETS between 2016 and 2017 by PHE Centre, England 202
Table Aiv.3. Percentage completeness of data fields for diagnosis, death and treatment in ETS by PHE Centre, England, 2017 203
Table Aiv.4. Percentage difference in completeness of data fields for diagnosis, death and treatment in ETS between 2016 and 2017 by PHE Centre, England 203
Table Aiv.5. Percentage completeness of data fields for co-morbidities in ETS by PHE Centre, England, 2017 204
Table Aiv.6. Percentage difference in completeness of data fields for co-morbidities in ETS between 2016 and 2017 by PHE centre, England 204
Table Aiv.7. Percentage completeness and difference to previous year of data fields for travel and visitor history in ETS by PHE centre, England, 2017 205