Title page
Contents
Key points 3
Acknowledgements 6
Notes on the report 7
Background 9
1. TB notifications and incidence 10
Key messages 10
Overall numbers, rates and geographical distribution 10
Demographic characteristics 17
Occupation 25
Clinical characteristics 25
Co-morbidities 27
Travel and visitor risk factors 28
2. Laboratory confirmation of TB 29
Key messages 29
Laboratory tests data collection 29
Culture confirmation 29
Sputum smear test results 30
Other laboratory test results 30
TB isolates not matched to notified cases 31
3. TB transmission 33
Key messages 33
Rate of TB in UK born children 33
Strain typing and clustering 34
Whole genome sequencing 36
4. Delay from symptom onset to treatment start 37
Key messages 37
Time from symptom onset to treatment start for pulmonary TB cases 37
5. TB outcomes in the drug sensitive cohort 40
Key messages 40
Drug sensitive cohort, 2006-2015 40
TB outcomes for the drug sensitive cohort with expected duration of treatment less than 12 months 41
TB outcomes for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB 43
TB outcomes in the entire drug sensitive cohort 44
6. Drug resistant TB (including TB outcomes in the drug resistant cohort) 46
Key messages 46
Initial first line drug resistance 47
Isoniazid resistance without MDR-TB 47
Drug resistant cohort 49
Multi-drug resistant/rifampicin resistant (MDR/RR) TB 50
Second line drug resistance and Extensively Drug Resistant (XDR) TB 52
Acquired drug resistance on repeat culture 53
TB outcomes for the drug resistant cohort 54
7. TB in under-served populations 56
Key messages 56
Social risk factors 56
Demographic characteristics 57
Geographical distribution 59
Clinical characteristics 61
Drug resistance 62
TB outcomes 62
Unemployment 63
TB cases that were asylum seekers or resident in an immigration removal centre 63
Deprivation 63
8. TB-HIV co-infection and HIV testing among TB cases 65
Key messages 65
TB-HIV co-infection 65
Testing for HIV in notified TB cases 67
9. BCG vaccination 69
Key messages 69
BCG vaccine coverage data 69
Annual universal BCG programme vaccine coverage data 70
Quarterly BCG coverage in London LAs with universal coverage 70
BCG vaccination status of TB cases 73
10. Latent TB infection testing and treatment 74
Key messages 74
Implementing and monitoring systematic LTBI testing and treatment in England 74
Data in this chapter 75
LTBI testing and treatment programme coverage 75
Programme coverage 75
LTBI testing 75
Demographic Characteristics 78
LTBI testing acceptance 79
IGRA test performance and LTBI positivity 81
Treatment for LTBI 83
11. UK tuberculosis pre-entry screening programme 85
Key messages 85
Drug susceptibility testing (DST) 87
12. Conclusions 89
13. Recommendations 92
To improve access to services and ensure early diagnosis (AfA1) 92
To provide universal access to high quality diagnostics (AfA2) 92
To improve treatment and care services (AfA3) 93
To reduce drug-resistant TB (AfA6) 93
To tackle TB in under-served populations (USPs) (AfA7) 94
To implement new entrant latent TB screening (AfA8) 94
References 96
Appendix I. Supplementary tables 98
Appendix II. Supplementary tables of local level data 165
Appendix III. Methods 180
Appendix IV. Surveillance data quality 189
Appendix V. National level data for TB strategy monitoring indicators, England, 2000-2016 197
List of acronyms 204
Glossary 205
Table 1.1. Most frequent countries of birth for TB cases and time between entry to the UK and TB notification, England, 2016 22
Table 1.2. TB case notifications by site of disease, England, 2016 26
Table 1.3. TB case notifications by co-morbidity status, England, 2016 27
Table 1.4. Number and proportion of TB case notifications with history of travel to and visitors received from a country outside the UK in the last two year prior to diagnosis, England, 2016 28
Table 2.1. Number and proportion of non-culture confirmed TB cases by method of laboratory confirmation, England, 2016 31
Table 2.2. Unmatched isolates by specimen year, England, 2007-2016 32
Table 3.1. Number and proportion of clustered cases and new clusters by place of birth and year, England, 2010-2016 34
Table 4.1. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start, England, 2011-2016 38
Table 4.2. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start by age group, England, 2016 38
Table 5.1. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈12 months, England, 2015 41
Table 5.2. Last recorded TB outcome for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB, England, 2015 43
Table 5.3. Last recorded TB outcome for the entire drug sensitive cohort, England, 2015 44
Table 6.1. Most frequent countries of birth of TB cases with drug resistance, England, 2016 48
Table 6.2. Number and proportion of TB cases with drug resistance by characteristic, England, 2016 49
Table 6.3. Number of TB cases with initial and acquired resistance to rifampicin and MDR-TB, England, 2000-2016 51
Table 6.4. 24-month and last recorded TB outcome for the drug resistant cohort, England, 2014 54
Table 7.1. Number and proportion of TB cases with social risk factors by demographic characteristic, England, 2016 59
Table 7.2. Last recorded TB outcome for the entire drug sensitive cohort by social risk factor, England, 2015 62
Table 8.1/Table 8.2. HIV testing in notified TB cases, England, 2011-2016 68
Table 8.2/Table 8.3. HIV testing in notified TB cases by age group, England, 2016 68
Table 9.1. BCG vaccine coverage estimates from CHISs for upper tier local authorities, England, April 2016 to March 2017 (April 2015 to March 2016) 71
Table 10.1. LTBI testing acceptance by CCG, July 2015-June 2017 80
Table 10.2. Treatment acceptance and completion by for individuals tested positive for LTBI by CCG, July 2014-June 2017 83
Figure 1.1. TB case notifications and rates, England, 2000-2016 11
Figure 1.2. TB case notifications and rates by PHE Centre, 2000-2016 12
Figure 1.3. Three-year average TB rates by local authority district, England, 2014-2016 (box shows enlarged map of London area)(원문불량) 14
Figure 1.4. Three-year average TB rates by clinical commissioning group (CCG), England, 2014-2016 (box shows enlarged map of London area)(원문불량) 15
Figure 1.5. TB case notifications and rates by TB control board, England, 2016 16
Figure 1.6. TB case notifications and rates by place of birth, England, 2000-2016 18
Figure 1.7. TB case notifications and rates by age group and place of birth, England, 2016 18
Figure 1.8. TB case notifications and rates by PHE Centre and place of birth, 2000-2016 19
Figure 1.9. Trend in TB case notifications for the top five countries of birth of non-UK born cases, England, 2007-2016 21
Figure 1.10. Time between entry to the UK and TB notification for non-UK born cases, England, 2007-2016 23
Figure 1.11. TB case notifications and rates by place of birth and ethnic group, England, 2016 24
Figure 1.12. Number of UK born TB cases over time by ethnic group, England, 2000-2016 25
Figure 3.1. Rate of TB in UK born children, England, 2000-2016 33
Figure 3.2. Proportion of clusters by size, England, 2010-2016 35
Figure 4.1. Proportion of pulmonary TB cases with a delay from symptom onset to treatment start by place of birth, England, 2011-2016 39
Figure 5.1. TB outcomes at 12 months for drug sensitive cases with expected treatment duration 〈12 months, England, 2006-2015 42
Figure 6.1. Number and proportion of TB cases with initial drug resistance, England, 2000-2016 47
Figure 6.2. Number and proportion of MDR/RR-TB cases with second-line drug resistance by most frequent country of birth, England, 2012-2016 53
Figure 6.3. Treatment completion for the drug resistant cohort, England, 2005-2014 55
Figure 7.1. Proportion of TB cases with at least one social risk factor, England, 2012-2016 57
Figure 7.2. Number and proportion of TB cases with social risk factors by place of birth, England, 2016 58
Figure 7.3. Number of TB cases with at least one SRF, by local authority, England, 2010-2016 (box shows enlarged map of London area)(원문불량) 60
Figure 7.4. Number of TB cases with at least one social risk factor by PHE Centre, England, 2012-2016 61
Figure 7.5. Rate of TB by deprivation decile, England, 2016 64
Figure 8.1. Number and proportion of TB cases with HIV co-infection, England, 2001-2015 66
Figure 8.2. Number of TB-HIV co-infected case notifications by age group, England, 2001-2015(원문불량) 67
Figure 9.1. Annual and quarterly proportion of BCG coverage for nine London local authorities with TB incidence ≥40 per 100,000 population and a universal BCG vaccination, for financial years 2015-16 and 2016-17 72
Figure 10.1. Number of individuals tested for LTBI by CCG, July 2014-June 2017 (box shows enlarged map of London area)(원문불량) 76
Figure 10.2. Number of individuals tested for LTBI by TB control board and year, July 2014-June 2017 77
Figure 10.3. Number of tests by year and quarter for latent TB testing, July 2014-June 2017 77
Figure 10.4. Number of tests by sex and age group for latent TB testing July 2014-June 2017 78
Figure 10.5. Number and proportion of individuals tested for LTBI by country of birth, July 2014-June 2017 79
Figure 10.6. Proportion and number of patients that tested positive for LTBI by sex and age group, July 2014-June 2017 81
Figure 10.7. Proportion of patients that tested positive for LTBI by CCG, July 2014-June 2017 (box shows enlarged map of London area)(원문불량) 82
Figure 10.8. Number and proportion of patients reporting adverse events following LTBI treatment, July 2014-June 2017 84
Figure 11.1. Number and rate of TB cases detected in high incidence countries through the UK pre-entry screening programme, 2006-2016 86
Figure 11.2. Number of pulmonary TB cases diagnosed by pre-entry screening in the 101 programme countries and those identified within one year of UK entry, 2006-2016 87
Figure 11.3. Drug susceptibility testing results of culture confirmed TB cases detected in high incidence countries through UK pre-entry screening programme, 2007-2016 88
Table Ai.1.1. TB case notifications, rates and annual percentage change, England, 2000-2016 98
Table Ai.1.2. TB case notifications and rates by PHE Centre, England, 2000-2016 99
Table Ai.1.3. TB case notifications and rates by age group and place of birth, England, 2016 101
Table Ai.1.4. TB case notifications, rates and annual percentage change by place of birth, England, 2000-2016 102
Table Ai.1.5. TB case notifications and rates by place of birth and PHE Centre, England, 2000-2016 103
Table Ai.1.6. Number and proportion of TB case notifications by most frequent country of birth in non-UK born population, England, 2000-2016 106
Table Ai.1.7. Time between entry to the UK and TB notification for non-UK born cases by year, England, 2007-2016 108
Table Ai.1.8. TB case notifications and rates by ethnic group and place of birth, England, 2016 109
Table Ai.1.9. Number of UK born TB case over time by ethnic group, England, 2000-2016 110
Table Ai.1.10. Number and proportion of TB case notifications by site of disease and place of birth, England, 2007-2016 111
Table Ai.1.11. Number of TB cases receiving directly observed therapy (DOT) by age group, England, 2007-2016 112
Table Ai.2.1. Number and proportion of all TB cases that are culture confirmed by PHE Centre, England, 2007-2016 113
Table Ai.2.2. Number and proportion of pulmonary TB cases that are culture confirmed by PHE Centre, England, 2007-2016 114
Table Ai.2.3. Species identification for culture confirmed TB cases, England, 2009-2016 115
Table Ai.3.1. Numbers and rate of TB in UK born children, England, 2000-2016 116
Table Ai.3.2. Number of TB clusters and proportion clustered cases by PHE Centre, England, 2010-2016 117
Table Ai.4.1. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start and PHE Centre, England, 2016 118
Table Ai.4.2. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start and place of birth, England, 2011-2016 119
Table Ai.5.1. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈12months, England, 2006-2015 120
Table Ai.5.2. Last recorded TB outcome for drug sensitive cases with expected treatment duration 〈12months, England, 2006-2015 121
Table Ai.5.3. Time to treatment completion for drug sensitive cases with expected treatment duration 〈12months, England, 2006-2015 122
Table Ai.5.4. Treatment completion at 12 months by age group for drug sensitive cases with expected treatment duration 〈12months, England, 2005-2014 123
Table Ai.5.5. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈12 months by PHE Centre, England, 2015 124
Table Ai.5.6. Treatment completion at 12 months for drug sensitive cases with expected treatment duration 〈12months by PHE Centre, England, 2006-2015 125
Table Ai.5.7. Last recorded TB outcome by end of follow-up period for drug sensitive cases with CNS, spinal, miliary or cryptic disseminated TB, England, 2006-2015 126
Table Ai.5.8. Last recorded TB outcome by end of follow-up period for the entire drug sensitive cohort, England, 2006-2015 127
Table Ai.5.9. Died at last recorded outcome for the entire drug sensitive cohort, England, 2006-2015 128
Table Ai.5.10. Last recorded TB outcome for the entire drug sensitive cohort by site of disease, 2015 129
Table Ai.5.11. Last recorded TB outcome for the entire drug sensitive cohort by PHE Centre, England, 2015 130
Table Ai.5.12. Last recorded TB outcome for the entire drug sensitive cohort by place of birth, England, 2015 131
Table Ai.6.1. Number and proportion of TB cases with first line drug susceptibility results, England, 2000-2016 132
Table Ai.6.2. Number and proportion of TB cases with first line drug resistance, England, 2000-2016 133
Table Ai.6.3. Number and proportion of TB cases with drug resistance, England, 2000-2016 134
Table Ai.6.4. Number and proportion of TB cases with drug resistance by PHE Centre, England, 2012-2016 135
Table Ai.6.5. Number and proportion of MDR/RR-TB cases with resistance to an injectable agent or a fluoroquinolone, England, 2000-2016 136
Table Ai.6.6. Number and proportion of MDR/RR-TB cases resistant to at least one injectable agent or at least one fluoroquinolone by most frequent country of birth, England, 2012-2016 137
Table Ai.6.7. TB outcome at 24 months for the drug resistant cohort, England, 2005-2014 138
Table Ai.6.8. Last recorded TB outcome for the drug resistant cohort, England, 2005-2014 139
Table Ai.6.9. Time to treatment completion for the drug resistant cohort, England, 2005-2014 140
Table Ai.6.10. Number and proportion of the drug resistant cohort reported as lost to follow-up at last recorded outcome by place of birth, England, 2005-2014 141
Table Ai.7.1. Number and proportion of TB cases with social risk factors by place of birth, England, 2010-2016 142
Table Ai.7.2. Number and proportion of TB cases with social risk factors, by ethnicity and country of birth, England, 2010-2016 143
Table Ai.7.3. Number and proportion of TB cases with social risk factors by PHE Centre, England, 2016 144
Table Ai.7.4. Number and proportion of TB cases with specific clinical characteristics, according to the presence of social risk factors, England, 2016 145
Table Ai.7.5. TB case notifications and rates by deprivation decile, England, 2016 146
Table Ai.8.1. Number and proportion of notified and un-notified TB cases matched to an HIV case, England, 2001-2015 147
Table Ai.8.2. Number and proportion of notified and un-notified TB cases matched to an HIV case by PHE Centre, England, 2001-2015 148
Table Ai.8.3. Number and proportion of TB-HIV co-infected case notifications by age group, England, 2001-2015 149
Table Ai.8.4. HIV testing in notified TB cases by PHE Centre, England, 2016 150
Table Ai.9.1. Proportion of BCG coverage by financial year and quarter for nine London upper-tier local authorities with TB incidence ≥40 per 100,000, 2015-2017 151
Table Ai.10.1. Availability of data by source and CCG for latent TB testing, July 2014-June 2017 153
Table Ai.10.2. Number of individuals tested for LTBI by CCG and year, July 2014-June 2017 155
Table Ai.10.3. Number and proportion of latent TB tests by country of birth, July 2014-June 2017 157
Table Ai.10.4. Number and proportion of latent TB tests by ethnicity, July 2014 to June 2017 159
Table Ai.10.5. Number and percentage of patients that tested positive for LTBI by CCG, July 2014-June 2017 160
Table Ai.11.1. Number and rate of TB cases detected in high incidence countries through the UK pre-entry screening programme, 2006-2016 162
Table Ai.11.2. Number of pulmonary TB cases diagnosed by pre-entry screening and identified within one year of UK entry, 2007-2016 163
Table Ai.11.3/Table A11.3. Drug susceptibility testing results of culture confirmed TB cases detected in high incidence countries through UK pre-entry screening programme, 2007-2016 164
Table Aii.1.1. Three-year average number of TB case notifications and rates by upper tier local authority and local authority district, England, 2014-2016 165
Table Aii.1.2. Three-year average number of TB case notifications and rates by clinical commissioning group (CCG), England, 2014-2016 175
Table Aiv.1. Percentage completeness of key data fields in ETS by PHE Centre, England, 2016 193
Table Aiv.2. Percentage difference in completeness of key fields in ETS between 2015 and 2016 by PHE Centre, England 193
Table Aiv.3. Percentage completeness of data fields for diagnosis, death and treatment in ETS by PHE Centre, England, 2016 194
Table Aiv.4. Percentage difference in completeness of data fields for diagnosis, death and treatment in ETS between 2015 and 2016 by PHE Centre, England 194
Table Aiv.5. Percentage completeness of data fields for co-morbidities in ETS by PHE Centre, England, 2016 195
Table Aiv.6. Percentage difference in completeness of data fields for co-morbidities in ETS between 2015 and 2016 by PHE centre, England 195
Table Aiv.7. Percentage completeness and difference of data fields for travel and visitor history in ETS by PHE centre, England, 2016 196