Title page
Contents
About Public Health England 2
Acknowledgements 4
Notes on the report 5
Background 7
Key points 8
1. TB notifications and incidence 10
Key messages 10
Overall numbers, rates and geographical distribution 10
Demographic characteristics 15
Occupation 22
Clinical characteristics 22
Smoking status 24
Travel and visitor risk factors 24
2. Laboratory confirmation of TB 25
Key messages 25
Laboratory tests data collection 25
Culture confirmation 25
Sputum smear test results 26
Other laboratory test results 26
TB isolates not matched to notified cases 27
3. TB transmission 28
Key messages 28
Rate of TB in UK born children 28
Strain typing and clustering 29
Whole genome sequencing 30
4. Delay from symptom onset to treatment start 31
Key messages 31
Time from symptom onset to treatment start for pulmonary TB cases 31
5. TB outcomes in the drug sensitive cohort 34
Key messages 34
Drug sensitive cohort, 2005-2014 34
TB outcomes for the drug sensitive cohort with expected duration of treatment less than 12 months 35
TB outcomes for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB 37
TB outcomes in the entire drug sensitive cohort 38
6. Drug resistant TB (including TB outcomes in the drug resistant cohort) 40
Key messages 40
Initial first line drug resistance 40
Initial isoniazid resistance without MDR-TB 40
Initial multi-drug resistant/rifampicin resistant (MDR/RR) TB 42
Second line drug resistance and Extensively Drug Resistant (XDR) TB 44
Acquired drug resistance on repeat culture 46
TB outcomes for the drug resistant cohort 46
7. TB in under-served populations 49
Key messages 49
Social risk factors 49
Demographic characteristics 50
Geographical distribution 52
Clinical characteristics 55
Drug resistance 56
TB outcomes 56
TB cases that were unemployed, asylum seekers or remanded in an immigration removal centre 57
Deprivation 57
8. TB-HIV co-infection and HIV testing among TB cases 58
Key messages 58
TB-HIV co-infection 58
Testing for HIV in notified TB cases 60
9. BCG vaccination 62
Key messages 62
BCG vaccine coverage data 62
BCG vaccination status of TB cases 63
10. Latent TB infection testing and treatment 65
Key messages 65
Implementing systematic LTBI testing and treatment in England 65
LTBI data collection and information governance 65
LTBI data limitations 66
CCG implementation status 66
Overall number, proportion and geographical distribution 69
Demographic characteristics 69
Positive tests for LTBI 71
Treatment for LTBI 71
11. UK tuberculosis pre-entry screening programme 73
12. Conclusion 76
13. Recommendations 78
To improve access to services and ensure early diagnosis (AfA1) 78
To provide universal access to high quality diagnostics (AfA2) 78
To improve treatment and care services (AfA3) 79
To reduce drug-resistant TB (AfA6) 79
To tackle TB in under-served populations (USPs) (AfA7) 80
To implement new entrant latent TB screening (AfA8) 80
References 82
Appendix I. Supplementary tables 84
Appendix II. Supplementary tables of local level data 138
Appendix III. Methods 153
Appendix IV. Surveillance data quality 161
Appendix V. National level data for TB strategy monitoring indicators, England, 2000-2015 167
Glossary 172
Table 1.1. Most frequent countries of birth for TB cases and time between entry to the UK and TB notification, England, 2015 20
Table 1.2. TB case notifications by site of disease, England, 2015 23
Table 2.1. Number and proportion of non-culture confirmed TB cases by other lab diagnostic confirmation, England, 2015 26
Table 2.2. Unmatched isolates by specimen year, England, 2006-2015 27
Table 3.1. Number and proportion of clustered cases and new clusters by place of birth and year, England, 2010-2015 29
Table 4.1. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start, England, 2011-2015 32
Table 4.2. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start by age group, England, 2015 32
Table 5.1. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈12 months, England, 2014 35
Table 5.2. Last recorded TB outcome for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB, England, 2014 37
Table 5.3. Last recorded TB outcome for the entire drug sensitive cohort, England, 2014 38
Table 6.1. Number and proportion of TB cases with drug resistance by characteristics, England, 2015 42
Table 6.2. Most frequent countries of birth of TB cases with drug resistance, England, 2015 43
Table 6.3. Number of TB cases with initial and acquired resistance to rifampicin and MDR-TB, England, 2006-2015 44
Table 6.4. 24-month and last recorded TB outcome for the drug resistant cohort, England, 2013 47
Table 7.1. Demographic characteristics of TB cases with social risk factors, England, 2015 52
Table 7.2. Last recorded TB outcome for the entire drug sensitive cohort by social risk factor, England, 2014 56
Table 8.1/Table 8.2. HIV testing in notified TB cases, England, 2011-2015 60
Table 8.2/Table 8.3. HIV testing in notified TB cases by age group, England, 2015 61
Table 9.1. BCG vaccine coverage estimates from CHISs for upper tier local authorities, England, April 2015 to March 2016 64
Table 10.1. Number and proportion of individuals offered and tested for LTBI by TB control board, 2015-2016 69
Table 10.2. Persons tested for LTBI by age group and sex, England, 2015-2016 70
Table 10.3. Most frequent countries of birth for individuals with LTBI, 2015-2016 70
Table 10.4. Number and proportion of IGRA test results by TB control board area, 2015-2016 71
Table 10.5. LTBI treatment acceptance status England, 2015-2016 72
Figure 1.1. TB case notifications and rates, England, 2000-2015 10
Figure 1.2. TB case notifications and rates by PHE Centre, 2000-2015 11
Figure 1.3. Three-year average TB rates by local authority district, England, 2013-2015 (box shows enlarged map of London area) 13
Figure 1.4. TB case notifications and rates by TB control board, England, 2015 14
Figure 1.5. TB case notifications and rates by place of birth, England, 2000-2015 16
Figure 1.6. TB case notifications and rates by age group and place of birth, England, 2015 16
Figure 1.7. TB case notifications and rates by PHE Centre and place of birth, 2000-2015 17
Figure 1.8. Trend in TB case notifications for the top five countries of birth of non-UK born cases, England, 2006-2015 19
Figure 1.9. Time between entry to the UK and TB notification for non-UK born cases, England, 2006-2015 20
Figure 1.10. TB case notifications and rates by place of birth and ethnic group, England, 2015 21
Figure 1.11. Number of UK born TB cases over time by ethnic group, England, 2000-2015 22
Figure 3.1. Rate of TB in UK born children, England, 2000-2015 28
Figure 3.2. Proportion of clusters by size, England, 2010-2015 30
Figure 4.1. Proportion of pulmonary TB cases with a delay from symptom onset to treatment start by place of birth, England, 2011-2015 33
Figure 5.1. TB outcomes at 12 months for drug sensitive cases with expected treatment duration 〈12 months, England, 2005-2014 36
Figure 6.1. Number and proportion of TB cases with initial drug resistance, England, 2000-2015 41
Figure 6.2. Number and proportion of MDR/RR-TB cases with second-line drug resistance by most frequent country of birth, England, 2011-2015 45
Figure 6.3. Treatment completion for drug resistant TB cases, England, 2004-2013 47
Figure 7.1. Proportion of TB cases with at least one social risk factor, England, 2010-2015 50
Figure 7.2. Proportion of TB cases with social risk factors by place of birth, England, 2015 51
Figure 7.3. Number of TB cases with at least one SRF, drug misuse, homelessness, imprisonment and alcohol misuse by local authority, England, 2010-2015 (box shows enlarged map of London area) 53
Figure 7.4. Number of TB cases with at least one social risk factor by PHE Centre, England, 2010-2015 55
Figure 7.5. Rate of TB by deprivation decile, England, 2015 57
Figure 8.1. Number and proportion of TB cases with HIV co-infection, England, 2001-2014 59
Figure 8.2. Number of TB-HIV co-infected case notifications by age group, England, 2001-2014 59
Figure 10.1. Timeline (by LTBI testing start of CCG) of the national LTBI testing and treatment programme roll-out April 2015-June 2016 67
Figure 10.2. Status of national systematic LTBI testing and treatment programme by CCG, 2015-2016 68
Figure 11.1. Number and rate of TB cases detected in high incidence countries through the UK pre-entry screening programme, 2006 to 2015 74
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 to 2015 75
Table Ai.1.1. TB case notifications, rates and annual percentage change, England, 2000-2015 84
Table Ai.1.2. TB case notifications and rates by PHE Centre, England, 2000-2015 85
Table Ai.1.3. TB case notifications and rates by age group and place of birth, England, 2015 87
Table Ai.1.4. TB case notifications, rates and annual percentage change by place of birth, England, 2000-2015 88
Table Ai.1.5. TB case notifications and rates by place of birth and PHE Centre, England, 2000-2015 89
Table Ai.1.6. Number and proportion of TB case notifications by most frequent country of birth in non-UK born population, England, 2000-2015 92
Table Ai.1.7. Time between entry to the UK and TB notification for non-UK born cases by year, England, 2006-2015 94
Table Ai.1.8. TB case notifications and rates by ethnic group and place of birth, England, 2015 95
Table Ai.1.9. Number of UK born TB case over time by ethnic groupings, England, 2000-2015 96
Table Ai.1.10. Number and proportion of TB case notifications by site of disease and place of birth, England, 2006-2015 97
Table Ai.1.11. Number of TB cases receiving directly observed therapy (DOT) by age group, England, 2006-2015 98
Table Ai.2.1. Number and proportion of culture confirmed TB cases by PHE Centre, England, 2006-2015 99
Table Ai.2.2. Number and proportion of pulmonary culture confirmed TB cases by PHE Centre, England, 2006-2015 100
Table Ai.2.3. Species identification for culture confirmed TB cases, England, 2009-2015 101
Table Ai.3.1. Numbers and rate of TB in UK born children, England, 2000-2015 102
Table Ai.3.2. Number of TB clusters and proportion clustered cases by PHE Centre, England, 2010-2015 103
Table Ai.4.1. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start and PHE Centre, England, 2015 104
Table Ai.4.2. Number and proportion of pulmonary TB cases by time from symptom onset to treatment start and place of birth, England, 2011-2015 105
Table Ai.5.1. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈12months, England, 2005-2014 106
Table Ai.5.2. Last recorded TB outcome for drug sensitive cases with expected treatment duration 〈12months, England, 2005-2014 107
Table Ai.5.3. Time to treatment completion for drug sensitive cases with expected treatment duration 〈12months, England, 2005-2014 108
Table Ai.5.4. Treatment completion at 12 months by age group for drug sensitive cases with expected treatment duration 〈12months, England, 2005-2014 109
Table Ai.5.5. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈12 months by PHE Centre, England, 2014 110
Table Ai.5.6. Treatment completion at 12 months for drug sensitive cases with expected treatment duration 〈12months by PHE Centre, England, 2005-2014 111
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, 2005-2014 112
Table Ai.5.8. Last recorded TB outcome by end of follow-up period for the entire drug sensitive cohort, England, 2005-2014 113
Table Ai.5.9. Died at last recorded outcome for the entire drug sensitive cohort, England, 2005-2014 114
Table Ai.5.10. Last recorded TB outcome for the entire drug sensitive cohort by site of disease, 2014 115
Table Ai.5.11. Last recorded TB outcome for the entire drug sensitive cohort by PHE Centre, England, 2014 116
Table Ai.5.12. Lost to follow-up at last recorded outcome for the entire drug sensitive cohort, 2005-2014 117
Table Ai.6.1. Number and proportion of TB cases with first line drug susceptibility results, England, 2006-2015 118
Table Ai.6.2. Number and proportion of TB cases with first line drug resistance, England, 2006-2015 119
Table Ai.6.3. Number and proportion of TB cases with drug resistance, England, 2000-2015 120
Table Ai.6.4. Number and proportion of TB cases with drug resistance by PHE Centre, England, 2011-2015 121
Table Ai.6.5. Number and proportion of MDR/RR-TB cases with resistance to an injectable agent or a fluoroquinolone, England, 2006-2015 122
Table Ai.6.6. The 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, 2011-2015 123
Table Ai.6.7. TB outcome at 24 months for drug resistant TB cases, England, 2004-2013 124
Table Ai.6.8. Last recorded TB outcome for drug resistant TB cases, England, 2004-2013 125
Table Ai.6.9. Time to treatment completion for drug resistant TB cases, England, 2004-2013 126
Table Ai.6.10. Drug resistant TB cases reported as lost to follow-up at last recorded outcome by place of birth, England, 2004-2013 127
Table Ai.7.1. Number and proportion of TB cases with social risk factors by place of birth, England, 2010-2015 128
Table Ai.7.2. Characteristics of TB cases with social risk factors, England, 2010-2015 129
Table Ai.7.3. Number and proportion of TB cases with social risk factors by PHE Centre, England, 2015 130
Table Ai.7.4. Clinical characteristics of TB cases with at least one social risk factor, England, 2015 131
Table Ai.8.1. Number and proportion of notified and un-notified TB cases matched to an HIV case, England, 2001-2014 132
Table Ai.8.2. Number and proportion of notified and un-notified TB cases matched to an HIV case by PHE Centre, England, 2001-2014 133
Table Ai.8.3. Number and proportion of TB-HIV co-infected case notifications by age group, England, 2001-2014 134
Table Ai.8.4. HIV testing in notified TB cases by PHE Centre, England, 2015 135
Table Ai.11.1. Number and rate of TB cases detected in high incidence countries through the UK pre-entry screening programme, 2006 to 2015 136
Table Ai.11.2. Number of pulmonary TB cases diagnosed by pre-entry screening and identified within one year of UK entry, 2006 to 2015 137
Table Aii.1.1. Three-year average number of TB case notifications and rates by upper tier local authority and local authority district, England, 2013-2015 138
Table Aii.1.2. Three-year average number of TB case notifications and rates by Clinical Commissioning Group (CCG), England, 2013-2015 148
Table Aiv.1. Percentage completeness of key data fields in ETS by PHE Centre, England, 2015 164
Table Aiv.2. Percentage difference in completeness of key fields in ETS between 2014 and 2015 by PHE Centre, England 164
Table Aiv.3. Percentage completeness of data fields for diagnosis and treatment in ETS by PHE Centre, England, 2015 165
Table Aiv.4. Percentage difference in completeness of data fields for diagnosis and treatment in ETS between 2014 and 2015 by PHE Centre, England 165
Table Aiv.5. Percentage completeness of data fields for travel and visitor risk factors in ETS by PHE Centre, England, 2015 166
Table Aiv.6. Percentage completeness of data fields for comorbidities in ETS by PHE Centre, England, 2015 166