Title page
Contents
About Public Health England 2
Acknowledgements 4
Notes on the report 6
Key points and recommendations 7
1. TB notifications and incidence 9
Key messages 9
Overall numbers, rates and geographical distribution 9
Demographic characteristics 15
Occupation 22
Clinical characteristics 22
2. Microscopy and culture confirmation 24
Key messages 24
Laboratory tests 24
Culture confirmation 24
Speciation 25
Sputum smear status for pulmonary cases 25
Other laboratory test results for TB cases 25
TB isolates not matched to notified cases 26
3. TB transmission 28
Key messages 28
Rate of TB in UK born children 28
Strain typing and clustering 29
Whole genome sequencing 31
4. Delay from symptom onset to treatment start 33
Key messages 33
Time from symptom onset to treatment start for pulmonary TB cases 33
Characteristics of pulmonary TB cases with a delay of more than four months from symptom onset to treatment start 34
5. TB outcomes in the drug sensitive cohort 36
Key messages 36
Drug sensitive cohort, 2004-2013 36
TB outcomes for the drug sensitive cohort with expected duration of treatment less than 12 months 37
TB outcomes for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB 39
TB outcomes in the entire drug sensitive cohort 40
Death in the entire drug sensitive cohort 41
Lost to follow-up in the entire drug sensitive cohort 42
6. Drug resistant TB (including TB outcomes in the drug resistant cohort) 43
Key messages 43
Initial first line drug resistance 43
Initial isoniazid resistance without MDR-TB 44
Initial multi-drug resistant/ rifampicin resistant (MDR/RR) TB 46
Second line drug resistance and Extensively Drug Resistant (XDR) TB 47
Amplification of drug resistance on repeat culture 49
TB outcomes for the drug resistant cohort, 2004-2012 52
Treatment completion in the drug resistant cohort 52
Deaths in the drug resistant cohort 54
Lost to follow-up in the drug resistant cohort 54
7. TB in those with social risk factors and health inequalities associated with TB 55
Key messages 55
Social risk factors 55
Delay from symptom onset to treatment start 57
Directly observed therapy (DOT) 57
TB outcomes in the drug sensitive cohort 57
Drug resistant TB and outcomes 58
Deprivation 60
8. Testing for HIV and TB-HIV co-infection 61
Key messages 61
Testing for HIV in notified TB cases 61
TB-HIV co-infection 62
9. Latent TB infection testing and treatment 65
Key messages 65
LTBI initiatives before implementation of the Collaborative TB Strategy 65
Implementing systematic LTBI testing and treatment in England 67
10. United Kingdom tuberculosis pre-entry screening programme 68
11. Discussion 71
References 74
Appendix I. Supplementary tables 76
Appendix II. Supplementary tables of local level data 125
Appendix III. Methods 139
Appendix IV. Surveillance data quality 146
Appendix V. National level baseline data for TB strategy monitoring indicators, England, 2000-2014 154
Glossary 159
Table 1.1. Most frequent countries of birth for TB cases and time between entry to the UK and TB notification (for non-UK born cases), England, 2014 17
Table 1.2. TB case notifications by site of disease, England, 2014 22
Table 2.1. Number and proportion of non-culture confirmed TB cases by another laboratory method other than culture, England, 2014 26
Table 2.2. Unmatched isolates by specimen year, England, 2005-2014 27
Table 3.1. Number and proportion of culture confirmed cases typed, or with 23 or 24 loci typed, England, 2010-2014 30
Table 3.2. Number and proportion of unique cases, clustered cases and new clusters by year, England, 2010-2014 30
Table 4.1. Number and proportion of pulmonary TB cases by delay from symptom onset to treatment start, England, 2011-2014 34
Table 5.1. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈 12 months, England, 2013 37
Table 5.2. Last recorded TB outcome for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated TB, England, 2013 40
Table 5.3. Last recorded TB outcome for the entire drug sensitive cohort, England, 2013 40
Table 6.1. Number and proportion of TB cases with drug resistance by age group, England, 2014 45
Table 6.2. Most frequent countries of birth of TB cases with drug resistance, England, 2014 46
Table 6.3. Number and proportion of MDR/RR-TB cases with resistance to an injectable agent or a fluoroquinolone, England, 2005-2014 48
Table 6.4. 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, 2010-2014 49
Table 6.5. Number of TB cases with initial and amplified rifampicin and MDR-TB, England, 2005-2014 51
Table 6.6. TB outcome at 24 months after treatment start for drug resistant cohort, England, 2012 52
Table 6.7. Last recorded TB outcome for the entire drug resistant cohort, England, 2012 54
Table 7.1. Last recorded TB outcome for the entire drug sensitive cohort by social risk factor, England, 2013 58
Table 7.2. Number and proportion of TB cases with at least one social risk factor by drug resistance, England, 2010-2014 58
Table 7.3. Number and proportion of TB cases with at least one social risk factor by place of birth and drug resistance, England, 2010-2014 59
Table 7.4. TB outcomes for drug resistant cases at last reported outcome by social risk factor, England, 2012 60
Table 8.1. HIV testing in notified TB cases, England, 2011-2014 62
Table 8.2. HIV testing in notified TB cases by age group, England, 2014 62
Figure 1.1. TB case notifications and rates, England, 2000-2014 10
Figure 1.2. Three-year average TB rates by local authority district, England, 2012-2014 (box shows enlarged map of London area) 11
Figure 1.3. Number of TB case notifications by TB control board1, England, 2014 (shown by TB burden) 12
Figure 1.4. TB case notifications and rates by Public Health England centre, 2000-2014 13
Figure 1.5. TB case notifications and rates by place of birth, England, 2000-2014 15
Figure 1.6. TB case notifications and rates by age group and place of birth, England, 2014 16
Figure 1.7. Trend in TB case notifications for the top five countries of birth of non-UK born cases, England, 2005-2014 18
Figure 1.8. Time between entry to the UK and TB notification for non-UK born cases by year, England, 2005-2014 19
Figure 1.9. TB case notifications and rates by place of birth and ethnic group, England, 2014 20
Figure 1.10. Trend of TB case notifications by age group and ethnic group in UK born cases, England, 2000-2014 21
Figure 3.1. Rate of TB in UK born children, England, 2000-2014 29
Figure 3.2. Proportion of clusters by size, England, 2010-2014 31
Figure 4.1. Proportion of pulmonary cases with a delay from symptom onset to treatment start of more than four months by age group, England, 2011-2014 35
Figure 4.2. Proportion of cases with a delay from symptom onset to treatment start by place of birth, England, 2011-2014 35
Figure 5.1. Treatment completion at 12 months for drug sensitive cases with expected treatment duration 〈 12 months, England, 2004-2013 38
Figure 5.2. Time to complete treatment for drug sensitive cases with known time to completion and with expected treatment duration 〈 12 months, England, 2004-2013 38
Figure 5.3. Time between treatment start and death for the entire drug sensitive cohort, England, 2004-2013 41
Figure 6.1. Number and proportion of TB cases with initial drug resistance, England, 2005-2014 44
Figure 6.2. Treatment completion for drug resistant TB cases, England, 2004-2012 53
Figure 7.1. Proportion of TB cases with a social risk factor by place of birth, England, 2014 56
Figure 7.2. Rate of TB by deprivation decile, England, 2014 60
Figure 8.1. Number and proportion of TB cases with HIV co-infection, England, 2001-2013 63
Figure 8.2. Number of TB-HIV co-infected case notifications by age group, England, 2001-2013 64
Figure 9.1. Clinical commissioning group areas which had LTBI testing and treatment initiatives in 2014 by areas of high TB incidence and/or burden (box shows enlarged map of London area) 66
Figure 10.1. Number and rate of TB cases detected in high incidence countries through the UK pre-entry screening programme, 2006 to 2014 69
Figure 10.2. Number of pulmonary TB cases diagnosed by pre-entry screening and identified within one year of UK entry, 2006 to 2014 70
Table A1.1. TB case notifications, rates and annual percentage change, England, 2000-2014 76
Table A1.2. TB case notifications and rates by PHE centre, England, 2000-2014 77
Table A1.3. TB case notifications and rates by age group and place of birth, England, 2014 79
Table A1.4. TB case notifications, rates and annual percentage change by place of birth, England, 2000-2014 80
Table A1.5. Number and proportion of TB case notifications by most frequent country of birth in non-UK born population, England, 2000-2014 81
Table A1.6. Time between entry to the UK and TB notification for non-UK born cases by year, England, 2005-2014 83
Table A1.7. TB case notifications and rates by ethnic group and place of birth, England, 2014 84
Table A1.8. TB case notifications by age group and ethnic group in UK born cases, England, 2000-2014 85
Table A1.9. Number and proportion of TB case notifications by site of disease and place of birth, England, 2005-2014 86
Table A1.10. Number of TB cases receiving directly observed therapy (DOT) by age group, England, 2005-2014 87
Table A2.1. Number and proportion of culture confirmed TB cases by PHE centre, England, 2005-2014 88
Table A2.2. Number and proportion of pulmonary culture confirmed TB cases by PHE centre, England, 2005-2014 89
Table A2.3. Species identification for culture confirmed TB cases, England, 2009-2014 90
Table A3.1. Number of tuberculosis clusters and proportion clustered by PHE centre, England, 2010-2014 91
Table A4.1. Number and proportion of pulmonary TB cases by delay from symptom onset to treatment start by PHE centre, England 2014 92
Table A4.2. Number and proportion of pulmonary TB cases with delay from symptom onset to treatment start by age group, England, 2011-2014 93
Table A4.3. Number and proportion of pulmonary TB cases with delay from symptom onset to treatment start by place of birth, England, 2011-2014 94
Table A5.1. TB outcome by 12 months after treatment start for drug sensitive cases with expected treatment duration 〈12months, England, 2004-2013 95
Table A5.2. Last recorded TB outcome for drug sensitive cases with expected treatment duration 〈12months, England, 2004-2013 96
Table A5.3. Time to treatment completion for drug sensitive cases with expected treatment duration 〈12months, England, 2004-2013 97
Table A5.4. Treatment completion at 12 months by age group for drug sensitive cases with expected treatment duration 〈12months, England, 2004-2013 98
Table A5.5. Treatment completion at 12 months by sex for drug sensitive cases with expected treatment duration 〈12months, England, 2004-2013 99
Table A5.6. TB outcome at 12 months by site of disease for drug sensitive cases with expected treatment duration 〈12months, England, 2013 100
Table A5.7. TB outcome at 12 months for drug sensitive cases with expected treatment duration 〈12 months by PHE centre, England, 2013 101
Table A5.8. Treatment completion at 12 months for drug sensitive cases with expected treatment duration 〈12months by PHE centre, England, 2003-2013 102
Table A5.9. Last recorded TB outcome by end of follow-up period for drug sensitive cases with CNS, spinal, miliary or cryptic disseminated TB cases, England, 2004-2013 103
Table A5.10. Median time to treatment completion for drug sensitive cases with CNS, spinal, miliary or cryptic disseminated TB cases, UK, 2004-2013 104
Table A5.11. Last recorded TB outcome for the entire drug sensitive cohort, England, 2004-2013 105
Table A5.12. The entire drug sensitive cohort reported to have died at last recorded outcome, England, 2004-2013 106
Table A5.13. Last recorded TB outcome for the entire drug sensitive cohort by site of disease, 2013 107
Table A5.14. Time between treatment start and death for the entire drug sensitive cohort, England, 2004-2013 108
Table A5.15. Last recorded TB outcome for the entire drug sensitive cohort by PHE centre, England, 2013 109
Table A5.16. The entire drug sensitive cohort reported as lost to follow-up at last recorded outcome, England, 2004-2013 110
Table A5.17. Lost to follow-up at last recorded outcome by age group in the entire drug sensitive cohort, England, 2004-2013 111
Table A6.1. Number and proportion of TB cases with first line drug susceptibility results, England, 2005-2014 112
Table A6.2. Number and proportion of TB cases with first line drug resistance, England, 2005-2014 113
Table A6.3. Number and proportion of TB cases with drug resistance, England, 2005-2014 114
Table A6.4. TB outcome at 24 months after treatment start for drug resistant TB cases, England, 2004-2012 115
Table A6.5. Time to treatment completion for MDR-TB cases, England, 2004-2012 116
Table A6.6. Last recorded TB outcome for drug resistant TB cases, England, 2004-2012 117
Table A6.7. Lost to follow-up at last recorded outcome in drug resistant TB cases by place of birth, England, 2004-2012 118
Table A7.1. Number and proportion of TB cases with a social risk factor by place of birth, England, 2010-2014 119
Table A8.1. Number and proportion of notified and unnotified TB cases matched to an HIV case, England, 2001-2013 120
Table A8.2. Number and proportion of TB-HIV co-infected case notifications by age group, England, 2001-2013 121
Table A8.3. Number and proportion of TB-HIV co-infected case notifications with drug resistance, England, 2001-2013 122
Table A10.1. Number and rate of TB cases detected in high incidence countries through the UK pre-entry screening programme, UK, 2006 to 2014 123
Table A10.2. Number of pulmonary TB cases diagnosed by pre-entry screening and identified within one year of UK entry, 2006 to 2014 124
Table AII.1. Three-year average number of TB case notifications and rates by upper tier local authority and local authority district, England, 2012-2014 125
Table AII.2. Three-year average number of TB case notifications and rates by Clinical Commissioning Group (CCG), England, 2012-2014 134
Table IV.1. Completeness of key data fields in ETS by PHE centre, England, 2014 150
Table IV.2. Completeness of data fields for diagnosis and treatment in ETS by PHE centre, England, 2014 151
Table IV.3. Percentage difference in completeness of key fields in ETS between 2013 and 2014 by PHE centre, England 152
Table IV.4. Percentage difference in completeness of data fields for diagnosis and treatment in ETS between 2013 and 2014 by PHE centre, England 153