TB incidence and epidemiology in England, 2021
Updated 3 August 2023
Applies to England
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About this report
Report series
This report presents people with tuberculosis (TB) disease notified to the national TB surveillance system (NTBS) in England and aims to describe the epidemiology of TB in England up to the end of 2021. 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.
It is the first in a series of 7 reports previously published as a single report, titled TB in England. This is the first year they have been published as a series of smaller reports. Each will describe different aspects of TB incidence, treatment and prevention in England:
- TB incidence and epidemiology in England, 2021
- TB diagnosis, microbiology and drug resistance in England, 2021
- TB in children: incidence, epidemiology and microbiology in England, 2021
- TB treatment in England, 2021
- TB treatment outcomes in England, 2021
- TB prevention in England, 2021
- TB in children: treatment and prevention in England, 2021
Report format
Information on how this series of reports fits within the TB action plan for England, 2021 to 2026 (jointly published with National Health Service (NHS) England), along with a list of important monitoring indicators for the report series, can be found in the TB in England section.
Main messages
In 2021:
- TB incidence in England was 7.8 per 100,000, below the World Health Organization (WHO) threshold for a low incidence country (less than or equal to 10 per 100,000 population)
- TB incidence decreased overall in England since 2011, but the rate of decline is slowing
- England was not on target to reach our commitment to reduce TB incidence by 90% from 2015 to 2035
- TB incidence was not evenly distributed across the country and was concentrated in particular large urban areas
- the majority of people with TB in England were born outside the UK
- TB in England continued to disproportionately affect the most deprived populations, including groups at risk of exclusion and other health inequalities
- infectious pulmonary TB disease remained more likely in males, people with a history of imprisonment and people with a history of drug and alcohol misuse
- social risk factors were more common in the UK-born population with TB, with drug or alcohol misuse and history of imprisonment more common compared with the non-UK-born population with TB
- in the non-UK-born population with TB, homelessness, asylum seeker status and mental health needs were more common than in the UK-born population with TB
- the long-term effect of the global coronavirus (COVID-19) pandemic on TB incidence in England was difficult to determine, but recent patterns mirror those seen in other countries
Executive summary
Tuberculosis (TB) is an infectious disease, caused by bacteria of the Mycobacterium tuberculosis complex. It is predominantly spread by the respiratory route; people with infection in their lungs breathe out infectious bacteria, which may then be inhaled by others.
TB notifications in England fell from the 1970s until the late 1980s, when numbers began rising slowly again, increasing year on year until a peak in 2011. After 2011, notifications again declined until 2019 when they increased slightly. Notifications subsequently decreased in 2020, coinciding with the first wave of the COVID-19 pandemic. The decline in 2020 was the largest annual decrease in notifications (12.3%) since enhanced surveillance began in 2000. Several unusual factors, including people being unable to access care and receive a diagnosis, pandemic control measures and a change in global travel patterns, are thought to have influenced the epidemiology of detected TB cases during the pandemic, worldwide and in England. The extent to which different factors have changed TB epidemiology in England will require ongoing analysis in coming years.
In July 2021, the UK Health Security Agency (UKHSA) and NHS England jointly launched the TB action plan for England, 2021 to 2026 to improve the prevention, detection and control of TB in England by defining objectives to help meet the targets in WHO’s End TB strategy and provide monitoring indicators to measure progress.
In 2021, a total of 4,425 people were notified with TB, an annual notification rate of 7.8 per 100,000 population. This is an increase of 7.3% in the number of notifications and 6.8% in the rate compared with 2020. England therefore remains a low incidence TB country (less than or equal to 10 per 100,000).
Despite an overall downward trend in the number and rate of TB notifications in England during the last 10 years, the rate of decline is slowing. Unless this can be altered, England will fall short of achieving WHO’s End TB strategy target of 90% reduction in people with TB from 2015 to 2035.
Overall, the patterns of TB epidemiology in England in 2021 have similar geographic distribution, social and demographic factors to previous years.
People born outside of the UK accounted for the majority of TB notifications in England (76.4% in 2021). TB rates in non-UK-born individuals steadily declined following a peak in 2005 (100.7 per 100,000) but in 2021 they held steady at a similar rate to 2020 (37.6 per 100,000 in 2021 compared with 36.8 per 100,000 in 2020). The vast majority (86%) of TB notifications in non-UK-born individuals occurred more than 2 years after UK entry, with 44% occurring in people 11 years or more after UK entry.
TB notification rates in UK-born individuals have been declining since the peak in 2012 (4.4 per 100,000) and were at 2.1 per 100,000 in 2021.
For both UK-born and non-UK-born individuals, TB notification rates in England were much higher in those who were recorded as belonging to non-white ethnic groups. In UK-born individuals, the highest notification rates were in the black-other ethnic group - 19.5 per 100,000 compared with 1.4 per 100,000 for the white ethnic group. For non-UK-born individuals, notification rates are highest in those who were recorded as being from the Indian ethnic group (99.8 per 100,000) and lowest in the white ethnic group (8.9 per 100,000).
TB notification rates varied widely across the country when compared by UKHSA region; highest in London (1,569 individuals, rate 17.8 per 100,000) and lowest in the North East (81 individuals, 3.1 per 100,000). Although London continues to have the largest number of UK-born and non-UK-born people with TB, notification rates in non-UK-born individuals were higher in the West Midlands, North West, East Midlands, and Yorkshire and the Humber compared with London.
TB continues to be more common in males than females, with males accounting for 60.6% of individuals with TB in 2021. The overall male-to-female ratio in people with TB in England is stable over time and is in line with global trends.
People with TB are concentrated in large urban areas, with the 2 highest notification rate local authority areas being Newham (London) at 41.4 per 100,000, and Leicester City (East Midlands) at 40.3 per 100,000.
TB notification rates remained strongly associated with deprivation (using index of multiple deprivation); 13.1 per 100,000 in the 10% most deprived areas compared with 2.1 per 100,000 in the 10% least deprived areas.
Certain social characteristics were also associated with an increased risk of TB. These include alcohol misuse, drug misuse, homelessness, imprisonment, mental health needs and asylum seeker status. Data on these 6 specific social characteristics are captured by NTBS and are referred to as social risk factors (SRFs).
Almost 15% of people with TB, aged 15 years or over, in England had one or more SRF. This is unchanged over the past 4 years and was higher in people with TB born in the UK (23%) compared with those born outside the UK (12%). The proportion of people with TB and one or more SRFs were highest in the North East (24%), followed by London (17.6%) and the West Midlands (17.4%).
More than half (52.8%) of people notified with TB in England had pulmonary infection (that is, the lungs and respiratory tract) and are therefore at risk of transmitting infection to others. This proportion has remained stable over time. Pulmonary TB is much more common in UK-born people with TB, comprising 69.9% of TB notifications in this group, compared with 47.5% in non-UK-born individuals. A history of having been in prison was strongly associated with pulmonary disease, recorded in 74.1% of individuals with this risk factor.
Other health conditions, which may affect TB risk and treatment, are common in people with TB. The most frequently reported health condition is diabetes, where 11.9% of people with TB also had diabetes in 2021.
The report presents detailed data on social and demographic factors associated with TB disease in England and concludes with recommendations mapped to objectives from the TB Action Plan for England, 2021 to 2026.
International context
TB continues to be a major cause of disease and death worldwide, being the second leading infectious killer after COVID-19, as reported in the WHO global tuberculosis report 2022. It is estimated that 10.6 million people became ill with TB in 2021 (according to the WHO Global tuberculosis report 2022), an increase of 4.5% compared with 2020. There was also an estimated 1.6 million TB related deaths in 2021, up from 1.4 million in 2020. The global increase in TB notifications and deaths in 2021 compared with 2020 is thought by WHO to most likely result from disruption to TB services caused by the COVID-19 pandemic.
The WHO End TB Strategy and United Nations sustainable development goals
WHO established a global End TB Strategy in 2015 which aims to end the global TB epidemic as part of the United Nations (UN) sustainable development goals. The strategy places communities and people affected by TB at the heart of TB control. It aims to eliminate the global TB epidemic by achieving the following targets by 2035 (compared with 2015 baseline):
- reduce TB deaths by 95%
- reduce new TB notifications by 90%
- ensure that no family is burdened with catastrophic costs.
The current global trajectory of TB decline makes these very ambitious targets.
To progress global TB elimination goals, the UN General Assembly convened a high level meeting on TB in 2018, where a declaration was made by all member states committing to treat 40 million people with TB between 2018 and 2022 including:
- 3.5 million children
- 1.5 million people with drug resistant TB
- at least 30 million with TB preventative therapy.
United Nations high level meeting on TB 2023
2023 is an important year for global TB control with the second United Nations General Assembly High Level Meeting (UNHLM) on TB taking place in September 2023. The meeting will assess the impact of the COVID-19 pandemic on global TB elimination and review commitments made in 2018 at the first UNHLM on TB (PDF, 847 KB).
National epidemiology and progress towards the WHO elimination targets
TB in England
TB has been a notifiable disease in England and Wales since 1913, when 117,000 people were notified (corresponding to an incidence rate of 300 per 100,000). TB notifications subsequently declined reaching a low in England in 1987 (4,854 people notified), corresponding to a TB notification rate of 10.3 per 100,000 (Figure 1). Between 1987 and 2011, a 70% increase in notifications was observed in England. This increase was against a backdrop of poor global TB control, leading to the declaration of TB as a global public health emergency in 1993. TB notifications and rates in 2020 and 2021 are now lower than in 1987.
Figure 1. Number of TB notifications and TB notification rate per 100,000, England, 1971 to 2021
When applied to England, the WHO End TB goal of a 90% reduction from 2015 to 2035, would result in a decrease in TB notification rate from 10.5 per 100,000 in 2015 to 1.05 per 100,000 in 2035. This is close to the WHO definition of pre-elimination of 1.0 per 100,000.
Between 2011 and 2021, there was an overall downward trend in TB notification rates in England. However, the rate of reduction has slowed in the last 4 years. Figure 2 shows the observed TB notification rates between 2010 and 2021 and the projected rate of decrease (10.9% annually) from 2015 incidence required to achieve the 90% reduction target. The observed rates diverge from this projection from 2016 to 2021 (average rate of decrease per year is 3.0%). If we continue at this rate of decrease, the estimated rate in 2035 would be 5.1 per 100,000. To meet the 2035 target, we now require an annual decrease of 13.4%.
Figure 2. Observed and projected rates of decrease in TB notification in England from 2010 to 2035 compared with required rate of decrease to achieve the WHO End TB goal of a 90% reduction in TB incidence from 2015 to 2035
TB action plan for England, 2021 to 2026
In order for the UK to meet its commitment to achieve the WHO TB elimination targets, a year-on-year reduction in people with TB disease is required, as well as addressing health inequalities that put people at risk of developing active TB disease. To help address this, in July 2021 the UKHSA and NHS England jointly launched the TB action plan for England (2021 to 2026). This is a road map for COVID-19 recovery of TB services and has 5 priority areas:
- recovery from COVID-19 pandemic – understanding and reporting the impact and learning from the pandemic
- prevent TB
- detect TB
- control TB disease
- workforce
The action plan aims to achieve these objectives through system wide actions involving close partnership working from UKHSA with NHS and local authorities.
A series of high-level indicators have been formulated in order to monitor progress. In addition, some historical indicators from the previous Collaborative TB strategy for England 2015 to 2020 have been retained.
High level monitoring indicators
Indicator 1: Overall TB incidence per 100,000 population (action plan 4.4)
Target: percentage reduction per year as required to meet 2035 target. This is reported in the TB notification numbers, notification rates and geographical distribution section of this report.
Indicator 2: Reduce the proportion of TB cases in those born outside of the UK in whom TB occurs within 5 years of entry (action plan 2.1)
Target: 5% reduction per year (2017 to 2019 baseline). This is reported in TB prevention in England, 2021.
Indicator 3: Proportion of cases with a minimum of 5 close contacts identified and screened (action plan 2.5)
Target: 90% of cases with minimum of 5 contacts identified and screened. This is reported in TB prevention in England, 2021.
Indicator 4: Proportion of people who are contacts with a positive latent TB infection (LTBI) test completing LTBI treatment (action plan 2.5)
Target: Report annually on percent improvement (2021 to 2022 baseline). This is reported in TB prevention in England, 2021.
Indicator 5: Proportion of new entrant migrants who take up the offer of an LTBI test (action plan 2.2)
Target: 15% increase per year (2019 to 2020 baseline). This is reported in TB prevention in England, 2021.
Indicator 6: Proportion of new entrant migrants diagnosed with LTBI who complete treatment (action plan 2.2)
Target: 20% increase per year (2019 to 2020 baseline). This is reported in TB prevention in England, 2021.
Indicator 7: BCG coverage and uptake (action plan 2.8)
Target: 100% offered to eligible people and an 80% uptake at 4 weeks of age. This is reported in TB prevention in England, 2021.
Indicator 8: Proportion of pulmonary TB cases with treatment delay of 2 to 4 months from symptom to onset (action plan 3.1 and 3.2)
Target: 5% reduction per year (2021 to 2022 baseline). This is reported in TB treatment in England, 2021.
Indicator 9: Mean duration from symptom onset to diagnosis for pulmonary TB cases (action plan 3.2)
Target: 5% reduction per year (2021 to 2022 baseline). This is reported in TB treatment in England, 2021.
Indicator 10: Mean duration from symptom onset to starting treatment for pulmonary TB cases (action plan 3.2)
Target: 5% reduction per year from 75 days in 2019, to 56 days in 2025 to 2027. This is reported in TB treatment in England, 2021.
Indicator 11: Proportion of TB cases that were culture confirmed (action plan 3.3)
Target: 5% increase per year for all cases (2020 to 2021 baseline) and 80% culture confirmation of pulmonary TB (WHO target). This is reported in TB diagnosis, microbiology and drug resistance in England, 2021.
Indicator 12: Proportion of culture confirmed TB cases with drug susceptibility testing reported for the 4 first line agents
Target: 100%. Note this is a historical indicator. This is reported in TB diagnosis, microbiology and drug resistance in England, 2021.
Indicator 13: Proportion of culture confirmed TB cases with any first line drug resistance
Target: Note this is a historical indicator and had no target. This is reported in TB diagnosis, microbiology and drug resistance in England, 2021.
Indicator 14: Proportion of TB cases offered an HIV test
Target: 100%. Note this is a historical indicator. Target was 100%. This is reported in the Clinical Characteristics of Disease section of this report
Indicator 15: Proportion of drug sensitive TB cases with at least one social risk factor who completed treatment within 12 months (action plan 3.5)
Target: 5% increase per year (2020 to 2021). This is reported in TB treatment outcomes in England, 2021.
Indicator 16: Proportion of drug sensitive TB cases who completed treatment within 12 months (action plan 4.1)
Target: 90% completion by 2026. This is reported in TB treatment outcomes in England, 2021.
Indicator 17: Proportion of drug sensitive TB cases who had died at last reported outcome
Target: N/A. Note this is a historical indicator. This is reported in TB treatment outcomes in England, 2021.
TB notification numbers, notification rates and geographical distribution
TB notification rates in 2021
Figure 3 shows the number of TB notifications and TB notification rate per 100,000 population from 2000 to 2021. In 2021, 4,425 people were notified with TB in England corresponding to a rate of 7.8 per 100,000 population (95% confidence interval (CI) 7.6 to 8.1). Between 2020 and 2021, the number of people notified in England increased by 7.3% (up from 4,125 notifications in 2020) and the annual incidence rate increased by 6.8% (up from 7.3; 95% CI 7.1 to 7.5 per 100,000 population in 2020), with this difference reaching statistical significance (95% confidence intervals do not overlap). The annual incidence rate remains below the 10 per 100,000 threshold which WHO defines as a low incidence country.
Data of TB notifications, notification rates and year on year percentage changes for England, 2001 to 2021 are available in Table 1 of the TB Incidence and epidemiology in England dataset.
TB notification rates estimated in this report use the recently released population estimates for 2021 from the Office for National Statistics (ONS), therefore rates published here may differ slightly to those published in the official statistics for 2021 which used 2020 population estimates.
Figure 3. Number of TB notifications and notification rates per 100,000 population, England, 2000 to 2021
Action plan indicator 1: Reduction in TB incidence to meet 90% reduction by 2035
Figure 4 shows that TB notification rates since 2016 have exceeded those required annually to achieve the goal of a 90% reduction by 2035 (equivalent to a rate of just over 1.0 per 100,000). For each year, the total length of each bar corresponds to the observed annual TB rate. The end section of the bar, furthest from the year axis, corresponds to the difference (excess) between the observed and the required rate.
Figure 4. Required rates and excess observed TB rates to meet 90% reduction by 2035, England, 2016 to 2021
Note: Error bars show the 95% CI for the observed TB rate for each year.
Geographical variations in the number and notification rate of people with TB
TB numbers and rates by NHS England Regions and UKHSA Centres in 2021
The number of TB notifications and rate in each of the 7 NHS Regions in 2021 are shown in Table 1 and for each of the 9 UKHSA centres in Figure 5.
Table 1. Number of TB notifications and annual notification rates per 100,000 people by NHS Region, England, 2021
| NHS Region | Number of TB notifications | TB notification rate (95% CI) |
|---|---|---|
| London | 1,569 | 17.8 (17.0 to 18.7) |
| Midlands | 917 | 8.5 (7.9 to 9.0) |
| South East | 511 | 5.7 (5.2 to 6.2) |
| North West | 481 | 6.5 (5.9 to 7.1) |
| North East and Yorkshire | 410 | 5.0 (4.6 to 5.6) |
| East of England | 375 | 5.7 (5.1 to 6.3) |
| South West | 162 | 2.8 (2.4 to 3.3) |
The number and rates of TB notifications by NHS regions for 2000 to 2021 are available in Table 2 of the TB Incidence and epidemiology in England dataset.
The number of TB notifications and TB rates in each of the 9 UKHSA centres over time from 2011 to 2021 are shown in Figures 5a to 5c and are available in Table 3 of the TB Incidence and epidemiology in England dataset for the period 2000 to 2021. In 2021, London continued to have the highest burden of disease, accounting for 35.5% (1,569 out of 4,425) of people with TB; with a rate of 17.8 per 100,000 people (95% CI: 17.0 to 18.7).
Between 2020 and 2021, the number of people notified with TB increased in almost all UKHSA centres, except for the South West and North East, which decreased by 3.0% and 3.6% respectively. The largest increase in the annual rate was observed in the South East centre (an increase of 15.6% compared with 2020). The smallest increase in the annual TB rate was observed in the West Midlands centre (an increase of 4.5% compared with 2020). The annual TB rate in East of England remained the same.
Across all 9 UKHSA centres, the 95% confidence intervals around the annual TB notification rates in both 2020 and 2021 are similar and overlap. This suggests that any changes observed in the annual rates between 2020 and 2021 are not statistically significant.
Figure 5a. Number of TB notifications and rate by UKHSA Centre for London, 2011 to 2021
Note: Y-axis scale differs from Figures 5b and 5c, due to higher notifications in London.
Figure 5. Number and rates of TB for West Midlands, South East, North West and East of England UKHSA centres 2011 to 2021
Figure 5c. Number and notification rates of TB for East Midlands, Yorkshire and Humber, South West and North East UKHSA centres, 2011 to 2021
TB numbers and notification rates for Integrated Care Boards, Clinical Commissioning Groups and local authorities (3-year average rates 2019 to 2021)
Integrated Care Boards (ICBs) were instituted in July 2022, replacing Clinical Commissioning Groups (CCGs) and were therefore not in place in 2021. To facilitate evaluation and planning of services going forwards, TB notifications and rates are presented for both (Tables 4 and 5 of the TB Incidence and epidemiology in England dataset).
More than half of ICBs (54.7%, 23 out of 42) and CCGs (57.1%, 60 out of 105) had a 3 year average rate of less than 5.0 per 100,000. No ICBs and 3 CCGs had achieved the WHO global pre-elimination rate of less than 1.0 per 100,000, (NHS Halton, NHS Knowsley and NHS Northumberland).
The main burden of disease remains concentrated in large urban areas, which is demonstrated best by analysing notification rates by local authority areas. (Figure 6 and Table 6 of the TB Incidence and epidemiology in England dataset).
Overall, 67.4% (209 out of 310) local authority districts had average annual rates of less than 5.0 per 100,000. Of these, 4.5% (14 out of 310) had reached the pre-elimination rate of less than 1.0 per 100,000.
In 2021, 2 out of 310 (0.64%) local authority areas had annual TB notification rates above 40 per 100,000. These were the:
- London Borough of Newham (41.4 per 100,000, 147 individuals)
- Leicester City (Unitary Authority) (40.3 per 100,000, 143 individuals)
There are 5 local authority areas with annual rates between 30 and 40 per 100,000:
- Brent at 35.7 per 100,000
- Ealing at 33.0 per 100,000
- Slough at 31.4 per 100,000
- Harrow at 31.2 per 100,000
- Hounslow at 30.7 per 100,000.
TB notification rates by local authority area are used to determine BCG vaccination policy for children.
Figure 6a. Three-year average TB notification rates by local authority district in London, England, 2019 to 2021
Figure 6b. Three-year average TB notification rates by local authority district, England, 2019 to 2021
Contains Ordnance Survey data © Crown copyright and database right 2022. Contains National Statistics data © Crown copyright and database right 2022.
Note: UKHSA centre boundaries are outlined in black.
Social and demographic characteristics of people with TB in England
Notification rates of TB by sex, age, place of birth (UK versus non-UK-born) and time since entry to the UK
Males are over-represented among individuals with TB
In 2021, 60.6% (2,682 out of 4,425) of people notified with TB were male; a similar proportion of male individuals with TB between UK-born and non-UK-born populations were observed. The overall male-to-female ratio of 1.5 in England is stable over time and reflects the excess risk in males reported globally. The excess risk in males is observed only in adulthood. Children aged under 15 years have a similar proportion of disease in males (50.4%) compared with females (49.6%). This is consistent with reports from other countries (as shown in the WHO Global tuberculosis report 2021). The reasons for the disparity between the sexes is poorly understood, though there are reported behavioural and biological explanations (as explored in Assortative social mixing and sex disparities in tuberculosis burden and Sexual Inequality in Tuberculosis). Detailed data on TB in children is presented in TB incidence, epidemiology and diagnosis in children in England 2021.
Age group distribution varies by sex and place of birth
In 2021, the number of TB notifications was highest in people aged 25 to 34 years (23.8%, 1,055 people), and lowest in children (aged under 15 years) with a total of 129 children (2.9% of total) notified with TB (Table 7 of TB Incidence and epidemiology in England dataset).
Figures 7a and 7b demonstrate variation in the age profiles between UK-born and non-UK-born cases, and between males and females. For example, in 2021 the largest proportion of individuals with TB in the UK-born population was in those aged 65 years and older (19.4%). In contrast, the largest proportion of individuals with TB in the non-UK-born population was in those aged 25 to 34 years (26.0%).
Figure 7a. Age and sex distributions by place of birth for UK-born people, 2021
Figure 7b. Age and sex distributions by place of birth for non UK-born people, 2021
TB notifications and rates in the non-UK-born and UK-born populations
In 2021, place of birth was known for 99.1% (4,385 out of 4,425) of people with TB with 76.4% of people born outside the UK; the largest proportion since 2000 (Table 8 of the TB Incidence and epidemiology in England dataset).
In 2021, TB incidence in the non-UK-born population was 37.6 per 100,000, (95% CI 35.5 to 38.1) compared with 2.1 per 100,000 (95% CI 2.0 to 2.3) in the UK-born population. Between 2020 and 2021, the number and rate of TB notifications increased in the non-UK-born population (13.2% increase, 2.1% increase) but decreased in the UK-born population, continuing the decline seen since 2012 for this population. In the non-UK-born, the rate in 2021 was similar to the 2019 pre-pandemic rate (Table 9 of the TB Incidence and epidemiology in England dataset). It is not possible to determine if the recent pattern in the non-UK-born population is due to pandemic travel restrictions or differences in access to healthcare during the pandemic.
Figure 8. Number of notifications and rate of TB in UK-born and non-UK-born population, England, 2000 to 2021
Since 2017 the difference in TB rate between the UK-born and non-UK-born has gradually increased.
Figures 9a to 9c and Table 10 of the TB Incidence and epidemiology in England dataset show the changes over time in TB notifications and incidence between the UK-born and non-UK-born populations for the 9 UKHSA centres.
Overall, between 2011 and 2021, TB rates demonstrate a downward trend across all UKHSA regions (Figures 9a to 9c). Further analyses of trends over time and populations within regions are included in reports published by each region.
Figure 9a. Number of TB notifications and rates by place of birth for London UKHSA Centre, 2011 to 2021
Figure 9b. Number of TB notifications and rates by place of birth for West Midlands, South East, North West and East of England UKHSA Centres, England, 2011 to 2021
Figure 9c. Number of TB notifications and rates by place of birth for East Midlands, Yorkshire and the Humber, South West and North East UKHSA centres, England, 2011 to 2021
TB incidence by age group varies between UK-born and non-UK-born populations
As shown in Figure 10, notification rates of TB by age group varied between UK-born and non-UK-born populations. In the UK-born population, TB notification rate increased in those aged 15 years and over and remained relatively stable with a peak incidence in 30 to 34 year olds of 3.1 per 100,000, (95% CI 2.5 to 3.9 per 100,000). In the non-UK-born population, there was very low incidence in the youngest age groups rising to a peak incidence in 25 to 29 year olds of 65.4 per 100,000 (95% CI 59.3 to 72.0 per 100,000) and then decreasing again in older age groups.
Figure 10. Number of TB notifications and rates by age groups and by place of birth (UK and non-UK-born), England, 2021
Note: the axis scales differ between UK and non-UK-born graphs.
Most common countries of birth in the non-UK-born population
Table 2 shows the countries of birth in order of frequency for people with TB in 2021.
Figure 11 shows the numbers of notifications for the 5 most frequent countries of birth over time. All countries with numbers and proportions over time can be found in Table 11 of the TB Incidence and epidemiology in England dataset. The number and proportion of TB cases in people born in countries generally declined between 2011 and 2017 and have since levelled off apart from an increase for those born in India in 2021 compared with 2020.
Table 2. Countries of birth for people with TB and time between entry to the UK and TB notification, England, 2021
| Country of Birth | Number of People notified with TB | Proportion of people notified with TB (%) | Median time since entry to UK (IQR) |
|---|---|---|---|
| United Kingdom | 1003 | 22.9 | |
| India | 958 | 21.8 | 6 (2 to 16) |
| Pakistan | 484 | 11.0 | 12 (4 to 29) |
| Romania | 206 | 4.7 | 5 (3 to 6) |
| Somalia | 134 | 3.1 | 15 (4 to 21) |
| Eritrea | 130 | 3.0 | 3 (1 to 6) |
| Philippines | 111 | 2.5 | 12 (4 to 19) |
| Bangladesh | 109 | 2.5 | 13 (5 to 26) |
| Nepal | 87 | 2.0 | 8 (3 to 14) |
| Nigeria | 81 | 1.8 | 6 (2 to 17) |
| Afghanistan | 69 | 1.6 | 5 (1 to 17) |
| Poland | 64 | 1.5 | 12 (6 to 16) |
| Sudan | 59 | 1.3 | 3 (1 to 6) |
| Sri Lanka | 46 | 1.0 | 13 (9 to 20) |
| Zimbabwe | 44 | 1.0 | 18 (13 to 20) |
| Other | 800 | 18.2 | 11 (4 to 21) |
| Total | 4385 | 100 |
Note: 1. Country of birth is missing for 40 notifications in 2021.
2. IQR stands for Inter-quartile range.
3. Time since entry to the UK was not known for 275 people.
Figure 11. Numbers of TB notifications for the top 5 countries of birth for the non-UK-born population, England, 2011 to 2021
Table 3 shows differences in important demographic characteristics between people in the top 5 countries. People with TB born in Romania, Eritrea and Somalia were younger. Eritrea had a higher percentage of males and Romania and Eritrea a greater proportion of pulmonary cases, including within 2 years of entry.
Table 3. Characteristics of people with TB from the top 5 countries of birth in the non-UK-born population, England, 2021
| Country of birth | Number | Mean age (years) | Percent male | Percent pulmonary | Percent UK entry less than 2 years | Percent pulmonary of those in the UK less than 2 years |
|---|---|---|---|---|---|---|
| India | 958 | 42.4 | 57.8 | 38.0 | 14.7 | 40.8 |
| Pakistan | 484 | 49.3 | 61.0 | 38.2 | 11.4 | 40.8 |
| Romania | 206 | 37.4 | 61.2 | 82.0 | 10.6 | 75.0 |
| Somalia | 134 | 39.0 | 64.2 | 36.6 | 11.2 | 35.7 |
| Eritrea | 130 | 27.3 | 78.5 | 56.2 | 34.2 | 54.8 |
Time between TB notifications and entry to the UK
In 2021, 40.0% (1,244 out of 3,110) of people with TB born outside the UK were notified under 6 years since entering the UK, with 13.9% (433 out of 3,110) being notified within 2 years. Table 2 shows that there was considerable variation by country of birth in the median time between a person’s first entry into the UK and the time of their TB notification. For people born in Pakistan or Somalia for example, the median time from entry to the UK to TB notification was over 10 years. If born in India, it was 6 years (a reduction from 2019 when it was 10 years) and for people born in Romania and Eritrea, the median time was 5 years and 3 years respectively.
Figure 12 and Table 12 of the TB Incidence and epidemiology in England dataset shows the median time between UK entry and TB notification by country of birth over time. The proportion of people notified more than 11 years since entry to the UK has generally increased since 2011, with a slight decrease in 2021 due to an increase in the group notified 2 to 6 years after UK entry.
Figure 12. Time between entry to the UK and TB notification for people born outside the UK, England 2011 to 2021
Differences in TB notification rates between UK and non-UK-born populations of the same ethnic group
Where ethnic group was known, the largest proportion of people with TB in the UK-born population were recorded as belonging to White ethnic groups, followed by South Asian (comprising Indian, Pakistani and Bangladeshi) and Black ethnic groups. Although the number and proportion of people notified with TB was highest in the White ethnic group, the notification rate in this group was the lowest for both UK-born (rate 1.4 per 100,000) and non-UK-born individuals (rate 8.9 per 100,000) (Figure 13). The highest notification rate was among people from non-White ethnic groups. For UK-born individuals in ethnic groups other than white, the rates were highest in the black-other group (19.5 per 100,000) and lowest among the mixed-other group (3.7 per 100,000) (Table 13 of the TB Incidence and epidemiology in England dataset).
Figure 13. Number of TB notifications and rates by place of birth (UK and non-UK-born) and ethnic group, England, 2021I 95% CI I 95% CI
Figure 13 shows the considerable differences in TB rates for ethnic groups between the non-UK-born and UK-born population, with the biggest difference observed in those of Indian descent, where the rate of TB was 10 times higher in the non-UK-born population (99.8 per 100,000 people, 95% CI 93.7 to 106.2) compared with the UK-born population (9.8 per 100,000 people, 95% CI 7.8 to 12.3).
Figures 14a and 14b shows the number of notifications by white, black, South Asian (Indian, Pakistani, Bangladeshi) and those of mixed or other ethnicities over time. People of South Asian ethnicity have consistently accounted for the greatest number of TB notifications. However, since 2000, the number of TB notifications from people with a South Asian ethnicity has decreased more rapidly than that of the other ethnic groups. Since 2018, there has been a slow increase of TB notifications in those of mixed or other ethnicities.
From 2020 to 2021 there was an increase in notifications across all ethnic groups (Figure 14a), including more notifications in those of South Asian ethnicity (9.5% increase, 1,804 in 2021 versus 1,647 in 2020) (Table 14 of the TB incidence and epidemiology in England dataset).
Figure 14a. All notifications of number of people with TB born in the UK by ethnic group, England, 2000 to 2021
Figure 14b. Number of UK-born people with TB by ethnic group, 2000 to 2021
Figure 14c. Number of non-UK-born people with TB by ethnic group, 2000 to 2021
Clinical characteristics of disease
Site of disease
The site of disease determines both onwards infectivity and public health management. More than half of people with TB notified in 2021 had pulmonary disease (52.8%, 2,334 out of 4,425) (Table 4).
Table 4. Number of people with TB by site of disease, England, 2021
| Type | Site of disease | Number of notifications | Percentage |
|---|---|---|---|
| Pulmonary | All pulmonary | 2334 | 52.7 |
| Pulmonary | Miliary | 125 | 2.8 |
| Pulmonary | Laryngeal | 14 | 0.3 |
| Extra- pulmonary | All extra-pulmonary | 2091 | 47.3 |
| Extra- pulmonary | Extra-thoracic lymph nodes | 990 | 22.4 |
| Extra- pulmonary | Intra-thoracic lymph nodes | 719 | 16.2 |
| Extra- pulmonary | Pleural | 370 | 8.4 |
| Extra- pulmonary | Other extra-pulmonary | 1068 | 24.1 |
| Extra- pulmonary | Gastrointestinal | 300 | 6.8 |
| Extra- pulmonary | Bone – spine | 189 | 4.3 |
| Extra- pulmonary | Bone – not spine | 89 | 2.0 |
| Extra- pulmonary | Central Nervous System (CNS) – meningitis | 96 | 2.2 |
| Extra- pulmonary | Genitourinary | 78 | 1.8 |
| Extra- pulmonary | Central Nervous System (CNS) – other | 62 | 1.4 |
| Extra- pulmonary | Cryptic disseminated | 42 | 0.9 |
Note: Individuals may have more than one site of disease. Pulmonary disease includes those with or without disease at another site in addition to the lungs, so the total number for all sites is more than the number of people with TB disease in 2021.
Risk factors for pulmonary disease
Table 5 shows the proportion of people with pulmonary TB (compared with non-pulmonary TB) by different levels of potential risk factors and the relative risk. Identified risk factors for pulmonary TB are incarceration, being born in the UK, being male, or being aged 65 years and over.
Table 5. Risk factors for pulmonary TB, England 2021
| Level of risk factor | Percentage with Pulmonary disease | RR | 95% CI |
|---|---|---|---|
| Female | 47.5 | Reference | NA |
| Male | 56.1 | 1.18 | 1.11 to 1.25 |
| Aged 15 to 44 years | 50.5 | Reference | NA |
| Aged 0 to 14 years | 54.3 | 1.08 | 0.91 to 1.27 |
| Aged 45 to 64 years | 53.6 | 1.06 | 0.99 to 1.13 |
| Aged 65 years and over | 60.0 | 1.19 | 1.10 to 1.28 |
| Non-UK-born | 47.5 | Reference | NA |
| UK-born | 69.9 | 1.47 | 1.40 to 1.55 |
| UKHSA centre: London | 49.7 | Reference | NA |
| UKHSA centre: West Midlands | 55.8 | 1.12 | 1.03 to 1.23 |
| UKHSA centre: South East | 50.7 | 1.02 | 0.92 to 1.13 |
| UKHSA centre: North West | 48.0 | 0.97 | 0.87 to 1.07 |
| UKHSA centre: East of England | 57.1 | 1.15 | 1.04 to 1.27 |
| UKHSA centre: East Midlands | 54.2 | 1.09 | 0.98 to 1.21 |
| UKHSA centre: Yorkshire and the Humber | 57.4 | 1.16 | 1.04 to 1.28 |
| UKHSA centre: South West | 64.8 | 1.30 | 1.15 to 1.48 |
| UKHSA centre: North East | 61.7 | 1.24 | 1.04 to 1.48 |
| No social risk factors | 50.1 | Reference | NA |
| One or more social risk factors | 68.8 | 1.37 | 1.29 to 1.46 |
| No history of imprisonment | 51.1 | Reference | NA |
| History of imprisonment | 74.1 | 1.45 | 1.31 to 1.60 |
Note: History of imprisonment was missing for 424 people (9.6%).
Associations of pulmonary disease with treatment delay and TB treatment outcomes will be reported in TB Treatment in England, 2021.
As shown in Figure 15 the proportion of pulmonary TB has not changed very much over recent years, varying between a low of 51.7% in 2013 and a high of 55.6% in 2018.
Figure 15. Proportion of pulmonary TB in all individuals, England 2011 to 2021
Co-morbidities in TB
Comorbidities with other infections or non-communicable diseases such as diabetes or chronic liver disease may affect TB treatment strategies and outcomes.
People with type 2 diabetes have an increased risk of developing TB disease (as explored in Association between diabetes mellitus and active tuberculosis) and may have worse treatment outcomes. In 2021, 20.5% (896 out of 4,425) of all people with TB were known to have at least one co-morbidity; the most frequent reported co-morbidity was diabetes (11.9%) (Table 7a). The second most frequent co-morbidity was immunosuppression (6.7%) with the most frequent documented cause being biological therapy (18.5% of those with immunosuppression co-morbidity, Table 7b).
Untreated HIV infection increases the risk of developing active TB disease and universal HIV testing is conducted within TB programmes. HIV infection status is not collected within NTBS data therefore is not shown in the tables below.
Table 6a. Number and proportion of people with co-morbidities in people with TB, England, 2021
| Co-morbidity | Number of people with TB | Proportion (%) | Total with recorded information |
|---|---|---|---|
| Diabetes | 492 | 11.9 | 4,123 |
| Hepatitis B | 78 | 2.0 | 3,849 |
| Hepatitis C | 44 | 1.1 | 3,861 |
| Chronic liver disease | 63 | 1.6 | 4,037 |
| Chronic renal disease | 127 | 3.1 | 4,066 |
| Immunosuppression | 271 | 6.7 | 4,041 |
Table 6b. Causes of immunosuppression co-morbidity in people with TB, England, 2021
| Reason for immunosuppression | Number of people with TB | Proportion (%) | Total |
|---|---|---|---|
| Biological therapy | 50 | 18.5 | 271 |
| Transplantation | 14 | 5.2 | 271 |
| Cancer | 29 | 10.7 | 271 |
| Steroids | 10 | 3.7 | 271 |
| Auto-immune disease | 3 | 1.1 | 271 |
| Other or not known Immunosuppression | 165 | 60.9 | 271 |
In 2021,11.9% of people with TB also had diabetes, static since 2017. Between 2016 and 2017 there was a slight increase (10.5%) when more complete records started with the introduction of the Collaborative TB Strategy for England 2015 to 2020. The amount of missing data reduced from 10.6% of all notifications in 2016 to 3.7% in 2020 and was 6.8% in 2021.
Action plan indicator 14: HIV testing
The target is for 100% of all individuals with TB to be offered an HIV test.
In 2021, 98.4% of all individuals with TB, who had information recorded and who were not diagnosed post-mortem or with HIV status already known, were offered an HIV test, the highest proportion since 2016 (Figure 16).
In 2021, information on whether a person was offered HIV testing was known for 95.5% (4,228 out of 4,425) of people notified with TB. Of the 4,228 with recorded information, 3,918 (92.7%) people were reported to have had a HIV test performed; 175 (4.1%) were not tested again due to known status; 81 people (1.9%) were not offered an HIV test (of whom 13 had TB diagnosed post-mortem); 46 people (1.1%) were offered a test, but it was not performed; and 8 people (0.2%) were offered a test but refused.
Figure 16. Proportion of people with TB offered an HIV test, England, 2016 to 2021
Social risk factors, deprivation and risk of TB
Social risk factors and cigarette smoking
There are demographic, social and economic characteristics that can lead to people experiencing social exclusion, stigma and discrimination, resulting in barriers in access to healthcare, poor health outcomes and contributing to increasing health inequalities. These population groups are commonly referred to as Inclusion Health Groups.
NTBS collects data on 6 specific social characteristics, referred to in this report as SRFs that are commonly reported to increase the risk of TB and are associated with barriers in access to healthcare and poor outcomes. These are; alcohol misuse, drug misuse, homelessness, imprisonment, mental health needs and asylum seeker status. Additionally, NTBS collects information on cigarette smoking.
Unless otherwise stated, the following analyses exclude children aged under 15 years (129 notifications) leaving 4,296 notifications in analysis for 2021. As a result of changes in collection of SRFs over time, analyses are restricted to 2018 onwards.
Full information on how the 6 social risk factors are recorded, definitions and data limitations are available the Methodology section.
Proportions of people with TB and social risk factors
The proportion of people with TB and one or more of the 6 SRFs recorded out of all people notified from 2018 to 2021 were:
- 635 out of 4,463 people (14.2%) in 2018
- 692 people out of 4,536 (15.3%) in 2019
- 549 people out of 3,974 (13.8%) in 2020
- 622 people out of 4,296 (14.5%) in 2021
Please note that these proportions cannot be compared with data in years before 2018 due to reduced data completeness and fewer SRFs collected.
Table 7 shows the proportion of people with each individual SRF for 2021, for those with available data. The most common SRF was asylum seeker status at 5.4%, but as no information or unknown is recorded for a large proportion of those born outside of the UK (61.5%) this should be interpreted with caution. However, in the non-UK-born population with recorded data, the proportion of asylum seekers is 9.3%. Table 15 of the TB incidence and epidemiology in England dataset describes the available data and proportion of SRFs over time between 2018 to 2021 for all people and by place of birth (UK-born and non-UK-born). The increase in asylum status in 2021 is likely in part due to increased ascertainment as in previous years there was even more missing data for this SRF.
Table 7. Proportion of people with individual SRFs, England 2021
| Social risk factor | Number and percentage (%) | Total with data reported | Number and proportion of missing data (%) |
|---|---|---|---|
| Drug misuse (current or previous) | 211 (5.3%) | 3,960 | 336 (7.8%) |
| Alcohol misuse (current) | 178 (4.5%) | 3,981 | 315 (7.33%) |
| Homelessness (current or previous) | 309 (4.9%) | 3,987 | 309 (7.2%) |
| Prison (current or previous) | 158 (4.1%) | 3,881 | 415 (9.7%) |
| Asylum seeker (current) | 119 (5.4 %) | 2,213 | 2,083 (48.5%) |
| Mental health needs (current) | 114 (4.8%) | 2,398 | 1,898 (44.2%) |
| More than one SRF | 234 (5.7%) | 4,072 | 224 (5.2%) |
Note: The denominator for more than one SRF is the number of people with data recorded for at least 2 out of the 6 SRFs.
In 2021, the prevalence of current smoking was 7.9% (269 out of 3,423) and 19.5% of people had a history of smoking (762 out of 3,916). This compares with 17.4% in 2020 with a history of smoking - the lowest recorded in the 4 years with more complete data (less than 10% of missing smoking information).
Geographical distribution of social risk factors
Figure 17 and Table 16 of the TB incidence and epidemiology in England dataset shows the proportion of notifications with at least one SRF recorded by UKHSA centre for the years 2018 to 2021.
Between 2020 and 2021, there were increases in the proportion of people with at least one SRF in the West Midlands, Yorkshire and the Humber and the North East (61.5, 32.8 and 33.7% increase respectively). There were decreases in the South West (41% decrease), East Midlands (21% decrease) and the East of England (14% decrease). London and the North East consistently had the highest proportions, with the North East having the highest proportion in 2021 at 24.0% compared with 17.6% in London and 9.9% in the South East, which consistently had the lowest proportion.
Figure 17. Proportion of people with TB aged 15 years or more with at least one social risk factor by UKHSA Centre, England, 2018 to 2021
Note: Denominators are all TB notifications for each region or year.
Risk of social risk factors in people with TB
Social risk factors are more common in males and less common in the non-UK-born population
Table 8 shows that males had a higher prevalence of each SRF than women, apart from mental health needs. Older people had a lower prevalence of most SRFs apart from mental health needs. Younger people had the highest prevalence of asylum seeker status. People born outside of the UK have a lower prevalence of all SRFs apart from homelessness. Drug use and prison are much less common SRFs in the non-UK-born population. Drug-misuse was the most common SRF in any of these subgroups at 15.9% in the UK-born population, but increased to 24.9% when limited to male, UK-born and aged 15 to 44 years.
Table 8. Number and proportion of people with TB aged 15 years or over with a social risk factor (SRF) by demographic characteristic, England, 2021
| Demographic characteristics | Drug misuse | Alcohol misuse | Homelessness | Prison | Asylum seeker | Mental health needs |
|---|---|---|---|---|---|---|
| Female | 31 (2.0%) | 35 (2.2%) | 29 (1.8%) | 8 (0.5%) | 18 (2.1%) | 45 (4.7%) |
| Male | 180 (7.5%) | 143 (5.9%) | 166 (6.9%) | 150 (6.5%) | 101 (7.4%) | 69 (4.8%) |
| Aged 15 to 44 years | 128 (5.5%) | 92 (3.9%) | 121 (5.2%) | 92 (4.0%) | 105 (8.6%) | 45 (3.2%) |
| Aged 45 to 64 years | 77 (7.0%) | 78 (7.1%) | 67 (6.1%) | 58 (5.4%) | 12 (1.9%) | 46 (7.0%) |
| Aged 65 years and over | 6 (1.1%) | 8 (1.4%) | 7 (1.3%) | 8 (1.5%) | 2 (0.6%) | 23 (7.0%) |
| UK-born | 137 (15.9%) | 68 (8.0%) | 54 (6.3%) | 86 (10.4%) | 0 (0.0%) | 38 (8.4%) |
| Non-UK-born | 74 (2.4%) | 108 (3.5%) | 141 (4.5%) | 72 (2.4%) | 119 (9.3%) | 76 (3.9%) |
| Unemployed | 115 (19.6%) | 78 (13.3%) | 108 (18.1%) | 82 (14.4%) | 36 (9.7%) | 56 (14.1%) |
Note: Missing data: Drug misuse (336, 7.8%), alcohol misuse (315, 7.3%), homeless (309, 7.2%), prison (415, 9.7%), asylum seeker (2,083, 48.5%), mental health (1,898, 44.2%).
Table 9 shows the relative risk of having at least one SRF in 2021 in those aged 15 years or more. Males are 2 and a half times more likely than females to have one or more SRFs (risk ratio (RR) 2.52, 95% CI 2.09 to 3.04). Those recorded as unemployed are also 2 and a half times more likely (RR 2.52, 95% CI 2.15 to 2.95). Those born in the UK are nearly twice as likely (RR 1.93, 95% CI 1.66 to 2.24) to have an SRF compared with those born outside of the UK. Compared with London, people notified in all regions apart from North East were between approximately 24% to 45% less likely to have one or more SRFs.
Table 9. Risk ratios of having any social risk factor (SRF) in people aged 15 years or more, England, 2021
| Demographic | % Any SRF | Risk Ratio (RR) | 95% CI Lower | 95% CI Upper |
|---|---|---|---|---|
| Female | 7.5 | Reference | ||
| Male | 18.9 | 2.52 | 2.09 | 3.04 |
| Aged 15 to 44 years | 15.1 | Reference | ||
| Aged 45 to 64 years | 16.8 | 1.12 | 0.95 | 1.31 |
| Aged 65 years and over | 7.6 | 0.51 | 0.38 | 0.68 |
| Non-UK-born | 12.1 | Reference | ||
| UK-born | 23.4 | 1.93 | 1.66 | 2.24 |
| London | 17.6 | Reference | ||
| West Midlands | 17.4 | 0.99 | 0.80 | 1.22 |
| South East | 9.9 | 0.56 | 0.42 | 0.75 |
| North West | 11.3 | 0.64 | 0.48 | 0.84 |
| East of England | 10.3 | 0.58 | 0.42 | 0.81 |
| East Midlands | 10.7 | 0.61 | 0.44 | 0.84 |
| Yorkshire and the Humber | 14.4 | 0.82 | 0.61 | 1.09 |
| South West | 11.0 | 0.63 | 0.40 | 0.99 |
| North East | 24.0 | 1.36 | 0.90 | 2.07 |
| Employed | 8.7 | Reference | ||
| Unemployed | 21.9 | 2.52 | 2.15 | 2.95 |
Note:
1. SRFs include history of homelessness, prison or drug misuse, asylum seeker or current mental health needs or current alcohol misuse.
2. Data missing for models: 1 missing for sex, 39 for UK-born status and 306 for unemployed status.
Prevalence of SRFs vary by ethnicity in the UK-born population and country of birth in the non-UK-born population
To further investigate what sub-populations have the greatest risk of SRFs, the proportion of SRFs by ethnicity (white, black Caribbean, black African, South Asian and ‘other’), for those born in the UK and by country of birth for those born outside, are analysed (Table 17 of the TB incidence and epidemiology in England dataset). Due to potentially small numbers in some of these sub-groups, data is presented for the years 2018 to 2021 combined.
In people with TB born in the UK, black Caribbean people had the highest proportion of people with at least one SRF (39.9%, 85 out of 213), with the most common being drug-misuse (27.2%, 55 out of 202) and imprisonment (18.9%, 38 out of 201). In contrast, in UK-born people with white ethnicity, alcohol misuse was the most common SRF (10.7%, 258 out of 2,414).
In people born outside of the UK, the 10 most frequent countries of birth between 2018 to 2021 were analysed. People born in Eritrea and Sudan had the highest proportion of people with at least one SRF at 41.9% (197 out of 470) and 42.7% (96 out of 225). This resulted from the high proportion who were asylum seekers and/or homeless with reporting of imprisonment in immigration return centres, which was also relatively higher in these populations. Those born in European countries, such as Poland and Lithuania, had the largest proportions of people with drug misuse (both nearly 10%), alcohol (18.0% and 23.5% respectively) and prison history (11.0% and 10.5%). Those born in India and Pakistan had the lowest proportion with at least one SRF at 4.9% (163 out of 3, 347) and 5.3% (96 out of 1816).
These data suggest that social risk factors vary by country of birth with those from some countries of birth more likely to report SRFs of homelessness and/or imprisonment, probably linked to their asylum seeker status.
TB notification rate increased with increased levels of deprivation
In 2021, the rate of TB was 13.1 per 100,000 in the 10% of the population living in the most deprived areas compared with only 2.5 per 100,000 in the 10% of the population living in the least deprived areas, with a clear trend of a decreasing rate of TB with decreasing deprivation (Figure 18).
Figure 18. TB notification rate by deprivation decile, England, 2021
Table 18 of the TB incidence and epidemiology in England dataset shows characteristics of people with TB by deprivation decile in 2021. The proportion of males is generally higher in the most deprived areas, as is the proportion of non-UK-born people. There is no clear trend for the proportion of people with pulmonary compared with non-pulmonary TB, but the proportion of people with TB with a social risk factor is higher in the more deprived areas. This data shows that people with TB in the most deprived areas are likely to have more complex needs and potentially worse treatment outcomes.
Conclusions
TB notification numbers and rates in England rose by 7% in 2021 compared with 2020. The COVID-19 pandemic has had a complex impact on healthcare access and delivery, migration, and social behaviours, all of which may have influenced TB transmission, diagnoses and notifications. As a result, further analysis is needed to understand how the COVID-19 pandemic has affected TB epidemiology.
Although significant progress has been made in reducing TB notification numbers and rates since 2011, England is not on trajectory to achieve WHO and UN elimination goals. Significant regional and local variation continues to be a feature, with the highest numbers and rates of notifications in urban areas.
Local authority districts and CCGs (reorganised into ICBs from 2022), reported that 67.4% and 60% of their areas had rates below 5 per 100,000, with 4 CCGs and 14 local authority districts having reached pre-elimination levels of less than 1 per 100,000.
This is good news for TB control but may pose challenges for TB commissioning and service delivery in low incidence areas. People and groups at higher risk of TB disease include those born outside the UK, people born in the UK in ethnic groups other than white and those in inclusion health groups, with social risk factors. The most deprived 10% of the population experience TB rates more than five times higher than the least deprived 10%.
The collaborative UKHSA and NHS England TB action plan for England, 2021 to 2026 contains actions and targets to drive forward improvements in TB care, prevention and control.
Data from this report should be used to support the identification and response to local needs in TB, detection, prevention and control. Each recommendation in the ‘recommendations’ section are linked to action plan objectives. Further details on TB diagnosis and drug resistance, plus TB in children are available. Reports on TB treatment and outcomes, and TB prevention will follow later in 2023.
While data completeness has improved, missing data for some variables, especially those for social risk factors, asylum status and prison history may result in biased estimates of the proportion of people with TB with these characteristics. Further efforts to improve these are needed to advocate for appropriate local services and resources to address these and to estimate the impact these have on transmission.
Recommendations
These recommendations are linked to the corresponding priorities in the TB action plan for England, 2021 to 2026.
Recommendation 1
UKHSA should undertake further analysis of surveillance data from 2019 to 2022 to put trends in context. This should include analysis of the impact of the COVID-19 pandemic on TB trends to understand actions required to improve the trajectory towards TB elimination.
Recommendation 2
UKHSA Regional Field Services teams should continue to produce reports on local and regional data to support stakeholders, who should use these data to identify local priorities and actions to improve TB detection, prevention and control.
Recommendation 3
Stakeholders including UKHSA, NHS England (NHSE), TB control boards (TBCBs) and regional prevention boards are recommended to identify and address needs among inclusion health groups at risk of TB in their local area . They should utilise the Underserved populations toolkit to support local developments to provide person-centred approaches to meet the needs of people affected by TB in inclusion health groups.
Recommendation 4
UKHSA should produce an update to the Underserved populations toolkit with a new inclusion health group toolkit to share best practice and support work by local stakeholders with inclusion health groups in 2023 to 2024.
Recommendation 5
All stakeholders in TB diagnosis, treatment and person-centred care in high and low incidence areas should ensure that they are working to the NHS national TB service specification. Stakeholders should adopt outcomes and recommendations from the Getting it Right First Time (GIRFT) TB review in 2023 to 2024. This national NHSE initiative aims to optimise care and service provision.
Recommendation 6
TBCBs, NHSE and regional prevention boards should identify low incidence TB services and commissioners to partner with high incidence areas and promote those partnerships.
How these recommendations support the action plan priorities
Recommendations 1 and 2 will support progress on action plan priorities 1.1 to 1.6: Plan and optimise the recovery of TB case detection and control, affected by the COVID-19 pandemic response.
Recommendations 3 and 4 will support progress on actions 2.4 and 3.5: Strengthen prevention, detection and treatment of active TB in higher risk groups including targeted screening in asylum seekers, including unaccompanied asylum-seeking children, the homeless and those in contact with the criminal justice system; and focus on improving the detection and management of TB in people with social risk factors or inclusion health groups.
Recommendations 5 and 6 will support action plan priority 4.1: Improve and optimise diagnosis, treatment and person-centred care in high and low incidence areas; and action plan priority 5.3.2: Appropriate service transformation to provide a people centred TB service that can sustain the management of people with active TB disease, the LTBI programme, meet the needs of incidents, outbreaks and surge capacity.
Methodology and definitions
TB notifications
People who are diagnosed with TB in England, Wales and Northern Ireland must be notified through 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).
Only individuals with disease caused by Mycobacterium tuberculosis complex (MTBC) are reported. Individuals were denotified and removed from the dataset if the infective agent was identified as non-MTBC or M. bovis Bacillus Calmette-Guerin (BCG) subspecies.
Data production
In 2021, NTBS was launched and replaced 2 historical surveillance systems:
- the Enhanced Tuberculosis Surveillance system (ETS)
- the London TB Register (LTBR)
Datasets from 2018 onwards were extracted from ETS and LTBR and were merged with NTBS following a series of data migrations between July and December 2021. Data reported here were obtained from the merged datasets (NTBS, ETS, LTBR) and the final extract was on 12 July 2022.
Data cleaning to improve data quality
Denotifications
People with BCGosis, on chemoprophylaxis for latent TB infection or with a non-tuberculous mycobacterial infection who were notified in error were identified using comments fields, and denotified. People with culture confirmed TB who had been denotified were queried with clinics, and lab contaminations were removed, or people were renotified if they were found to have been denotified in error.
In addition, a probabilistic matching process was carried out for notifications between January 2020 and December 2021 to identify people with more than one notification within a 12-month period. Identified duplicates were denotified with any missing information transferred from the duplicate to the original notification.
Geography
The postcode field (used to map postcodes to geographic areas) was cleaned by identifying invalid postcodes based on matching to the May 2022 Postcode Directory from ONS. Where cleaning was necessary, the correct postcode was identified using the address fields.
For people who were homeless or who had a residence outside the UK, but were notified in England, the postcode of the clinic or hospital at which they were treated was assigned to the notification. For people with no postcode or treatment clinic or hospital, the local authority and UKHSA centre were updated using the local authority field recorded based on the area that the notifying case manager was located in.
UKHSA centre was derived from UKHSA region of residence based on the individual’s residential postcode. If missing, UKHSA centre in which treatment occurred (most recently, as care may have been transferred) was used, for example if a person had no fixed abode.
Site of disease
The site of disease was reclassified to pulmonary if a positive sputum smear (microscopy) sample was recorded or if a positive culture was grown from a pulmonary laboratory specimen. People with laryngeal TB were included in pulmonary breakdowns, and people with miliary TB were included in both pulmonary and extra-pulmonary breakdowns. Site of disease for people with culture confirmation was reclassified based on the site in the body from which the specimen was taken. Site of disease classifications were also updated using the free text field for site of disease.
Social risk factors including prison and asylum status
The presence or absence of the social risk factors (current or a history of drug misuse, alcohol misuse, homelessness, prison, mental health and asylum status; including if remanded in an immigration detention centre) were updated from missing or unknown if relevant information was found in the free text comments fields within NTBS.
Homelessness was updated to ‘yes’ if mentioned in the comments fields or if the address given was ‘no fixed abode’ or a shelter or hostel for homeless people was named.
Prison (current or in the past) was updated to ‘yes’ if mentioned in the comments fields, if HMP or a prison name was recorded as the address or if the residential postcode corresponded with a prison. Up until 2020, data on incident TB cases reported to the Public Health in Prisons (PHiP) log were used to further identify people who had been imprisoned, but this was not conducted in 2021.
The immigration detainee variable was updated if the address given at notification, comments fields or occupation field showed the person to be an immigration detainee. The asylum seeker variable (newly introduced in NTBS) was updated as asylum seeker if recorded in the occupation field sub-category under ‘no occupation’. For analysis, asylum seeker was then recoded as ‘yes’ if either asylum seeker variable or immigration detainee variable were ‘yes’. The asylum seeker variable was further updated so that all UK-born individuals with a missing value for this variable was updated to ‘no’.
Demographic characteristics
Sex is reported as male or female. Where missing from the raw data, it was derived from the name of the individual where names were unambiguous.
Age is derived from the date of notification and date of birth and calculated within NTBS on entering of data. Those with negative values were cross-referenced with other dates to resolve. Age groups were derived from the age at notification.
UK and non-UK-born status occurs in the raw data. It was amended if missing and the country of birth indicated non-UK birth.
Entry to the UK is entered as year only by NTBS users. Time since entry is derived as year of notification minus entry year.
Reporting methodology
Individuals with TB are reported by area of residence and by calendar year of notification.
Time periods
TB rates are presented from the year 2000, the first year of enhanced surveillance for TB. Most other data presentations over time are presented from 2011 onwards, which corresponds to the most recent peak in TB notification rates. For TB action plan (2021 to 2026) indicators, data are presented from 2016 onwards, representing the first year after implementation of the previous TB Strategy 2015 to 2020. Social risk factors are presented from 2018 onwards, when more complete data collection started, and additional risk factors were collected.
Geography
UKHSA centre was derived from UKHSA region of residence based on individual’s residential postcode. If missing, UKHSA centre in which treatment occurred was used, for example if a person had no fixed abode.
Data presented by UKHSA centres is presented in order of most individuals with TB in 2021.
Cleaned postcodes were assigned boundary layers and merged with boundaries for CCGs, ICB, Upper Tier Local Authorities (UTLA) and local authorities (LAs) sourced from the Central Lookups Database within the UKHSA Data Lake which is managed by the Public Health Data Science (PHDS) team. These are available in the UKHSA layers of the map software (GIS).
Sources of population data for calculation of notification rates
TB notification rates in this report have been estimated using the recently released population estimates for 2021, updated using the 2021 population census and released in December 2022 from ONS. As a result, notification rates for 2021 published here may differ slightly than those previously published for the UK in November 2022. However, 3-year average rates are unchanged and will not be updated until the revised back estimates for populations in 2019 and 2020 are released by the ONS in November 2023. Population estimates for more specific sub-groups such as place of birth and ethnic groups are derived from the Labour Force Survey (LFS) which has not yet been updated to reflect the 2021 population census data at the time of production of this report.
Index of Multiple Deprivation (IMD)
TB notifications were assigned an Index of Multiple Deprivation (IMD) 2019 rank based on lower super output area (LSOA) of residence (2011 census). To assign LSOAs to deprivation categories, the LSOAs were first sorted from most to least deprived using the IMD 2019 rank, before being divided into deciles. The LSOA mid-year population estimates were also assigned to these deciles and the rate per decile was calculated by dividing the TB notifications per decile by the population per decile and multiplying by 100,000.
Social risk factors
People with TB are reported as having at least one SRF (‘yes’) if any of the 6 social risk factors (current alcohol misuse, current or a history of homelessness, drug misuse, imprisonment, asylum seeker status and mental health needs) had ‘yes’ recorded. As a result, the denominator is all notifications. This assumes that people for whom no data were recorded for individual SRFs were a ‘no’ and may result in under-estimation.
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 is recorded by TB case managers and is based on their judgement if mental health concerns are likely to affect the person’s ability to adhere to treatment. This was added to surveillance in London UKHSA centre in 2018 and is a simple ‘yes’ or ‘no’ response. It was introduced nationally in 2021 with the introduction of NTBS. Here we report this as the person has need of support for mental health and therefore has ‘mental health needs’.
Asylum seeker status and immigration removal centre were added to national surveillance as discrete variables in 2020. Prior to this, ‘asylum seeker’ status was extracted from free-text comment fields and user entered values within occupation (LTBR). As a result, more complete data on this exposure is assumed from 2020 to 2021 compared with previous years.
Alcohol misuse is as recorded by case managers and is based on their judgement if 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; as 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.
Disclosure control methods
Only aggregate data is reported. Aggregated data values less than 5 are suppressed except if it is:
- the aggregate number of notifications within a single year for England for children aged under 5 years for each sex as the risk of disclosure is considered very low compared with the importance of monitoring changes in young children
- the aggregated number across multiple years for large geographic areas (England or UKHSA centre)
- the average notifications over multiple years for a geographical area, the smallest of which (by population) is clinical commissioning group (CCG)
Statistical methods
TB rates
TB rates per 100,000 population are calculated using the mid-year population estimates from ONS.
Average annual rates per 100,000 for the 3-year period are calculated by dividing the numerator (the number of TB notifications in the 3-year period) by the denominator (the sum of the mid-year population estimates for the same 3-year period) and multiplying by 100,000.
Confidence intervals
95% confidence intervals are model derived and were calculated using assumptions of the Poisson distribution for rates and the binomial distribution for proportions.
Risk ratios
Risk ratios are model derived using the binomial distribution for proportions.
Software packages
All statistical analysis was carried out using Stata 17.0. ArcGIS 10.5 was used to produce all maps shown in the report.
Glossary
Pulmonary TB
A person with pulmonary TB is defined as having TB involving the lungs and/or tracheo-bronchial tree, with or without extra-pulmonary TB diagnosis. In this report, in line with the WHO’s recommendation and international reporting definitions, miliary TB is classified as pulmonary TB due to the presence of lesions in the lungs, and laryngeal TB is also classified as pulmonary TB.
Social risk factor
Social risk factors for TB include current alcohol misuse, current or history of homelessness, current or history of imprisonment, current or history of drug misuse, current mental health needs, or current status as an asylum seeker or detainee in an immigration removal centre. Please see relevant section under reporting methodology for further details of these variables.
Under-served populations
Under-served populations refer to people with TB who have a social risk factor as well as those who were remanded in an immigration removal centre, identified as asylum seekers or unemployed.
95% Confidence Interval
In this report, model derived 95% confidence intervals (CI) are often presented alongside percentages and rates. For example, the percentage of TB notifications with pulmonary disease is 52.7% (95% CI 51.3 to 54.2%). This can be loosely interpreted as that we have 95% confidence that the true but unknown value of this percentage in the population lies within the range of 51.3% to 54.2%.
Post-mortem diagnosis
A person diagnosed at post-mortem is defined as having TB which was not suspected before death, but a TB diagnosis was made at post-mortem, with pathological and/or microbiological findings consistent with active TB that would have warranted anti-TB treatment if discovered before death.
Risk Ratios (RR)
RRs quantify the relative risk of the outcome we are interested in between 2 different groups. For example, the relative risk of pulmonary disease in males compared with females. This is calculated as the proportion of males with pulmonary disease divided by the proportion of females with pulmonary disease, which is a RR of 1.18, (95% CI 1.11 to 1.25). This is interpreted that males have an 18% increased risk of pulmonary disease compared with females and we have 95% confidence that the true increased risk lies within the range of 11% to 25%. If a 95% CI for a RR includes the value of 1.0, then we cannot infer that the true RR is different from 1.
As a result, we would say that these results are not providing any evidence that the observed magnitude of the RR is ‘statistically important’. If an RR of less than 1.0 is reported, such as RR 0.85, this is interpreted that the group of interest have a 15% reduced risk of the outcome.