TB treatment in England, 2021
Updated 3 August 2023
Applies to England
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About this report
Report series
The aim of this report is to describe the diagnostic and treatment pathways of tuberculosis (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 fourth in a series of 7 reports previously published as a single report, titled TB in England. This is the first year that they have been published as a series of smaller reports and 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 key monitoring indicators for the report series can be found in TB incidence and epidemiology in England, 2021.
Main messages
In 2021:
- enhanced case management (ECM) is a package of tailored supportive care in addition to standard management and is offered to individuals in clinical or social risk groups
- approximately a third of people notified with TB were assessed as needing ECM
- ECM can include directly observed treatment (DOT), which was offered to one in 6 individuals with TB, of whom 70% received it
- measures of treatment delay (time from onset of symptoms to start of treatment for TB) have not notably changed compared with the previous 6 years; 60% were delayed by 2 months or more, and half of these experienced a delay of at least 4 months
- diagnostic delay (time from onset of symptoms to TB diagnosis) accounts for most of treatment delay with median diagnostic delay of 76 days compared with median treatment delay of 79 days; neither of these measures have notably changed over the previous 6 years
- just over half of treatment delay was accounted for by the interval between onset of symptoms and presentation to healthcare services
- older people were more likely to experience treatment delay; younger people and those with severe TB disease were less likely to experience treatment delay, and there was regional variation
- the action plan target of a 5% annual decrease in diagnostic delay compared with 2019 has not been met
- action plan targets for treatment delay are 5% annual decreases (median and proportions more than 2 and 4 months delayed) compared with a baseline average from 2021 to 2022; these will need to be addressed by targeting time to presentation and time to diagnosis after presentation
- only 57.2% of notifications were reported within the mandatory 3-day window from diagnosis; this has not changed since 2016 and varied by region
Directly observed treatment (DOT)
According to NICE guidelines, DOT should be offered to people with TB who:
- do not adhere to treatment (or have not in the past)
- have been treated previously for TB
- have a history of homelessness, drug or alcohol misuse
- are currently in prison, or have been in the past 5 years
- have a major psychiatric, memory or cognitive disorder
- are in denial of the TB diagnosis
- have multidrug resistant TB
- request directly observed therapy after discussion with the clinical team
- are too ill to administer the treatment themselves
In 2021, information on offer of DOT was recorded for 55.4% (2,450 out of 4,425) people notified with TB, the highest since 2011 (Table 1, TB treatment in England supplementary dataset). In 2021 DOT was offered to 15.4% (683 out of 4,425) of all people notified with TB. When limited to the 2,450 in whom information was recorded this increased to 27.9%, of whom 70.3% received it.
For people with at least one social risk factor notified in 2021 (history of imprisonment, homelessness, drug misuse, current alcohol misuse or mental health needs or asylum status) where information on DOT was known, DOT was offered to 65.0% (292 out of 449). In comparison, it was offered to 19.5% (391 out of 2,001) of those without a social risk factor.
In 2021, for those with information recorded, DOT was offered to a greater proportion of children aged less than 15 years (43.6%) compared with other age groups, which ranged from 26% to 30% (Table 2, TB treatment in England supplementary dataset).
Enhanced support for people undergoing TB Treatment
Four levels of ECM are recorded in national TB surveillance system (NTBS) and comprise:
- level 0 is standard care management
- level 1 is people with clinical or social issues or both which have an impact on treatment; this may include children with TB, or those with HIV and taking antiretrovirals
- level 2: People with complex clinical or social issues or both affecting treatment and necessitating, for example, weekly visits and may include persons with complex side effects or single drug resistance
- level 3: People with very complex clinical or social issues or both affecting treatment and necessitating DOT or video enhanced therapy (VOT) and may include people experiencing homelessness, multidrug resistant (MDR) or rifampicin resistant (RR) TB, those with complex contact tracing or cases in which the involvement of social services is required (Nurse guidance document)
Table 1 shows levels of ECM by year. In 2021, almost a third of all people notified with TB (31.7%) were assessed as requiring some level of enhanced case management. This is the highest proportion since 2018, but with a lower proportion of these assessed as requiring level 3. However, the amount of missing data for ECM level before the current year means this data should be interpreted with caution.
Table 1. Enhanced case management (ECM) by year, England, 2018 to 2021
| Year | Total | Any ECM | Level 1 | Level 2 | Level 3 | Unknown level |
|---|---|---|---|---|---|---|
| 2018 | 4,610 | 1,181 (25.6%) | 21 (0.5%) | 9 (0.2%) | 726 (15.7%) | 425 (9.2%) |
| 2019 | 4,705 | 1,295 (27.5%) | 12 (0.3%) | 9 (0.2%) | 765 (16.3%) | 509 (10.8%) |
| 2020 | 4,123 | 1,172 (28.4%) | 62 (1.5%) | 58 (1.4%) | 646 (15.7%) | 406 (9.8%) |
| 2021 | 4,423 | 1,400 (31.7%) | 355 (8.0%) | 306 (6.9%) | 599 (13.5%) | 140 (3.2%) |
Enhanced case management by UKSHA centre
In 2021, London had the most TB cases and highest proportion requiring ECM, with 48.2% (757 out of 1,569) of all TB cases on some level of ECM. Of these, 51.9% (392 out of 757) were offered DOT or VOT, of whom 58.4% (229 out of 392) received it. The South West is the region with the lowest proportion of people with TB requiring ECM (21 out of 161, 13.0%) (Table 3, TB treatment in England supplementary dataset). One person in the South West had no information available on ECM.
Enhanced case management by sex, age group and social risk factors
Table 2 shows the proportion of people with TB that required any level of ECM by different levels of potential risk factors and the risk ratio. ECM was required the most in:
- children (61.2%, 79 out of 129)
- people with TB with at least one social risk factor (62.8%, 393 out of 626)
- those with multiple risk factors (76.5%, 179 out of 234)
- those with MDR or RR TB (84.4%, 65 out of 77), in line the NICE guidance for MDR TB
As ECM encompasses DOT which should be offered to all those with MDR or RR TB or with a previous episode of TB, this data suggests that practice is not following recommendations, or that the data collected are not reflecting practice. This will be followed up as part of the Getting it Right First Time review currently underway as part of action plan activities.
Table 2. Predictors of enhanced case management (ECM) by risk group, England, 2021 (univariable analysis)
| Predictor | Level | % Any ECM | Risk Ratio | 95% CI |
|---|---|---|---|---|
| Sex | Female | 29.7 | Reference | NA |
| Sex | Male | 32.9 | 1.11 | 1.01 to 1.21 |
| Age group (years) | 15 to 44 | 28.2 | Reference | NA |
| Age group (years) | 0 to 14 | 61.2 | 0.46 | 0.40 to 0.53 |
| Age group (years) | 45 to 64 | 32.9 | 0.54 | 0.46 to 0.63 |
| Age group (years) | 65 and over | 37.0 | 0.60 | 0.51 to 0.72 |
| Previous TB | No | 31.5 | Reference | NA |
| Previous TB | Yes | 45.1 | 1.43 | 1.23 to 1.67 |
| Any social risk factor | No | 26.5 | Reference | NA |
| Any social risk factor | Yes | 62.8 | 2.37 | 2.18 to 2.56 |
| Multiple risk factors | No | 29.7 | Reference | NA |
| Multiple risk factors | Yes | 76.5 | 2.58 | 2.37 to 2.81 |
| History of imprisonment | No | 31.3 | Reference | NA |
| History of imprisonment | Yes | 63.9 | 2.04 | 1.80 to 2.32 |
| MDR or RR TB | No | 30.7 | Reference | NA |
| MDR or RR TB | Yes | 84.4 | 2.75 | 2.47 to 3.05 |
Table 4 of the TB treatment in England supplementary dataset shows the percentages of people with ECM required and the levels of ECM for different levels of risk factors for people notified with TB in 2021.
Treatment delay
The prompt diagnosis and treatment of active TB can improve patient outcomes and reduce the period of infectiousness and thus TB transmission.
Breakdown of the period of treatment delay into the periods between symptom onset, healthcare seeking, diagnosis and then start of treatment can identify where further research into the causes of delay and of appropriate interventions should be targeted. For example, delays in seeking healthcare may result from people associating TB symptoms with other respiratory illnesses (like COVID-19) and thus following isolation guidance rather than presenting to healthcare, or from difficulties in accessing appropriate health care services. Delays between presentation at a healthcare service, receiving a diagnosis and then starting treatment are more likely to results from healthcare associated delays.
Time from symptom onset to TB diagnosis
Treatment delays for people with pulmonary TB
In 2021, information was analysed on the time between symptom onset to treatment start for 86.1% (1,919 out of 2,310) of people with pulmonary TB notified who were not diagnosed post-mortem. Thirty people were excluded due to apparent treatment delays of more than 2 years. These outlier cases may result from inaccurate recall of start of symptoms or symptoms before arrival in the UK. The remaining had missing data for either symptom onset date (260 people) or date of treatment start (97 people) or both.
Action plan indicator 8: Proportion of people notified with pulmonary TB with treatment delay
The target is to achieve a 5% annual reduction in the proportion of pulmonary TB cases with a treatment delay greater than or equal to 2 months, as well as 4 months from symptom onset, from a baseline average from 2021 to 2022.
Figure 1 shows that the proportion of people with pulmonary TB in England with a treatment delay over 2 months has remained at around 60% over the last 6 years.
Figure 1. Proportion of people with pulmonary TB with a treatment delay over 2 months, England, 2016 to 2021
Notes: 1. The bars represent the 95% confidence interval of the proportion.
2. Excludes people diagnosed with TB at post-mortem, those with delays over 2 years and those with missing data.
Table 3 shows the proportion of eligible people notified with pulmonary TB with treatment delay between 2 to 4 months and more than 4 months from 2016 to 2021. Over this period there was no notable change in the proportion that experienced treatment delay of more than 4 months, which accounted for approximately half of all people who experienced a treatment delay of 2 months or more.
Table 3. Number and proportion of people with treatment delay notified with pulmonary TB by time from symptom onset to treatment start, England, 2016 to 2021
| Year | 2 to 4 months delay | Over 4 months delay | Total (n) | Missing (%) | Total eligible |
|---|---|---|---|---|---|
| 2016 | 857 (31.1%) | 821 (29.8%) | 2,752 | 227 (7.6%) | 2,979 |
| 2017 | 787 (30.9%) | 775 (30.4%) | 2,548 | 195 (7.1%) | 2,743 |
| 2018 | 721 (31.3%) | 625 (27.2%) | 2,302 | 233 (9.2%) | 2,536 |
| 2019 | 665 (29.1%) | 697 (30.5%) | 2,283 | 258 (10.2%) | 2,541 |
| 2020 | 570 (29.2%) | 626 (32.1%) | 1,950 | 184 (8.6%) | 2,135 |
| 2021 | 583 (30.4%) | 607 (31.6%) | 1,919 | 391 (16.9) | 2,310 |
Notes: 1. Delays of 2 to 4 months includes delays between 61 to 121 days and over 4 months includes delays from 122 to 730 days.
2. Excludes people diagnosed with TB at post-mortem, those with delays over 2 years and those with missing data.
3. The total includes the number of people with pulmonary TB for whom time between symptom onset to treatment start was known.
Action plan indicator 9: Median duration of TB diagnosis delay in people notified with pulmonary disease
The target is a 5% annual decrease in the median duration from symptom onset to diagnosis for pulmonary TB cases from the 2021 to 2022 baseline.
In 2021, information was analysed on the time between symptom onset to date of diagnosis for 87.1% (2,011 out of 2,310) of people with pulmonary TB notified who were not diagnosed post-mortem. the median diagnostic delay was 76 days between symptom onset and TB diagnosis, which is the same as in 2020 and slightly higher than the 4 years prior (range of 70 to 75 days from 2016 to 2019) as shown in Figure 2.
Figure 2. Median diagnostic delays for people with pulmonary TB in England, 2016 to 2021
Notes: 1. The bars represent the upper and lower limits and the box the 25th percentile and 75th percentile with the median number (50th percentile) displayed.
2. Excludes people diagnosed with TB at post-mortem, those with missing data and those with delays over 2 years.
Action plan indicator 10: Median duration of TB treatment delay in people notified with pulmonary TB
The target is to have a 5% annual decrease in the median duration from symptom onset to treatment start for pulmonary TB cases from 75 days in 2019 to 56 days in 2025 to 2027.
Figure 3 summarises total treatment delay by year from 2016 to 2021. Calculation of eligible values this year indicate a median of 74 days treatment delay for 2019. In 2021 this was 79 days (inter-quartile range (IQR): 40 to 153) with no indication of improvement in treatment delay during the last 6 years with a median of 77 days (IQR: 39 to 142) over the whole 6-year duration. The small difference in median total treatment delays compared with median diagnostic delay demonstrates that the majority of total treatment delay is due to diagnostic delay and not from delay between diagnosis to start of treatment.
Figure 3. Treatment delays among people with pulmonary TB, England, 2016 to 2021
Notes: 1. The bars represent the upper and lower limits and the box the 25th percentile and 75th percentile with the median number (50th percentile) displayed. The grey dashed line represents the target treatment delay of 56 days by 2027 (indicator 10).
2. Excludes people diagnosed with TB at post-mortem, those with delays over 2 years and those with missing data.
Median durations of treatment delay for people with pulmonary TB in England are available in Table 5 of the TB Treatment in England dataset.
Breakdown of treatment delay in people notified with pulmonary disease
Figure 4 shows further breakdowns of treatment delay for years with sufficient data available (2017 to 2021). The median number of days and proportion of treatment delay from the time between symptom onset and presentation at a health facility has been consistent over the last 5 years, at:
- 51% in 2017
- 53% in 2018
- 54% in 2019
- 55% in 2020
- 54% in 2021
This suggests that a slightly larger proportion of the delay to treatment start is due to the person with TB delaying seeking or being able to access healthcare (Figure 4).
Figure 4. Breakdown of median treatment delay among people with pulmonary TB, by time from symptom onset to presentation at any healthcare service and time from presentation at healthcare service to start of treatment, England, 2017 to 2021
Notes: 1. Numbers of observations out of eligible pulmonary notifications with valid date of onset of symptoms to date of treatment start; In 2017: 1,610 out of 2,548 (63%); In 2018: 2,211 out of 2,303 (96%); In 2019: 2,191 out of 2,283 (96%); In 2020: 1,883 out of 1,951 (97%); In 2021: 1,875 out of 1,919 (98%).
2. In this figure, the date of presentation to any healthcare service refers to the earliest date the person was seen, whether this was at a health facility or at a TB service.
Treatment delay by UK Health Security Agency (UKHSA) centre
Figure 5 (and Table 6 of the TB Treatment in England dataset) shows the proportion of people notified with pulmonary TB experiencing a treatment delay of 4 months or more by UKHSA centre since 2017. In 2021, the North East had the lowest proportion of people experiencing a treatment delay of 4 months or more (21.1%) compared with highest of 41.4% for the East of England. The only region that showed a consistent change was the South West which decreased since 2017 from 44.5% to 32.1% in 2021. For most regions proportions were similar between 2020 and 2021, with no notable increase in 2020 compared with pre-pandemic 2019.
Figure 5. Proportion of people notified with pulmonary TB with a delay of more than 4 months between symptom onset and treatment start by UKHSA centre, England, 2017 to 2021
Notes: 1. Ordered by UKHSA centre with most notifications in 2021.
2. Excludes people diagnosed with TB at post-mortem, those with delays over 2 years and those with missing data.
The median treatment, diagnostic and reporting delays by year from 2011 to 2021 and by UKHSA centre over the same period are available in Tables 7 and 8 of the TB Treatment in England dataset.
Treatment delays by upper-tier local authority district (3-year average proportions 2019 to 2021)
Averaging over the period 2019 to 2021, there was considerable variation by upper-tier local authority in the proportion of people with pulmonary TB who experienced a treatment delay of 4 months as shown in Table 9 of the TB treatment in England dataset. Averaged over the period 2019 to 2021, 18 out of 150 (12%) of upper tier local authorities (UTLAs) had 45% or more people notified with pulmonary TB who experienced a treatment delay of more than 4 months. Eleven (7.3%) of local authorities had less than 15% of people notified with pulmonary TB with treatment delay of more than 4 months.
Treatment delay by sex, age group and place of birth
Table 4 shows the proportion of people notified with pulmonary TB who experienced treatment delay in 2021 by age group. In 2021 older age groups had the highest proportions of people with pulmonary TB who experienced a delay of more than 4 months, reaching nearly 40% in those aged 45 to 64 years. Nearly 75% of those aged 65 years or more had a delay of at least 2 months. There was no indication of a notable difference in the proportion experiencing a treatment delay of 4 months or more by sex across the different age groups (Table 5).
Table 4. Number and proportion of people with pulmonary TB by time from symptom onset to treatment start by age group, England, 2021
| Time from symptom onset to treatment start | 0 to 14 years | 15 to 44 years | 45 to 64 years | Over 65 years | Total |
|---|---|---|---|---|---|
| 2 to 4 months | 7 (16.7%) | 345 (31.8%) | 137 (26.8%) | 94 (33.5%) | 583 (30.3%) |
| Over 4 months | 7 (16.7%) | 288 (26.6%) | 201 (39.3%) | 111 (39.5%) | 607 (31.5%) |
| Total | 42 | 1,084 | 512 | 281 | 1,919 |
Note: The total includes the number of eligible people notified with pulmonary TB with a valid duration between symptom onset and treatment start.
Table 5. Number and proportion of people with pulmonary TB who experienced a delay of more than 4 months between symptom onset and treatment start by age group and sex, England, 2021
| Age group (years) | Female | Male | Total (n) |
|---|---|---|---|
| 0 to 14 | 3 (12.5%) | 4 (22.2%) | 7 |
| 15 to 44 | 119 (29.8%) | 169 (24.7%) | 288 |
| 45 to 64 | 65 (42.8%) | 136 (37.8%) | 201 |
| 65 and over | 36 (39.6%) | 75 (39.5%) | 111 |
| Total | 223 (33.5%) | 384 (30.6%) | 607 |
Note: The total includes the number of eligible people notified with pulmonary TB with a valid duration between symptom onset and treatment start.
There were no notable and consistent differences between UK-born and non-UK-born people in treatment delay over time. In 2021, 35.4% (198 out of 559) of people born in the UK notified with pulmonary TB experienced treatment delay of over 4 months. This is compared with 30.3% (408 out of 1,348) of those born outside of the UK (Table 10 of the TB Treatment in England dataset).
Factors associated with treatment delay
Risk factors for treatment delay
The proportion of people with pulmonary TB with a treatment delay of more than 2 months (compared with those with no treatment delay) by different levels of potential risk factors and the risk ratio are presented in Table 11 of the TB treatment in England dataset. People aged 65 years or more had an estimated 25% (risk ratio 1.25, 95% CI 1.15 to 1.36) increased risk of treatment delay whilst children under 15 years old had an estimated 43% decreased risk (risk ratio 0.57, 95% CI 0.37 to 0.88) compared with people aged 15 to 44 years. There was no evidence of an effect of whether people were born in the UK or not (risk ratio 1.06, 95% CI 0.99 to 1.15), or if people had a social risk factor or not. Those with severe TB disease requiring a longer treatment period had an estimated 20% decreased risk (risk ratio 0.80, 95% CI 0.69 to 0.93) and those with MDR TB an estimated 15% decreased risk (risk ratio 0.85, 95% CI 0.62 to 1.15).
There was also evidence that the risk of experiencing treatment delays varied between regions. When compared with people notified with TB in London:
- the East of England had a 25% increased risk (risk ratio 1.25, 95% CI 1.11 to 1.41) of experiencing treatment delays
- the East Midlands 24% increased risk (risk ratio 1.24, 95% CI 1.09 to 1.40)
- the South East 21% increased risk (risk ratio 1.21, 95% CI 1.08 to 1.36)
- the West Midlands had a 20% increased risk (risk ratio 1.20, 95% CI 1.08 to 1.34)
Delays in notification
Notification of TB is required within 3 days of a suspected or confirmed TB diagnosis. As shown in Figure 6, median reporting delay for people with pulmonary TB in England has remained at 2 to 3 days from 2016 to 2021 and thus within the 3-day mandatory statutory notification period.
Figure 6. Reporting delays for people with pulmonary TB in England, 2016 to 2021
Notes: 1. The bars represent the upper and lower limits and the box the 25th percentile and 75th percentile with the median (50th percentile) displayed.
2. Excludes people diagnosed with TB at post-mortem, those with missing data and those with reporting delays over 2 months.
In 2021 just over half of notifications (57.2%) were notified within 3 days of diagnosis. As shown in Figure 7a, this proportion has not notably changed since 2016. The highest proportion reached was in 2015 at just under 60% (please see Table 12 of the TB treatment in England dataset). In 2021 the proportion of people with pulmonary TB notified within 3 days of diagnosis was comparable across all UKHSA centres ranging from 45.4% in the South West to 66.5% in Yorkshire and the Humber (Figure 7b).
Figure 7a. Proportion of people notified with TB within 3 days of diagnosis by year, England, 2016 to 2021
Figure 7b. Proportion of people notified with TB within 3 days of diagnosis by UKHSA centre, England, 2021
Notes: 1. Excludes people diagnosed with TB at post-mortem, those with missing data for date of diagnosis and those with reporting delays over 2 months.
2. Figure 9b is ordered by UKHSA centre with most notifications in 2021.
Conclusions
One in three people with TB notified in 2021 were either assessed as needing or received ECM. The highest proportions were in London, but even in low incidence regions, around 1 in 5 individuals were recorded as needing ECM. However, levels of ECM received by individuals is not currently well documented within NTBS.
Median treatment delays for people with pulmonary TB have remained consistent at about 2 and a half months between symptom onset and treatment start over the last 10 years.
Overall, delays in the treatment pathway were comparable to previous years with approximately a third of people with pulmonary TB experiencing a delay of more than 4 months between symptom onset and the start of TB treatment. Just over half of the treatment delay was from onset of symptoms to presentation at healthcare facilities. Delay between diagnosis and treatment start was short. Further investigation and data is required to investigate causes amenable to interventions.
Further analysis of delays in TB diagnosis and treatment initiation are being carried out as part of the TB Action Plan for England, 2021 to 2026, published jointly by UKHSA and NHS England. A “Getting it Right First Time” (GIRFT) review of TB services in England is under way and will support development of local actions.
Recommendations
Recommendation 1
NHS Trusts to engage with GIRFT to assess at TB service level: enhanced case management requirements, resources available, identify pinch points in service-related treatment delay potentially amenable to intervention.
Recommendation 2
UKHSA Regional reports should include reporting by TB service of enhanced case management and treatment delay supported by the findings of the GIRFT.
Recommendation 3
NHS TB services and Health protection teams to analyse and use cohort review data to identify delays in patient presentation that may be amenable to intervention.
How these recommendations support the action plan priorities
These recommendations will address action plan priorities:
- 3.1. Improve early detection of TB by identifying, investigating, and acting on the evidence and components that contribute to patient (people affected by TB) delay
- 3.2. Reduce healthcare system delay by reviewing and improving access and delivery to diagnostics and treatment
- 4.1. Improve and optimise diagnosis, treatment, and patient-centred care in high and low incidence areas for adults and children
Methodology and definitions
General methodology for TB notifications, data production, cleaning and reporting are described in the methodology and definitions section of Report 1: TB incidence and epidemiology an England in 2021.
Enhanced Case Management (ECM)
Numbers and proportions of people with ECM per level, and those receiving DOT were calculated for all of those with information on ECM, and DOT available in UKHSAs surveillance systems (NTBS/ enhanced TB surveillance (ETS)). People who had information on DOT/VOT but were missing ECM data, were coded as “Yes” for any ECM and coded into level 3 of ECM. Those who had missing information on any ECM but were recorded as being in level 0 of ECM (equivalent to standard treatment) were recoded as having “No” in the ECM binary variable of ECM required, thereby considerably reducing proportion of notification with missing information.
The percentage of any ECM was calculated as the proportion of cases that reported “Yes” (1) to ECM, or (2) to DOT offered or (3) DOT received out of all cases with information. The percentage of ECM per level was calculated as the proportion of cases with a known level of ECM out of all cases with information on ‘any ECM required’ (“Yes” or “No”). The percentage missing data is calculated as the proportion of all TB notifications for each year with no information recorded in (1) ECM required, (2) ECM level required or (3) DOT offered or (4) DOT received.
Diagnostic delays
Delays to TB diagnosis is calculated as the days difference between self-reported date of TB symptom onset and the date of TB diagnosis as recorded in UKHSAs surveillance systems (NTBS/ETS). Diagnostic delays are not calculated for those who were diagnosed with TB at post-mortem and those with missing data, so these are not included in the denominator for the proportion of people with delays to TB diagnosis. Diagnostic delays exceeding 2 years (730 days) are excluded from analysis as symptoms lasting for over 2 years are thought to relate to another episode of TB. Negative diagnostic delays, resulting from symptoms presenting post diagnosis, were also excluded from the analysis as these are likely to indicate data errors or treatment side effects as opposed to disease symptoms.
Reporting delays
Reporting delay is calculated as the days difference between TB diagnosis date and date of TB notification to UKHSAs surveillance systems (NTBS/ETS). Reporting delays are not calculated for those who were diagnosed with TB at post-mortem and those with missing data, so these are not included in the denominator for the proportion of people with reporting delays. Reporting delays exceeding 3 months (90 days) are excluded from analysis as these delays typically reflect changes outside of healthcare control (such as a patient moving abroad, not attending treatment, patient having died) as opposed to true healthcare delays to notifying the case.
Treatment delays
Treatment delay is calculated as the days difference between self-reported date of TB symptom onset and the date treatment started as recorded in UKHSAs surveillance systems (NTBS/ETS). Treatment delays are not calculated for those who have not started treatment, those who were diagnosed with TB at post-mortem and those with missing data, so these are not included in the denominator for the proportion of people with treatment delays.
Treatment delays exceeding 2 years (730 days) are excluded from analysis as symptoms lasting for over 2 years are thought to relate to another episode of TB. Negative treatment delays, resulting from symptoms presenting post treatment start, were also excluded from analysis as these are likely to indicate data errors or treatment side effects as opposed to disease symptoms. Where treatment delays are categorised, categories comprise of:
- 0 to 2 months (0 to 60 days)
- 2 to 4 months (61 to 121 days)
- more than 4 months (121 to 730 days)
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 clinical commissioning groups, integrated care boards, UTLAs and local authorities 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).
Disclosure control methods
Only aggregate data is reported. Aggregated data values less than 5 are suppressed.
Statistical methods
Confidence intervals
95% confidence intervals are model derived and were calculated using assumptions of 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
Diagnostic delay
The diagnostic delay represents the time (in days) from when a person self-reported TB symptom onset to when they are diagnosed with TB.
Directly observed treatment (DOT)
DOT is a treatment strategy which refers to the patient taking treatment under direct in-person observation of a trained health care worker or designated individual to ensure treatment adherence for patients requiring ECM.
Enhanced case management
ECM is defined as the increased level of patient monitoring for people with (complex) clinical or social issues or both affecting treatment. There are 3 levels of ECM depending on the complexity of the clinical or social issue(s) or both and the intensity of patient monitoring required, ranging from fortnightly or weekly visits to necessitating DOT or VOT. ECM may be required for children with TB, those with HIV and taking antiretrovirals, people with complex side effects or single drug resistance and those with complex contact tracing or cases in which the involvement of social services is required. For more information see the Nurse guidance document.
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 or microbiological findings or both, consistent with active TB that would have warranted anti-TB treatment if discovered before death.
Pulmonary TB
A person with pulmonary TB is defined as having TB involving the lungs or tracheobronchial tree or both, with or without extra-pulmonary TB diagnosis. In this report, in line with the World Health Organization’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.
Reporting delay
The reporting delay represents the time (in days) from when a person is diagnosed with TB to when they are notified on UKHSAs TB surveillance systems (ETS or NTBS). Statutory notification of a person with TB should be made within 3 working days of diagnosis.
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
- current status as an asylum seeker or detainee in an immigration removal centre
Please see the reporting methodology in TB incidence and epidemiology in England for further details of these variables.
The UK Health Security Agency (UKHSA)
UKHSA was launched on 1 October 2021. It is an executive agency of the Department of Health and Social Care. UKHSA is responsible for planning, preventing and responding to external health threats, and providing intellectual, scientific and operational leadership at national and local level as well as with partners in other countries. 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.
Treatment delay
Treatment delay represents the time (in days) from when a person self-reported TB symptom onset to when they are diagnosed with TB.
Video observed therapy
VOT refers to the use of a videophone or other video or computer equipment by a patient to record their treatment intake whilst observed remotely by a trained health care worker or designated individual. This method is a flexible and non-invasive option to monitor treatment adherence in patients requiring ECM.
Risk ratios
Risk ratios 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 risk ratio 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 risk ratio includes the value of 1.0 then we cannot infer that the true risk ratio is different from 1. Thus, we would say that these results are not providing any evidence that the observed magnitude of the risk ratio is ‘statistically important’.
If a risk ratio of less than 1.0 is reported, such as risk ratio 0.85, this is interpreted that the group of interest have a 15% reduced risk of the outcome.
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%.