Research and analysis

Executive summary

Updated 15 February 2024

Tuberculosis (TB) is caused by bacteria of the Mycobacterium tuberculosis complex. It is spread predominantly by the respiratory route, where bacteria are aerosolised by people with pulmonary disease and are then inhaled by susceptible individuals. 

In 2014 the World Health Organization (WHO) adopted the Global End TB Strategy, which aims to eliminate TB. In September 2023 the UK reconfirmed its commitment to the fight against TB at the United Nations high-level meeting on TB. The UK Health Security Agency (UKHSA) and National Health Service England (NHSE) joint TB Action Plan for England 2021 to 2026 outlines outcomes and indicators to achieve a 90% reduction in people with TB by 2035, aligned with the WHO elimination targets. 

In 2022, a total of 4,380 people were notified with TB in England, with an annual TB notification rate of 7.75 per 100,000 general population. England remains a WHO low incidence TB country (less than or equal to 10 per 100,000). 

This century TB notifications in England peaked in 2011 (15.6 per 100,000) and subsequently declined but in 2019 that rate of downward trend started to slow. There were fewer TB notifications in 2020 to end 2022 compared with 2019, which was most likely a temporary phenomenon due to changes in international travel and healthcare presentation related to the COVID-19 pandemic. 

Since 2022 there has been a subsequent rebound in notifications post-pandemic. Early indications in 2023 are that TB numbers are now rising above pre-pandemic levels. Provisional 2023 data indicates that notifications have increased by over 10% from 4,380 in 2022 to 4,850 in 2023. Although England remains a low incidence country, the decline in the rate of TB notifications has now reversed and England is not on course to achieve WHO’s End TB targets. 

In 2022, TB notification rates varied widely across the country when compared by UKHSA region: highest in London (1,575 individuals, rate 17.9 per 100,000) and lowest in the South West (161 individuals, 2.8 per 100,000). People with TB continue to be concentrated in large urban areas, the 2 local authority areas with the highest notification rates being Newham (London) at 41.3 per 100,000 and Leicester City (East Midlands) at 38.9 per 100,000. 

In 2022, non-UK born individuals continued to account for most TB notifications in England (79.1%), with the rate stable from the previous year at 37.5 per 100,000. In non-UK born people notified with TB, approximately half (46.3%) of the notifications were within 6 years of their entry to the UK, and half from beyond that period. For non-UK born individuals, notification rates were highest in those who were recorded as being from the Indian ethnic group (93.4 per 100,000). 

The minority of TB notifications (21%) occurred in UK born individuals. Two-fifths of UK born individuals notified with TB are aged over 65 years. Although white adults make up the largest group numerically of UK born individuals with TB, the rate of TB in this group is low (1.2 per 100,000). 

TB notification rates remain strongly associated with deprivation (using index of multiple deprivation), 13.5 per 100,000 in the 10% most deprived areas compared with 2.6 per 100,000 in the 10% least deprived areas. 

Social risk factors (alcohol misuse, drug misuse, homelessness, imprisonment, mental health needs and asylum seeker status) were reported in 16% of individuals notified with TB in 2022.  

Whole genome sequencing (WGS) on culture-confirmed specimens is used to identify genetically similar MTB strains which ‘cluster’, suggestive of recent transmission. One in 5 individuals with TB in England are in a genomic cluster. WGS data identifies that UK transmission networks are frequently associated with substance misuse, homelessness, and a history of imprisonment. They are also more likely to occur in people born in the UK than those not UK born. 

Timely and accurate detection and management of TB improves disease outcomes and reduces onward transmission. Diagnostic delays have not improved in England in over 5 years and 30% of individuals notified with TB experienced delays of more than 4 months from symptom onset to diagnosis. 

Laboratory culture confirmation of TB disease provides information on drug resistance and likely transmission. In 2022, less than two-thirds of individuals with TB overall achieved culture confirmation and this figure is static. 

Numbers of rifampicin-resistant (RR) or multidrug-resistant (MDR) TB in England are low. Between 2017 and 2022, the number of individuals with culture-confirmed RR/MDR-TB was stable. Preliminary 2023 data indicates that this number increased from 43 individuals in 2022 to 66 individuals in 2023.  

The proportion of individuals who complete their treatment and overall mortality rates have not improved in the last decade, with just under 90% completing treatment and 4% dying in outcomes recorded in 2022 for individuals diagnosed in 2021. Lower success rates continue to occur in those with social risk factors, with approximately one in 4 not completing treatment.

Children are particularly vulnerable to TB, especially those aged under 5 years, who are at greatest risk of developing severe TB disease. For the purpose of  TB reporting, children are defined as those aged under than 15 years. This is in line with data reported to the World Health Organization. Children make up a small proportion of notifications in England and numbers and rates in children remained stable in 2022 compared to 2021.