Research and analysis

Tuberculosis prevention, England, 2023

Published 5 December 2024

Applies to England

Main points

The number of long-term visa applicants from high TB incidence countries screened before entry to the UK for pulmonary tuberculosis (TB) doubled in 2023 to 1,059,309 compared with 2021.

In 2023, 505 people were diagnosed with pulmonary TB by the UK pre-entry screening programme.

The number of new entrant migrants eligible for the NHSE Latent TB infection (LTBI) testing programme increased in 2023 by 50.1% compared with 2022 (from 201,765 to 302,782 individuals), by 203.1% compared with 2021 (149,070 individuals), and by 378.7% compared with 2019 (79,944 individuals).

The number of people tested through the NHSE LTBI programme increased in 2023 by 98.4% (from 17,484 to 34,680 individuals) compared with 2022, by 152.8% compared with 2021 (13,717 individuals), and by 106.2% compared with 2019 (16,816 individuals).

The proportion of eligible new entrant migrants tested in 2023 was 11.5%; an increase from 2022 and 2021 (8.7% and 9.2% respectively), below the ambition of 25% of eligible new entrant migrants; in 2023 numbers tested exceeded the original commission of 20,000 tests.

The proportion of positive LTBI tests in 2023 was 15.1% compared with 14.2% in 2022 and 14.0 % in 2021 after a decline from a peak of 19.7% in 2016, soon after the programme began.

Between 2019 and 2023, 218 (0.2%) people tested for LTBI through the NHS programme were subsequently notified with active TB, only 4 of whom were recorded to have successfully completed treatment.

Between 2019 and 2023, 1,519 eligible new entrant migrants did not have an LTBI test recorded and were notified with active TB; increased LTBI testing has the potential to allow earlier detection of the majority of these and prevention of active disease.

In 2023, screening of the contacts of people notified with active pulmonary TB resulted in the identification of 182 people with active TB disease and 1,135 people with LTBI.

UK pre-entry TB screening programme

In 2022 and 2023 combined, 80.5% of all people notified with TB in England were born outside the UK (TB incidence and epidemiology in England, 2023). The UK pre-entry TB screening programme is intended to reduce the importation of active pulmonary TB among applicants for long term visas by screening migrants from high TB incidence countries (more than 40 per 100,000) for active pulmonary TB by symptoms review, and where appropriate, chest X-ray when applying for a long term (more than 6 months) UK visa (as detailed in the UK tuberculosis technical instructions).

Screening numbers over time, by country and screening provider

The programme has operated in 102 countries since 2014 (see Supplementary Table 1).

In 2023 there were 1,059,130 people screened, an increase of 93.3% from 2021 (547,873 people) and a quadrupling since 2014 (230,960 people) (Figure 1 and Supplementary Table 2). This is consistent with the large increase in visa applications from high incidence countries, especially since 2021. Screening is provided by either International Organization of Migration (IOM) or non-IOM clinics. Detailed analysis is reported for the provider types separately due to issues with data completion from non-IOM providers. Some countries have both types of provider (see Supplementary Table 1 of the accompanying dataset for more details).

Figure 1. Number of people screened by screening provider, 2014 to 2023

Data used to create Figure 1 can be found in Supplementary Table 2 of the accompanying dataset.

The largest number of people screened in 2023 were in India (245,142 people, 23.1% of total) followed by Nigeria (186,100 people, 17.6%) (see Table 2 and Supplementary Table 3). These proportions are similar with 2022 (see Supplementary Table 4) and 2021 (see Supplementary Table 5 of the accompanying dataset). China was the country with the highest number and proportion of people until 2020 but has since dropped to 9.9%. The number of screens in Zimbabwe in 2023 (60,336) has increased more than 9-fold since 2021 (5,790) (see Supplementary Table 6).

Table 1. Number of reported screening episodes and people screened by country of screening and screening provider in 2023

Country of screening	IOM or non-IOM	Number of screening episodes	Number of people screened	Percentage of people screened by country
India	Non-IOM	253,516	245,142	23.1
Nigeria	IOM	191,404	186,100	17.6
Pakistan	Non-IOM	105,613	103,301	9.8
Pakistan	IOM	57,375	56,335	5.3
China	Non-IOM	105,887	105,096	9.9
Bangladesh	IOM	61,110	59,186	5.6
Zimbabwe	IOM	60,336	57,140	5.4
Ghana	IOM	35,701	35,108	3.3
Sri Lanka	IOM	32,367	31,574	3.0
South Africa	IOM	22,978	22,190	2.1
Nepal	IOM	21,052	20,719	2.0
Philippines	IOM	16,990	16,674	1.6
Hong Kong	Non-IOM	14,394	14,303	1.4
Kenya	IOM	12,881	12,591	1.2
Other	Non-IOM	48,103	47,280	4.5
Other	IOM	47,398	46,567	4.4
Total	Both	1,087,105	1,059,130	100.0

Note: Table 1 is ordered by number of screens per country and limited to countries reporting more than 10,000 screening episodes. Some individuals were reported as having been screened more than once, accounting for the difference between episodes and people screened. Some people were also screened in more than one country, so the total of people screened is less than the sum of people screened in each country.

TB case detection rate by the programme

In 2023, there were 505 people diagnosed with pulmonary TB by the programme. This increased from 264 people in 2021. As the number of screening episodes also nearly doubled between 2021 and 2023, the TB case detection rate remained stable across this period but has fallen since 2018 (see Figure 2 and Supplementary Table 7).

Figure 2. Number of people with confirmed TB (graph A) and TB case detection rate (graph B) by screening provider, 2018 to 2023

Note: data is presented from 2018 due to earlier data quality and a change in methodology affecting non-IOM clinics – for more information see Methodology and data sources.

Data used to create Figure 2 can be found in Supplementary Table 7 of the accompanying dataset.

Data returns from non-IOM clinics were frequently missing culture results and evidence was used from other reported data, such as whether a person was referred for TB treatment and, if a clearance certificate was issued to determine a second category of possible TB (see Methodology and data sources for more details).

Data reflecting the diagnostic flow resulting in a person being diagnosed with culture confirmed or clinically diagnosed TB reported by IOM clinics and non-IOM clinics is shown in Appendix Figures A1 and A2 and Supplementary Table 8 in the accompanying dataset. These confirmed TB diagnoses are shown in Figure 2 below. The total number of people with confirmed and possible TB from 2018 to 2023 is shown in Appendix Figure A3 and Supplementary Table 7.

TB case detection rates were lower in non-IOM screening clinics, however, due to incomplete data returns of sputum culture results this is likely an underestimate of the true rate of detection. Where people with possible TB were included (Appendix Figure A3) the total number of people with active TB in 2023 was 1,604. This results in a TB case detection rate that is higher in non-IOM compared with IOM clinics and, therefore, is most likely an overestimate.

Drug susceptibility in culture confirmed TB

TB culture and drug susceptibility testing (DST) is a mandatory requirement under the (UK tuberculosis technical instructions). Very limited conclusions can be drawn about drug resistance in the pre- entry screening cohort due to incomplete data returns. While culture confirmation is reported for 87.7% (852 of 972) individuals with confirmed TB in 2022 and 2023, this is mainly from IOM countries and excludes a number of high burden countries for multidrug resistant (MDR) disease. Drug susceptibility is only reported for 25.6% (218 of 852) of culture confirmed individuals Table 2 and Supplementary Table 9).

Table 2. Drug resistance in people with culture confirmed tuberculosis in both IOM and non-IOM clinics in 2022 and 2023

Drug susceptibility category	Number of people with positive sputum culture	Percentage of total positive sputum cultures
Isoniazid mono-resistant	39	4.6
Multidrug resistant or rifampicin resistant	16	1.9
Pre-extensively drug resistant	1	0.1

Note: drug sensitivity results were reported for 218 of 852 positive cultures in 2022 and 2023.

Table 2 shows drug resistance in people with culture confirmed tuberculosis in 2022 to 2023 in both IOM and non-IOM clinics as defined under the 2021 WHO TB DST definitions (see Supplementary Table 9 of the accompanying dataset).

LTBI testing and treatment programme for new entrants

The LTBI programme is commissioned by NHSE in Integrated Care Boards (ICBs) with a higher burden of TB (27 out of 42 ICBs in 2023, see Supplementary Table 10 of the accompanying dataset). Individuals are eligible for testing in the programme if they migrated to England from a high TB incidence country (more than 150 per 100,000 population or any country in sub-Saharan Africa), have registered with a GP within 5 years of entering the UK and are 16 to 35 years of age (see National latent tuberculosis infection testing and treatment programme for more).

Proportion of eligible new entrant migrants tested

The numbers of people eligible for testing increased nearly 4-fold between 2019 (79,944 individuals) and 2023 (302,782 individuals) (see Figure 3 and Supplementary table 11 in the accompanying dataset). Despite an increase in testing activity across the same period, with 34,680 new entrant migrants in 2023 being tested, this represents only 11.5% of all those eligible that year. This is below the initial annual goal of the programme to test 25% of eligible new entrant migrants; but significantly exceeds the original commissioned number of 20,000 tests annually. The increased number was only possible in 2023 because of additional non-recurrent funding being released by NHS England for the programme.

Figure 3. Number of eligible new entrant migrants and number tested by year with the proportion tested, England, 2019 to 2023

Data used in Figure 3 can be found in Supplementary Table 9 and by UKHSA region and ICB for each year in Supplementary Tables 12 and 10 of the accompanying dataset.

Numbers tested by UKHSA region from 2018 to 2023 are shown in Appendix Figure A4. London, with the highest number of eligible migrants, has the most people tested in each year, but the proportion of people tested is highest outside London. In 2023, Yorkshire and the Humber tested the greatest proportion at 28.9% (with the second largest number of tests) and East of England the least at 2.9%. in (Supplementary Table 12 in the accompanying dataset). Data by ICB is found in Supplementary table 10. As a low incidence area, the North East region of England does not have any ICBs commissioned to do programmatic testing.

Demographic characteristics of eligible new entrant migrants who were tested compared with those who were not tested for the period 2019 to 2023 can be seen in Supplementary Table 13.

In 2023 the greatest number of eligible new entrant migrants were born in or travelled from India. However, the country with the highest proportion of eligible new entrant migrants tested was Afghanistan. This may reflect the influence of the Afghan Relocation and Assistance Policy (ARAP). Appendix Table A1 and Supplementary Table 14 of the accompanying dataset describe numbers, numbers tested and test positivity for the country of birth or travel with the top ten highest eligible new entrant migrants’ numbers and information for all countries respectively.

Proportion of people testing positive

In 2023, 5,247 people tested positive for latent TB through the commissioned programme. 15.1% of those tested were positive in 2023, slightly higher than in 2022 (2,478 people positive, 14.2%, p=0.004) (see Figure 4).

Figure 4. The number of tests and number of positive tests with the proportion of tests positive in the LTBI dataset alongside, in England from 2018 to 2023

Note: the positivity percentage can be found at the end of the positive test number bar.

Data accompanying this Figure can be found in Supplementary Table 15 of the accompanying dataset.

The proportion of migrants testing positive in the programme varied widely by country of birth (see Supplementary table 14 of the accompanying dataset). The proportions may be unreliable where only small numbers of individuals have been tested, but for countries with at least 100 individuals tested between 2019 and 2023, the range was from 7.7% positivity in people from Thailand (21 of 271 individuals tested) to 44.4% in people from Sierra Leone (55 of 124 individuals).

LTBI testing rates and positivity for the top 10 countries by number of eligible new migrants in 2023 can be seen in Appendix Table 1. Of these top 10 countries, Nepal, Nigeria and Zimbabwe had a LTBI positivity of 20% or higher. For other countries and years see Supplementary Table 14 in the accompanying dataset.

Proportion of new entrant migrants diagnosed with LTBI who complete prophylactic treatment

In 2023, 750 of the 5,247 people tested positive for LTBI were recorded as having completed treatment (14.3%). Recorded treatment completion in 2023 was significantly lower than in 2022 and 2021 where the recorded treatment completion rates were 23.1% (572 people) and 27.6% (531 people) respectively (p-value less than 0.001). Due to large amounts of missing data on treatment completion (see Figure A6 and methods) these figures should be interpreted with caution. There is currently no additional payment to TB services for recording the treatment completion data.

Figure 5 and Supplementary Table 16 of the accompanying dataset describe number of people that are positive, started treatment and completed treatment from 2018 to 2023.

Figure 5. The numbers of LTBI positive tests, completed treatments and proportion of treatments completed in England from 2018 to 2023

Note: percentage completion can be found at the end of the completed treatment bar.

Data accompanying this Figure can be found in Supplementary Table 16 in the accompanying dataset .

Figure A5 of the appendix and Supplementary Table 12 describe number of tests done and positive by UKHSA region in 2023 and from 2018 to 2023 respectively.

London had the highest number of positive tests (n=3,093) but its recorded treatment completion percentage was low (9.8%) compared to the South West (42.9%), South East (33.8%) and West Midlands (27.2%).

Active and latent TB infection in new entrant migrants eligible for LTBI programmatic testing

Between 2019 and 2023, 93,101 LTBI tests were conducted through the commissioned NHSE programme out of an estimated total eligible population of 800,388 (11.6%). It is likely that the actual eligible population was larger as our estimate is derived from Flag4 data, which not all ICBs were using. A Flag4 code is provided at the point a person registers with a GP practice whose previous address was outside of the UK or when they had lived outside of the UK for three months. This data is used to identify and invite eligible migrants for LTBI screening by most TB services (see methodology and data sources for more detail).

Figure 6 shows the numbers of migrants eligible for testing, those tested, and those notified with active TB.

Figure 6. Populations of eligible new entrant migrants tested and untested by the NHS LTBI programme and people notified with active TB, England, 2019 to 2023 (aggregated data)

Between 2019 and 2023 358 people tested by the NHSE programme were subsequently notified with active TB. Of those, 140 (39.1%) were notified within 90 days of their LTBI test, indicating that active disease was likely present at the time of the test. Over half (56.4%) of the 140 people had pulmonary TB and were potentially infectious (see Supplementary Table 17 in the accompanying dataset). It is likely that these people were detected earlier through the programme than would otherwise have been the case, reducing the period in which they could pass TB on to others. This demonstrates a secondary benefit of the programme, in supporting earlier access to diagnosis and treatment in this higher risk population.

The remaining 218 people were notified with active TB more than 90 days after their LTBI test (see Appendix Figure A6 and Supplementary Table 17 in the accompanying dataset)).

Completion of prophylactic treatment for latent TB infection was effective in reducing risk of developing active TB. Only 4 of the 2,575 (0.16%) people known to have completed prophylactic treatment were subsequently notified with active TB. There were 168 people for whom no LTBI treatment information was available who developed active disease (1.61%). Although the risk of developing active TB was highest in the 2 years after infection, people may go on to develop disease many years later, so with increased follow up time, these numbers may increase (see Supplementary Table 17 in the accompanying dataset and Appendix Figure A6).

1,519 individuals eligible for the programme but not tested for LTBI developed TB of whom half had pulmonary disease. This highlights an opportunity to detect and prevent TB earlier.

Contact Tracing 

Contact tracing remains a cornerstone of TB management and prevention by interrupting chains of transmission and reducing the overall burden of disease.

Contact tracing has 3 main objectives:

• identification of individuals with undiagnosed active TB
• testing to identify people with latent infection followed by chemoprophylaxis to prevent development of active disease
• vaccination with BCG of those eligible

There is evidence that treating latent infection with chemoprophylaxis is safe and prevents progression to active disease, reducing morbidity and mortality for the individual and further spread of TB into the population.

Assessment and screening of close contacts should be undertaken in line with National Institute for Health and Care Excellence (NICE) guidance.

Contact tracing data is presented from England between 2018 and 2023. Data on contact tracing information in individuals with pulmonary TB was first reported in the TB prevention in England 2021 report. Individuals with more than 65 contacts were excluded as indicative of a large outbreak investigation and therefore not representative of the routine contact tracing.

Contact tracing information for people with active TB

In 2023, there were 2,668 people notified with pulmonary TB and who therefore required contact tracing according to NICE guidance. Of these, 80.8% (2,151 individuals) had contact tracing information recorded or had fewer than 65 contacts identified; a 9.2% reduction from 2022. The proportion of people with pulmonary TB for whom contact information was recorded from 2021 to 2023 for England and by UKHSA region are shown in Appendix Figure A7 and Supplementary Table 18 in the accompanying dataset.

Figure 7 describes the number of contacts of people notified with pulmonary TB (index individuals) who had contacts assessed in England in 2023. Data between 2021 and 2023 is presented in Supplementary Table 19 in the accompanying dataset. Where contact information was recorded, the median number of contacts identified per person notified with pulmonary TB was 3 (IQR: 1 to 5). The distribution of the total number of contacts identified per notification of infectious TB between 2021 and 2023 is presented in Appendix Figure A8.

The majority of individuals with pulmonary TB (70.4%; 1,515 of 2,151) for whom contact tracing information was recorded had fewer than 5 contacts identified. The median number of contacts per person was 3.

Figure 7. Flow diagram of the number of contacts of people notified with pulmonary TB (index individuals) identified, traced and assessed, England 2023

Notes:

• proportions for individuals with contact tracing information entered, missing contact tracing information and those with greater 65 contacts identified are derived from the total number of pulmonary notifications
• proportions for individuals with 0, 1 to 4, and 5 or more contacts identified are derived from individuals with contact tracing information entered
• proportions for individuals with information recorded for assessed contacts was derived from the number of individuals with 0, 1 to 4, and 5 or more contacts identified
• proportions for individuals with 0, 1 to 4, and 5 or more contacts assessed are derived from the number of individuals with information recorded for assessed contacts

Figure 7: text description

The flowchart shows the number and proportion of individuals with contact information in England in 2023. It starts with 2,668 pulmonary cases, of which 510 (19.1%) are missing contact information. There were 7 (0.3%) individuals who had more than 65 contacts identified.

A total of 8,665 contacts were identified for the 2,151 individuals that did have contact tracing information entered. This is a median of 3 identified for every individual notified with pulmonary TB.

Of the 2,151 individuals that did have contact tracing information entered, 261 (12.1%) had zero contacts entered, and therefore no contacts were identified.

Of 2,151 individuals with contact tracing information entered, 1,254 individuals (58.3%) had 1 to 4 contacts identified. Of these 1,254 individuals, 284 (22.6%) had no information recorded for contacts, leaving 970 (77.4%) who did have information recorded for contacts and who were assessed with further screening. Of these 970, 103 (10.6%) had zero contacts assessed, and 867 (89.4%) had 1 to 4 contacts assessed.

Of the 2,151 individuals that did have contact tracing information entered, 636 (29.6%) had 5 or more contacts identified. Of these 636 individuals, 109 (17.1%) had no information recorded for contacts, leaving 527 (82.9%) who did have information recorded for contacts and who were assessed with further screening. Of these 527, 14 (2.7%) had zero contacts assessed, 75 (14.2%) had 1 to 4 contacts assessed, and 438 (83.1%) had 5 or more contacts assessed.

People notified with pulmonary TB (index individuals) who were identified, traced and assessed

Contact tracing information by demographic and social risk factors, and disease characteristics between 2021 and 2023 are presented in Supplementary table 20 in the accompanying dataset.

Contact tracing practices vary between services; some services routinely carry out contact tracing on individuals with non-pulmonary disease based on local epidemiology though this is not included in NICE guidance. Contact tracing information was recorded for 76.8% of people with non-pulmonary TB in 2023 (1,680 out of 2,187); fewer contacts were recorded than for those with pulmonary disease with a total of 3,213 contacts (median of 1 contact; IQR: 0 to 3 close contacts).

Screening and treatment results in close contacts

Table 3 shows the numbers and proportion of adult and child contacts in 2022 and 2023 who were identified, screened, tested positive for LTBI, then started and completed treatment.

In 2023, a total of 8,665 contacts were identified from 2,151 people notified with pulmonary TB who had contact information recorded. Of those contacts, 69.9% were screened for active and latent TB; 18.7% tested positive for latent TB. A further 3.0% were reported to have active TB disease, compared with 2.5% in 2022 (see Table 3). This equates to 85 people with active TB and 528 with LTBI being identified for every 1000 index individuals contact traced.

Table 3. Number of adult and child contacts of people notified with pulmonary TB (index individuals) screened and treated for active TB and latent TB infection, England, 2022 and 2023

Screening and treatment categories	All adult contacts in 2022	All child contacts in 2022	Total contacts in 2022	All adult contacts in 2023	All child contacts in 2023	Total contacts in 2023
Number of contacts identified	6,651	2,149	8,800	6,520	2,145	8,665
Number of contacts screened for active TB and latent TB (%)	5,117 (76.9)	1,780 (82.8)	6,897 (78.4)	4,487 (68.8)	1,573 (73.3)	6,060 (69.9)
Number of contacts with active TB (%)	105 (2.1)	65 (3.7)	170 (2.5)	124 (2.8)	58 (3.7)	182 (3.0)
Number of contacts with latent TB (%)	908 (17.7)	413 (23.2)	1,321 (19.2)	767 (17.1)	368 (23.4)	1,135 (18.7)
Number of contacts who started treatment for latent TB (%)	648 (71.4)	390 (94.4)	1,038 (78.6)	520 (67.8)	329 (89.4)	849 (74.8)
Number of contacts who completed treatment for latent TB (%)	514 (56.6)	326 (78.9)	840 (63.6)	388 (50.6)	274 (74.5)	662 (58.3)

Notes:

• the denominator for proportion of contacts screened for active TB and latent TB infection is number of contacts identified
• the denominator for the proportion of contacts positive for active TB and LTBI is the number of contacts screened
• the denominator for the proportion of contacts who started and completed treatment is the number of contacts positive for LTBI
• individuals with greater than 65 contacts were excluded in the analysis

In 2023, children (aged 14 years or under) made up 24.8% of all contacts identified. Child contacts were more likely to be screened than adult contacts, and slightly more likely to have active (3.7% of child contacts, 2.8% of adults) and latent TB disease (23.4% versus 17.1%). This was similar to 2022 (see Table 3). Nearly three-quarters (74.8%) of contacts with a positive LTBI test started treatment for latent TB and 58.3% were recorded as having completed treatment, lower than the previous low of 62.0% in 2019 (see Supplementary Table 21 in the accompanying dataset).

Screening and treatment results varied by UKHSA region and are shown in Supplementary Table 22 in the accompanying dataset and proportions of treatment completion for LTBI by UKHSA region are shown in Appendix Figure A9 for 2021 to 2023.

Contacts of child index individuals compared with adult index individuals have generally had higher LTBI treatment completion rates, most notably in 2018 and 2019, but LTBI treatment completion rates have decreased since 2018 in contacts of both adult and child index individuals (see Figure 8 and Supplementary Table 23 in the accompanying dataset).

Figure 8. Latent TB infection (LTBI) treatment completion (proportion) in close contacts of adult or child index individuals and UK born or non-UK born index individuals with pulmonary TB, England, 2018 to 2023

Note: individuals with more than 65 contacts were excluded.

Data underlying this figure can be seen in Supplementary Table 23 of the accompanying dataset.

BCG Vaccination

The BCG vaccination programme is a risk-based programme recommended for individuals at higher risk of exposure to TB. This includes all infants (0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is over 40 notifications per 100,000 population per year. In addition to this, all infants living in an area of the UK with an incidence above 40 per 100,000 population should be offered the BCG vaccine.

Eligible babies should be offered the BCG vaccine at 28 days or soon after. Detailed information on the BCG programme can be found in the Green Book. Evaluation studies have identified that BCG is most effective against the most severe forms of the disease, such as TB meningitis in children and less effective in preventing respiratory disease, which is the more common form in adults.

As part of the Cover of Vaccination Evaluated Rapidly (COVER) programme, BCG is included in the quarterly childhood vaccine coverage data extraction from local child health information systems (CHIS). This includes denominators of eligible children and therefore coverage for all local authorities of children at 3 months.

In Table 4, BCG vaccine coverage data is presented for England and by region from January to December 2023. For England BCG coverage at 3 months of age for eligible children was 73.1%, varying from 39.5% in the North East to 81.1% in the East of England.

In Table 5, the BCG vaccine coverage data is presented for the 5 local authorities in London that offered universal vaccination and coverage of the selective programme for Leicester local authority. The Newham and Leicester 3-year TB incidence is greater than 40 per 100,000 population with BCG coverage of 83.7% and 86.2% respectively.

Table 4. Annual BCG vaccine coverage of children up to 3 months old in England and in regions: January to December 2023

Area	Eligible population	Number of children vaccinated	Coverage (%)
England	166,625	121,837	73.1
North East	3,329	1,316	39.5
North West	17,322	11,941	68.9
Yorkshire and The Humber	13,160	10,039	76.3
East Midlands	11,058	7,937	71.8
West Midlands	21,770	16,562	76.1
East of England	16,081	13,046	81.1
London	55,725	41,514	74.5
South East	21,589	15,738	72.9
South West	6,591	3,731	56.6

Table 5.  Annual BCG vaccine coverage of children up to 3 months old in English local authorities with universal BCG programmes and Leicester local authority: January to December 2023

Upper tier local authority	Three-year average (2021 to 2023) annual TB rate per 100,000	Number of eligible children	Number of children vaccinated	BCG coverage
Newham	40.6 (36.9 to 44.6)	5,380	4,501	83.7
Brent	39.1 (35.4 to 43.1)	3,045	1,598	52.5
Hounslow	27.3 (24.0 to 31.0)	2,327	2,069	88.9
Ealing	31.6 (28.4 to 35.1)	3,174	2,497	78.7
Redbridge	28.1(24.8 to 31.7)	3,254	2,510	77.1
Leicester	40.7 (37.0 to 44.6)	2,864	2,468	86.2

Notes:

• BCG vaccine coverage for calendar year 2023 for children at 3 months of age is extracted from Childhood Vaccination Coverage quarterly statistics
• 3-year average TB incidence rate per 100,000 for upper tier authority is shown in Supplementary Table 8

Appendix

Pre-entry TB screening

Figure A1. Flow diagram of the number of screening episodes, chest X-ray results, sputum test results and laboratory and clinically confirmed cases of TB for IOM screening providers in 2023

Note 1: other sputum referrals are sputum tests carried out in applicants that 1) did not have a CXR suggestive of TB, but TB was still suspected or 2) in applicants that did not have a CXR due to pregnancy.

Note 2: a clinically confirmed case is one that does not have a sputum culture positive test result but meets clinical criteria for diagnosis.

Data used to create Figure A1 can be found in Supplementary Table 8 in the accompanying dataset.

Figure A2. Flow diagram of the number of screening episodes, chest X-ray results, sputum test results and laboratory and clinically confirmed cases of TB for non-IOM screening providers in 2023

Note 1: other sputum referrals are sputum tests carried out in applicants that 1) did not have a CXR suggestive of TB, but TB was still suspected or 2) in applicants that did not have a CXR due to pregnancy.

Note 2: where an applicant had been recorded as referred to treatment or been recorded as clinically confirmed (does not have a sputum culture positive test result but meets clinical criteria for diagnosis) they were considered a case. See methods section for full explanation.

Data used to create Figure A2 can be found in Supplementary Table 8 in the accompanying dataset.

Figure A3. Number of people with confirmed and possible TB by screening provider, 2018 to 2023

Data underlying this figure can be seen in Supplementary Table 7 of the accompanying dataset.

To investigate the likely under or overestimate of TB case detection by non-IOM clinics using confirmed or confirmed and possible TB cases we calculated the number of cases we would expect to have detected for non-IOM clinics, based on the number of screens for each country applying the WHO estimated population incidence.  

However, the following provisions should be noted:

1. Not all people are born in the country in which they are screened (estimated at 5 to 7%).

2. People being screened may have a different TB incidence compared with the population average, and this difference may vary by country.

For example, if we assume that people being screened by IOM and non-IOM clinics in Pakistan were similar, we would expect similar TB detection rates by clinic provider, the TB detection rate per 100,000 in 2023 by IOM clinics was 74.9 and by non-IOM was 21.8 with confirmed cases only and 213.0 when including possible cases, supporting our conclusion that the true TB detection rate for non-IOM clinics likely lay somewhere between the two.

Table A1. LTBI testing rates and positivity for the top 10 countries by number of eligible new migrants, England, 2023

Country of birth	TB disease rate (notifications per 100,000) from WHO (2022)	Number of eligible new entrant migrants	Number of eligible new entrant migrants tested	Percent eligible new entrant migrants tested (%)	Positive tests	Positivity (%)
India	199	143,157	12,726	8.9	1,999	15.7
Pakistan	259	39,175	3,825	9.8	444	11.6
Nigeria	219	33,854	3,026	8.9	664	21.9
Bangladesh	221	20,809	2,406	11.6	226	9.4
Ghana	133	13,193	860	6.5	130	15.1
Nepal	299	8,644	517	6.0	108	20.9
Zimbabwe	204	6,609	345	5.2	71	20.6
Afghanistan	185	5,995	1,256	21.0	221	17.6
South Africa	468	3,789	192	5.1	18	9.4
Philippines	638	3,323	250	7.5	46	18.4

Note: data about country of birth was missing for 6,811 (19.6%) individuals in 2023.

Data used in this table can be found in Supplementary Table 14 of the accompanying dataset.

Figure A4. Number of valid LTBI tests by UKHSA region in England from 2018 to 2023

Data used in this Figure can be found in Supplementary Table 12 of the accompanying dataset.

Figure A4 and Supplementary Table 12 in the accompanying dataset describe testing numbers by UKHSA region from 2018 to 2023. The South West were not entering negative tests prior to 2022 and so is under-reported before this time. In 2023 Yorkshire and the Humber tested the highest proportion of its eligible migrant population (28.9%), the region that tested the smallest proportion of its eligible migrant population was East of England (2.9%). Information by ICB level can be found in Supplementary Table 10 in the accompanying dataset.

Figure A5. Number of positive LTBI tests and treatment completion by UKHSA region, England, 2023

Note: treatment completion as a percentage of those who tested positive is shown at the end of the completed treatment bar. 

Data used in this figure can be found in Supplementary Table 12 of the accompanying dataset.

In 2023, the UKHSA regions with over 25% completion of treatment in 2023 were the South East (33.8%), South West (42.9%) and West Midlands (27.2%). Information by ICB level can be found in Supplementary Table 10 of the accompanying dataset.

Figure A6. Number of people tested through the LTBI programme subsequently notified with active TB, sub-grouped by test positivity, treatment initiation and completion, England, 2019 to 2023 (aggregate data)

Figure A6: flow chart text explanation

A flow chart showing aggregated counts of people tested for LTBI (number = 93,101) from 2019 to 2023.

140 people were notified with active TB within 90 days of an LTBI test.

The flow chart shows that 79,233 people had negative LTBI test result of these 40 people were notified of active disease.

People that had negative LTBI test results had TB notifications in the following time points:

• 13 within 1 year number
• 14 within 2 years
• 9 within 3 years
• 2 within 4 years
• 2 within 5 years

There were 13,738 people with positive LTBI test results.

Of the people with LTBI positive test results 3,344 started treatment and 10,394 had an unknown treatment status.

Of the people with positive test results that started treatment 2,584 completed treatment and 760 treatment completion is unknown.

Of the people that completed treatment 4 were notified with active TB with 2 notifications within 1 year of the LTBI positive test and 2 notifications within 2 years of the LTBI positive test.

Of the people that started treatment with an unknown treatment status 6 were notified with active TB with 2 notifications within 1 year of LTBI positive test, 3 notifications within 2 years of LTBI positive test and 1 notification within 1 year of a LTBI positive test.

Of those people that had a positive LTBI test but no record of treatment 168 were notified with active TB. Of these 123 were notified within 1 year, 28 within 2 years, 9 within 3 years and 8 within 4 years of the positive LTBI test.

People notified with active TB, sub-grouped by test positivity, treatment initiation and completion

After exclusion of the 140 people with probable active TB at the time of testing, from analysis of risk of incident active TB after testing: 14.76% of those tested were positive and were confirmed as latent TB infection, of whom 24.28% were recorded as having started prophylactic TB treatment. Data on treatment was missing for the remaining 10,403 people who had tested positive. Treatment completion in those that were recorded as having initiated treatment was high at 77.21%, resulting in 18.74% of positives known to have completed treatment.

The majority of incident TB disease notifications occurred within 1 year of the date of their LTBI test (and after 90 days) (see Supplementary Table 17 in the accompanying dataset), which is consistent with data globally that the highest risks of developing active TB occurs within the first 2 years of a positive test result (Behr MA and others) and supports the implementation of early testing after arrival within the UK to prevent more cases of active disease.

Contact tracing

Figure A7. Proportion of people notified with pulmonary TB with contact tracing information recorded by UKHSA region, England 2021 and 2023

Note: a total of 16 people were excluded as they had more than 65 contacts (a range of 70 to 174). This is due to large congregate setting incidents being included in the NTBS records of these individuals. The 16 comprised: one individual with 126 contacts; (2021) 8 individuals with 67 to 168 contacts; (2022) and 7 individuals with 70 to 174 contacts (2023).

Data underlying this figure is available in Supplementary Table 18 in the accompanying dataset.

Figure A8. Histogram of the number of contacts per notification of pulmonary TB in 2021 (A), 2022 (B) and 2023 (C), England

Figure A8: A

Figure A8: B

Figure A8: C

Note: a total of 16 people were excluded as they had more than 65 contacts (range 70 to 174). This is due to large congregate setting incidents being included in the NTBS records of these individuals. The 16 comprised: one individual with 126 contacts; (2021) 8 individuals with 67 to 168 contacts; (2022) and 7 individuals with 70 to 174 contacts (2023).

Figure A9. LTBI treatment completion in close contacts of people with pulmonary TB by UKHSA region, England 2021 to 2023

Note: a total of 16 people were excluded as they had more than 65 contacts (a range of 70 to 174). This is due to large congregate setting incidents being included in the NTBS records of these individuals. The 16 comprised: one individual with 126 contacts; (2021) 8 individuals with 67 to 168 contacts; (2022) and 7 individuals with 70 to 174 contacts (2023).

Data underlying this figure is available in Supplementary Table 22 in the accompanying dataset.

Background information

Pre-entry screening programme

The UK pre-entry screening programme replaced on-entry screening at UK airports in March 2014. It uses chest x-ray (CXR) based screening for active pulmonary TB carried out by appointed panel clinics, usually in the country of origin, with sputum cultures conducted for those with those with abnormal CXR considered to be consistent with TB.

NHSE new entrant migrant LTBI testing programme

The NHSE National LTBI testing, and treatment programme was introduced in 2015 as part of the Tuberculosis (TB): collaborative strategy for England (2015 to 2020). It is a key component of the TB Action Plan. The programme is commissioned and managed by NHSE with UKHSA responsible for the data collection database and the analysis and submission of these data to NHSE, used for payment per test to participating ICBs and monitoring and evaluation of the programme.

Some ICBs have local arrangements for LTBI testing and treatment outside of the nationally commissioned programme, for which no data is received by UKHSA and are not reported here.