Research and analysis

Tuberculosis in the North West: annual review 2022

Updated 14 March 2024

Executive summary

The number of tuberculosis (TB) cases reported in England increased by 7.3% in 2021, to an incidence of 7.8 per 100,000 population. TB incidence in the north-west of England also increased by 5.5% to 6.5 per 100,000 population (1). The highest incidence areas in the region were Manchester, Blackburn with Darwen and Preston.

Most TB cases reported in the North West in 2021 were born outside the UK (72.9%). Of these cases, 16.4% were diagnosed within one year of entry and 39.5% were diagnosed 11 or more years after entry. Highest rates among those born outside the UK occurred in the Pakistani ethnic group (127.4 per 100,000 population).

TB rates were generally highest in the most socio-economically deprived populations: 11.9 per 100,000 population in the most deprived decile compared with 2.2 per 100,000 population in the least deprived decile. In 2021, 20.0% of TB cases were resident in areas containing the 10% most socio-economically deprived populations in the North West.

Those in under-served populations (including migrants, refugees, asylum seekers and those with social risk factors (SRFs), such as substance misuse, prison history and homelessness) have been associated with an increased risk of acquiring TB. In the North West, 9.5% of cases notified in 2021 had at least one SRF. The proportion of cases with SRFs has remained fairly consistent, comprising 8.9% of cases on average over the last 10 years.

Over half of the cases with at least one SRF were white (53.5%), and 23.3% were in the black-African ethnic group. Most cases with at least one SRF were male (84.1%), half (50.0%) were in the 15 to 44 years age group and 70.5% had pulmonary disease.

Pulmonary TB comprised 48.0% of all cases in the North West, and over two-thirds of these cases started treatment within 4 months of symptom onset. Among UK born cases of pulmonary TB, 40.0% experienced a treatment delay of 4 months or more after symptom onset.

In the non-severe TB cohort (cases without central nervous system disease and not identified as having multi-drug resistant or rifampicin resistant TB), 85.9% of those notified in 2020 completed treatment within 12 months, similar to the previous year. Treatment completion was lower in cases with central nervous system disease at 59.5% (at the last recorded outcome). In the drug resistant cohort, 57.1% of cases had completed treatment at 24 months.

The proportion of TB cases with isoniazid resistance (without multi-drug resistance) was 7.7% in 2021; lower than in 2020 (8.6%) but higher than in years 2000 to 2019 (average 4.3%). This was higher than reported nationally (5.6%). The proportion of multidrug or rifampicin resistant TB cases was higher than in previous years at 2.8%, and higher than the proportion of 1.9% reported nationally (1).

Data presented in this report detail the social and demographic characteristics of TB in the North West.

Recommendations

The main recommendations for NHS and UKHSA stakeholders involved in TB diagnosis, treatment and prevention include the following:

1. The TB Action Plan for England, 2021 to 2026 sets out the improvements that need to be achieved to bring about a sustained decline in TB and the mechanism by which these improvements should be achieved. The North West TB Control Board (covering Greater Manchester, Cumbria, Lancashire, Cheshire and Merseyside) oversees improvements in TB control, especially among the most vulnerable groups, in addition to the provision of strong and effective public health and clinical services. TB service providers should utilise the UKHSA TB Strategy Monitoring Indicators Tool to track performance and support development of local TB action plans.

2. TB rates were highest in the most socio-economically deprived areas of the North West, and the proportion of cases with SRFs highlights that underserved populations remain a priority for intervention. It is therefore necessary to engage with prison health, drug and alcohol services and homelessness sectors to promote TB prevention and treatment, and to utilise the Tackling Tuberculosis in Under-served Populations resource to inform and develop services designed to reduce health inequalities.

3. Most cases of TB in the North West were in those born abroad, and a substantial proportion were resident in the UK for at least 11 years. This highlights the continued need for the identification and treatment of migrants with latent TB infection (LTBI) to reduce the risk of future development of active disease. Commissioners and care providers should continue to support the LTBI screening programme to ensure the effective prevention, detection and treatment of TB and LTBI in high-risk groups. Work should continue to raise awareness about TB in migrant communities and with their primary and secondary care providers. Clinical pathways should be in place to increase detection and diagnosis for those at highest risk.

4. Every effort should be made to increase the proportion of sputum smear results among pulmonary cases to enable better TB control.

5. UKHSA and partner organisations should continue to ensure cohort review is used as an opportunity to review local incidents (such as TB deaths and delays in treatment) to promote learning and sharing of ideas for case management.

6. The NHS should offer HIV testing for all those diagnosed with TB and ensure that tests are done in line with national guidance (2).

7. NHS stakeholders should implement recommendations from the Getting It Right First Time (GIRFT) programme, which aims to improve the treatment and care of TB patients by promoting consistency and best practice.

Tuberculosis notifications and incidence

Overall numbers, rates and geographical distribution

In 2021, 481 TB cases were reported among North West residents, a rate of 6.5 per 100,000 population. This was a 5.5% increase compared to 2020 (455 cases; rate of 6.2 per 100,000 population). The North West TB rate remained below the England rate of 7.8 per 100,000 (Figure 1), and the North West rate was the fourth highest of the 9 UKHSA regions in England (1).

Overall, TB incidence in the North West has decreased since 2011, with fluctuations in recent years. The decrease seen in 2020, and subsequent increase in 2021, may be partly due to factors arising from the COVID-19 pandemic, such as restrictions on travel and access to healthcare. However, the extent to which these factors have impacted TB surveillance and epidemiology are unknown.

Figure 1. TB case reports and rates in the North West and England, 2000 to 2021

Description of Figure 1: a combination line-column chart, with columns showing counts of TB cases in the North West and lines showing TB incidence in the North West and England from 2000 to 2021. There was a general increase in case numbers and rates from 2000 to 2011, then a decreasing trend from 2011 to 2021.

Among North West county councils, the highest rates were in Manchester at 21.1 per 100,000 and Blackburn with Darwen at 20.0 per 100,000 population. The most significant changes in incidence occurred in Preston, which increased from 11.8 per 100,000 population in 2020 to 19.0 per 100,000 population in 2021 (from 17 to 28 cases), and in Tameside, where incidence increased from 5.3 per 100,000 population in 2020 to 12.1 per 100,000 population in 2021 (from 12 to 28 cases). In Rochdale, the rate decreased from 13.0 per 100,000 population in 2020 to 5.8 per 100,000 population in 2021 (from 29 to 13 cases). In 2021, 6 of the 39 North West county councils had zero notifications of TB.

Figure 2. Three-year average TB incidence per 100,000 population by county council of residence, North West, 2019 to 2021

Description of Figure 2: a thematic map showing the three-year average TB incidence in the North West from 2019 to 2021 by county of residence. The data displayed on the map are detailed in Appendix C, Table C1.

Demographic characteristics

Age and sex

In 2021, 64.4% of North West TB cases were male, and rates among males were higher than in females (8.5 per 100,000 in males and 4.5 per 100,000 in females), a consistent pattern from previous years. The number of males with TB was greater than the number of females across all age groups (Figure 3). More than half (51.8%) of all TB cases occurred in the 15 to 44 years age group. There were 19 cases of TB reported in children aged 0 to 14 years, similar to the previous year (25 cases reported in 2020).

Figure 3. TB case reports by age and sex in the North West, 2021

Description of Figure 3: a two-sided horizontal bar chart with bars showing counts of TB cases in the North West in 2021, split by sex and age group. The number of males was greater than the number of females in each age group, with males aged 15 to 44 years comprising the largest group.

Rates were highest in residents aged 15 to 44 years (Figure 4). The rate in the 45 to 64 years age group increased from 6.1 per 100,000 in 2020 to 7.3 per 100,000 in 2021. Incidence in the 0 to 14 years age group decreased from 1.9 per 100,000 population in 2020 to 1.4 per 100,000 population in 2021.

Thirty-two cases aged 0 to 17 years were reported in 2021, an incidence of 2.0 per 100,000 population (compared with 33 cases and an incidence of 2.1 per 100,000 population reported in 2020).

Figure 4. TB case rates by age group in the North West, 2012 to 2021

Description of Figure 4: a line chart showing rates of TB by age group in the North West from 2012 to 2021. There was a general decreasing trend across all age groups during this time period. The highest rates were in those aged 15 to 44 years, followed by 45 to 64 years and 65 years and over. Lowest rates were in the 0 to 14 years age group.

Place of birth and time since entry to the UK

In 2021, place of birth was known for 97.3% (468 out of 481) of TB cases in the North West. Of these, 27.1% (127 out of 468) were born in the UK, similar to previous years (29.5% in 2020, 28.0% in 2019).

Incidence of TB in the non-UK born population was considerably higher than the rate of TB among those born in the UK, as reported nationally (1). In 2021, the rate in the non-UK born population was 43.9 per 100,000 compared with 2.0 per 100,000 in the UK born population (Figure 5). Incidence decreased in the non-UK born population (from 46.7 per 100,000 in 2020), while the rate in the UK born population remained low (2.0 per 100,000 in 2020).

Figure 5. TB case reports and rates by place of birth, North West, 2012 to 2021

Description of Figure 5: a combination line-column chart, with separate columns showing counts of TB in UK born and non-UK born cases and separate lines showing TB rates among the UK born and non-UK born from 2012 to 2021. Numbers of cases and incidence of TB were consistently higher for non-UK born cases than for the UK born. Case numbers and rates have generally decreased in the period 2012 to 2021.

Year of entry was reported for 87.7% (299 out of 341 cases) of non-UK born cases in 2021. Of these, 16.4% were notified less than 2 years after entry and 28.1% were notified 2 to 5 years after entry (Figure 6), meaning that, overall, 44.5% were notified within 5 years of entering the UK. A further 16.1% were notified 6 to 10 years after entry. The highest proportion (39.5%, 118 out of 299) were notified to TB surveillance 11 or more years after entering the UK.

Figure 6. Time between entry to the UK and TB notification for non-UK born cases by year, North West, 2012 to 2021 (showing cases where year of entry was recorded)

Description of Figure 6: a horizontal bar chart with bars for each year from 2012 to 2021, showing a proportional split of the time between entry to the UK and notification of TB for non-UK born cases. Cases that were notified 11 or more years after entry comprised the greatest proportion in each year.

Approximately one-third of non-UK born TB cases reported in the North West in 2021 were born in Pakistan (Table 1), similar to the previous year (32.0% in 2021 compared with 34.0% in 2020).

Table 1. Most common countries of birth of non-UK born TB cases (where country of birth was known), North West, 2021

Country of birth	Number of cases	Proportion of cases	Median time in years since entry to UK (interquartile range (IQR))
Pakistan	109	32.0%	10 (3 to 24)
India	49	14.4%	5 (2 to 18)
Romania	19	5.6%	5 (4 to 6)
Somalia	16	4.7%	13 (3 to 17)
Bangladesh	15	4.4%	17 (11 to 27)
Sudan	14	4.1%	5 (3 to 6)
Nigeria	13	3.8%	7 (3 to 19)
Eritrea	12	3.5%	2 (1 to 4)
Others (each <3.0%)	94	27.6%	9 (3 to 17)
Total	341	100.0%	8 (2 to 18)

Among the most common countries of birth for non-UK born TB cases in 2021, those born in Eritrea had the shortest median time between entry to the UK and TB notification. The country with the longest median time between entry to the UK and notification was Bangladesh (17 years, IQR 11 to 27 years).

Ethnic group

In 2021, ethnicity was known for 98.1% (472 out of 481) of cases. The most common ethnic groups among all TB cases in the North West were the Pakistani, white and black-African ethnic groups (Figure 7). The proportion of cases in the Pakistani ethnic group decreased from 31.2% in 2020 to 27.0% in 2021, while the proportion of white cases increased from 21.1% in 2020 to 24.3% in 2021. The proportion of cases with black-African ethnicity increased from 12.9% in 2012 to 22.9% in 2020, decreasing to 19.5% in 2021.

Figure 7. Proportion of TB cases in most common ethnic groups, North West, 2012 to 2021

Description of Figure 7: a line chart with lines showing the proportion of cases in the most common ethnic groups among North West TB cases from 2012 to 2021. Highest proportions were generally in the Pakistani and white ethnic groups. There was an increase in the proportion of black-African TB cases from 2012 to 2020, but decreased in 2021.

Of UK born TB cases notified in 2021, the white ethnic group comprised the greatest proportion (64.0%, 80 out of 125), followed by the Pakistani ethnic group (12.8%, 16 out of 125). Among the non-UK born, 33.0% (112 out of 339) were in the Pakistani ethnic group, 25.4% (86 out of 339) were in the black-African ethnic group, and 15.0% (51 out of 339) were in the Indian ethnic group.

Figure 8. TB case numbers and incidence by ethnic group and place of birth, North West, 2021

Description of Figure 8: a two-sided chart of UK born and non-UK born TB cases in 2021, with columns showing counts of TB by ethnic group and marker points showing rates of TB by ethnic group.

Among UK born TB cases notified in 2021, the highest rate occurred in the Bangladeshi ethnic group (43.7 per 100,000 population, 4 cases), followed by the black-other ethnic group (41.5 per 100,000 population, 2 cases). For those born outside the UK (Figure 8), incidence was highest in the Pakistani ethnic group (127.4 per 100,000 population, 112 cases) and the Bangladeshi ethnic group (100.3 per 100,000 population, 16 cases).

The rate of TB increased in non-UK born cases of Bangladeshi ethnicity, from 81.5 per 100,000 population in 2020 to 100.3 per 100,000 in 2021 (from 13 to 16 cases). Incidence also increased in the non-UK born Indian ethnic group, from 73.4 to 81.4 per 100,000 population (from 46 to 51 cases); and in the non-UK born white ethnic group, from 4.5 to 9.0 per 100,000 population (from 16 to 32 cases).

There was a decrease in UK born cases of Pakistani ethnicity from 17.1 to 9.1 per 100,000 population (from 30 to 16 cases).

These rates should be interpreted with caution. The Labour Force Survey (LFS) was used to calculate population estimates based on a random sample of surveyed individuals, weighted to represent others in the region. Small populations are often underrepresented in the sample, which may inflate TB rates for small population groups.

Occupation

In 2021, occupation information was known for 80.9% (310 out of 383) of North West TB cases aged between 18 and 65 years, less than in the previous year (87.3% known in 2020). Of these, 32.6% (101 out of 310) were not in education or employment, 8.1% (25 out of 310) were healthcare workers, 7.7% (24 out of 310) were either studying or working in education, and the remaining cases (51.6%, 160 out of 310) were working in other occupations.

Clinical characteristics

Site of disease

In 2021, 48.0% of TB cases in North West England had pulmonary disease (Table 2), slightly lower than the national level of 52.8% (1). Of the 231 pulmonary cases, 80.5% (186 cases) were culture confirmed (compared with 81.0% in 2020).

Table 2. Site of disease of TB cases, North West, 2021

Site of disease (with or without disease at another site)	Number of cases	Proportion of cases
Pulmonary	231	48.0%
Miliary	14	2.9%
Laryngeal	2	0.4%
Extra-pulmonary	250	52.0%
Extra-pulmonary (other)	146	30.4%
Lymph nodes (extra-thoracic)	85	17.7%
IT lymph nodes	82	17.0%
Pleural	35	7.3%
Gastrointestinal	27	5.6%
Bone (spine)	25	5.2%
Bone (other - not spine)	12	2.5%
CNS meningitis	10	2.1%
Genitourinary	10	2.1%
CNS (other - not meningitis)	9	1.9%
Cryptic	0	0.0%
Extra-pulmonary (unknown)	0	0.0%

Previous history of tuberculosis

Information on previous history of TB was known for 87.7% (422 out of 481) of North West cases in 2021. Of these, 4.3% (18 out of 422) had received a previous diagnosis of TB, similar to previous years (5.3% in 2020, 4.8% in 2019). For those with a previous history of TB reported, information on previous treatment was known for 88.9% (16 out of 18) of cases. All 16 of these cases had previously received treatment (at least one month of treatment for active TB with a minimum of 2 anti-TB drugs for suspected TB disease).

Labratory confirmation of TB

Laboratory tests data collection

Laboratory data on culture confirmed TB isolates from the National Mycobacterium Reference Service were matched to TB case notifications, and the results were used to report culture confirmation. Results for microscopy, polymerase chain reaction (PCR) and histology were also recorded in NTBS (National TB Surveillance system).

Culture confirmation and speciation

A total of 62.2% (299 out of 481) of all cases in 2021, both pulmonary and extra-pulmonary, were confirmed by culture in the North West. Of the 231 pulmonary cases, 80.5% (186 out of 231) were culture confirmed, compared with 74.4% nationally (1). Among extra-pulmonary cases, 45.2% (113 out of 250) were confirmed by culture in the North West, similar to 45.6% confirmed nationally (1).

Culture confirmation was 42.1% (8 out of 19) in those aged 0 to 14 years, lower than in other age groups (58.9% and over).

Among all culture confirmed cases, 92.3% (276 out of 299) were identified with Mycobacterium tuberculosis (M. tuberculosis) infection, 3.0% (9 out of 299) with Mycobacterium africanum (M. africanum), and 0.7% (2 out of 299) with Mycobacterium bovis (M. bovis).

Sputum smear

Of the 231 pulmonary cases in the North West in 2021, 58.0% (134 out of 231) had a sputum smear result reported, a higher proportion than in previous years (55.7% in 2020). Among cases with a known sputum smear result, 71.6% (96 out of 134) were positive. 94.8% (91 out of 96) of those with a positive sputum smear were also culture confirmed.

Any diagnostic test result

The results of various diagnostic tests for TB (including culture, PCR, microscopy, histology and chest X-ray) were recorded on NTBS. In 2021, the proportion of cases with any diagnostic test recorded was 86.3% (415 out of 481 cases) in the North West, similar to previous years and lower than 92.8% reported nationally (1). Pulmonary cases were more likely to have a test performed (96.1%, 222 out of 231) than cases with extra-pulmonary disease (77.2%, 193 out of 250). In cases where no test was performed (13.7%, 66 out of 481), TB was either diagnosed on clinical grounds or diagnosed abroad and test results were unavailable.

Of cases with a TB test recorded, 74.9% (311 out of 415 cases) had a positive test result. This was lower than in the previous year (81.0%, 315 out of 389 cases).

Tuberculosis in children

The incidence of TB in children is considered to be an acceptable, indirect indicator of recent transmission within communities, since TB in children is likely to be caused by recent exposure (as opposed to reactivation of LTBI acquired some time previously).

Overall numbers and incidence

In 2021, 19 children (aged under 15 years) were notified with TB in the North West, a rate of 1.4 per 100,000 population. This was lower than the previous year (25 cases, 1.9 per 100,000 in 2020) and similar to the national rate of 1.3 per 100,000 (1). Overall, annual rates have declined since the peak of 4.6 per 100,000 (57 cases) in 2011 (Figure 9).

Figure 9. Numbers and incidence of TB in children (aged under 15 years), North West, 2000 to 2021

Description of Figure 9: a combination line-column chart, with columns showing counts of North West TB cases aged 0 to 14 years and a line showing TB incidence in this group from 2000 to 2021. There was an increase in case numbers and rates from 2003 to 2011, then a general decreasing trend from 2011 to 2021.

Demographic characteristics

Over half (52.6%, 10 out of 19 cases) of children notified with TB in 2021 were born in the UK. The rate of TB in UK born children was 0.8 per 100,000 population in 2021, lower than in the previous year (1.1 per 100,000 in 2020) and in line with the national rate of 0.8 per 100,000 (1). There has been an overall decrease in the North West rate since the peak of 3.6 per 100,000 in 2010 (Figure 10).

Figure 10. Incidence of TB in UK born children [note 1], North West, 2010 to 2021

Note 1: Aged 0 to 14 years. Rates calculated using LFS population estimates. Error bars represent upper and lower 95% confidence intervals.

Description of Figure 10: a line chart with error bars showing the rate of TB in UK born cases aged 0 to 14 years from 2010 to 2021. There was a generally decreasing trend in this time period.

Among children born outside the UK, the rate of TB remained stable at 11.6 per 100,000 (9 cases) in 2021, the same as in the previous year. This was higher than the rate of 8.2 per 100,000 reported nationally (1).

In 2021, 52.6% of children with TB (10 out of 19 cases) were male. Most common ethnic groups were Pakistani (31.6%, 6 out of 19 cases) and black-African (31.6%, 6 out of 19 cases).

Site of disease

In 2021, less than half (47.4%, 9 out of 19 cases) of children with TB had pulmonary disease, with or without extra-pulmonary TB. The most common extra-pulmonary site of disease was intra-thoracic lymph nodes (42.1%, 8 out of 19 cases).

Culture confirmation

Overall, 42.1% (8 out of 19) of cases of TB in children were confirmed by culture in 2021, compared with 33.3% nationally (1). Half of these culture confirmed cases were pulmonary (50.0%, 4 out of 8 cases).

Delay from onset of symptoms to start of treatment

Time symptomatic

The time between onset of symptoms and start of treatment was available for 68.1% of North West TB cases notified in 2021. The median number of days between symptom onset and treatment start was 92 (Table 3). This was lower among those with pulmonary disease at 71.5 days, and higher among extra-pulmonary cases at 102 days. Among pulmonary cases, 37.3% (59 out of 158) were treated within 2 months of symptom onset, and 69.6% (110 out of 158) were treated within 4 months.

Table 3. Time between symptom onset and treatment start [note 2], North West, 2021

	Median days (IQR)	0 to 2 months (n)	0 to 2 months (%)	2 to 4 months (n)	2 to 4 months (%)	More than 4 months (n)	More than 4 months (%)
Extra-pulmonary	102.0 (50-63)	48	28.7%	51	30.5%	68	40.7%
Pulmonary	71.5 (36-149)	59	37.3%	51	32.3%	48	30.4%
Pulmonary smear positive	68.0 (33-115)	34	41.0%	28	33.7%	21	25.3%
All Cases	92.0 (42-158)	107	32.9%	103	31.7%	115	35.4%

Note 2: Excluding asymptomatic patients, those with missing data, patients diagnosed post-mortem and those with delays over 2 years.

Characteristics of pulmonary tuberculosis patients with a delay from onset of symptoms to treatment of more than 4 months

Among pulmonary cases with treatment delays of more than 4 months, 43.8% (21 out of 48 cases) were in the 15 to 44 years age group, and treatment delays occurred more often in males (58.3%, 28 out of 48 cases). Among UK born cases of pulmonary TB, 40.0% (22 out of 55 cases) were treated 4 months or more after symptom onset, compared with 25.5% (26 out of 102 cases) of non-UK born pulmonary cases.

There was variation among ethnic groups: 54.8% (17 out of 31) of pulmonary cases (with known onset and treatment dates) in the black-African ethnic group were treated within 2 months of symptom onset, with 22.6% (7 out of 31) starting treatment after 4 months. In contrast, only 25.9% of cases in the white ethnic group began treatment within 2 months, with 35.2% (19 out of 54) starting treatment after 4 months. Although numbers were low, cases of Bangladeshi ethnicity had the highest proportion of cases starting treatment after 4 months at 66.7% (4 out of 6 cases).

Tuberculosis treatment outcomes in the non-multi-drug or non-rifampicin resistant tuberculosis cohort

Treatment outcomes for the non-MDR (multi-drug resistant) or non-RR (rifampicin resistant) TB cohort are reported separately for the following groups:

For patients with an expected duration of treatment less than 12 months, outcomes at 12 months are reported. This group excludes individuals with central nervous system (CNS) disease, who would be treated for 12 months. In addition, those with spinal, cryptic disseminated or miliary disease are excluded from this group, as CNS involvement cannot be reliably ruled out for the purposes of reporting.

For patients with CNS, spinal, cryptic disseminated or miliary disease, the last recorded treatment outcome is reported.

Outcomes for tuberculosis patients in the non-MDR or non-RR TB cohort without central nervous system (CNS) disease

In 2020, 455 TB cases were notified in the North West, 89.7% (408 out of 455) of which had non-severe TB, not identified as multi-drug resistant (MDR) or rifampicin resistant (RR) TB (non-MDR or non-RR TB). In the non-severe TB cohort, 85.9% (346 out of 403) completed treatment within 12 months, similar to the previous year (85.2%, 398 out of 467; Figure 11). This proportion is likely to increase as more outcomes are recorded. Nationally, treatment completion was similar at 84.2% in 2020 (1).

Figure 11. Outcomes at 12 months for TB patients in the non-MDR or non-RR TB cohort (without central nervous system disease), North West, 2010 to 2020 [note 3]

Note 3: Not evaluated includes missing and unknown outcomes, and cases transferred out.

Description of Figure 11: a stacked column chart showing TB treatment outcomes as a proportion of cases in each year from 2011 to 2020. Over 85% of cases in each year had completed treatment.

Of cases that did not complete treatment within 12 months (14.1%, 57 out of 403), the most common reasons for not completing treatment were death and still being on treatment (Table 4).

Table 4. TB outcomes at 12 months for TB patients in the non-MDR or non-RR TB cohort (without central nervous system disease), North West cases notified in 2020

TB outcome	n	%
Treatment completed	346	85.9%
Died	20	5.0%
Lost to follow up	8	2.0%
Still on treatment	10	2.5%
Treatment stopped	3	0.7%
Not evaluated (see note 3)	16	4.0%
Total	403	100.0%

Of the 20 cases that died before treatment completion, the relationship between TB and death was unknown for 40.0% (8 out of 20). Of the 12 cases for which information was recorded, TB caused 1 death, contributed to 6, and was incidental to 5. The median age of those who died was 74 years.

Older cases were less likely to complete treatment: 65.0% (39 out of 60) of those aged 65 years or older completed treatment within 12 months, compared with over 87% in other age groups. The 65-or-older age group also had a higher proportion of deaths (18.3%, 11 out of 60).

Treatment completion was 87.5% (244 out of 279) among the non-UK born, and lower in the UK born at 82.6% (100 out of 121). The proportion of males that died was 6.5% (15 out of 230), compared with 2.9% (5 out of 173) of females.

A greater proportion (86.6%, 323 out of 373) of cases with no recorded SRFs completed treatment within 12 months than cases with at least one recorded risk factor (76.7%, 23 out of 30).

Outcomes for TB patients in the non-MDR or non-RR TB cohort with CNS disease

Of the 42 cases with CNS, spinal, miliary or cryptic disseminated disease in 2020, 59.5% (25 out of 42) had completed treatment at the last recorded outcome (Table 5). This was lower than in the previous year (84.1%, 37 out of 44) and lower than recorded nationally (77.0%, 348 out of 452) (1). However, the proportion completing treatment is expected to increase, as in previous years. Half (50.0%, 21 out of 42) of cases in this cohort completed treatment within 12 months.

The most common reason for non-completion of treatment was death (Table 5). The proportion of patients in this cohort that died (21.4%, 9 out of 42) is the highest yet seen in the North West, and is higher than recorded in England in 2020 (12.8%, 58 out of 452) (1). Most of these deaths occurred in males (6 cases), 4 cases were aged 65 years or older and 5 cases were born outside the UK. TB contributed to death in 3 cases, was incidental to death in one case and in 5 cases the relationship between TB and death was unknown.

Table 5. TB outcome at last recorded outcome for TB patients in the non-MDR or non-RR TB cohort with CNS disease, North West cases notified in 2020

TB outcome	n	%
Treatment completed	25	59.5%
Died	9	21.4%
Lost to follow up	1	2.4%
Still on treatment	1	2.4%
Treatment stopped	1	2.4%
Not evaluated (see note 3)	5	11.9%
Total	42	100.0%

For most of the 9 cases that died before treatment completion, the relationship between TB and death was unknown (55.6% (5 out of 9)), TB contributed to death in 3 cases and was incidental to death in one further case. The median age of those who died was 63 years.

The median age of all cases in this cohort was 40 years. Older cases were less likely to complete treatment: 25.0% (2 out of 8) of those aged 65 years or older had completed treatment at the last recorded outcome, compared with 37.5% to 76.9% in other age groups.

Last recorded TB treatment outcomes for the entire non-MDR or non-RR TB cohort

The proportion of cases in the entire non-MDR or non-RR TB cohort who had completed treatment at the last recorded outcome was 85.6% (381 out of 445), lower than in the previous year (90.0%, 460 out of 511 in 2019) and similar to the proportion of 86.4% recorded in England (1).

The proportion of cases who had died at the last recorded outcome increased to 6.5% (29 out of 445) compared with 4.1% (21 out of 511) in 2019. This was similar to the proportion of deaths in England (6.0% in 2020) (1). The relationship between TB and death was unknown for 44.8% (13 out of 29) of cases. TB caused death in one case (3.4%), contributed to death in 9 cases (31.0%) and was incidental to death in 6 cases (20.7%). Over half of deaths (51.7%, 15 out of 29) were in cases aged 65 years and over, and 72.4% of deaths were in males. Most cases who died had pulmonary disease (79.3%, 23 out of 29).

The proportion of cases that were lost to follow up at the last recorded outcome remained low at 2.2% (10 out of 445), compared with 3.3% (17 out of 511) in 2019. Of these, most were born outside the UK (80.0%, 8 out of 10), and half (5 out of 10) had left the UK. Males accounted for 60.0% (6 out of 10) of cases lost to follow up and 80.0% (8 out of 10) of cases were in the 15 to 44 years age group.

Drug resistant tuberculosis (including outcomes in the drug resistant cohort)

Drug resistance   

Resistance to one or more TB antibiotic drugs may be in complex combinations. A distinction is made between first, second and third line TB antibiotic drugs depending upon their clinical effectiveness. First line drugs include isoniazid, rifampicin, pyrazinamide and ethambutol. Second line drugs are injectable agents (for example, amikacin, capreomycin, kanamycin), fluoroquinolones (for example, moxifloxacin, ofloxacin, ciprofloxacin) and other oral bacteriostatic agents. MDR TB cases are initially resistant to at least isoniazid and rifampicin. Extensively drug resistant TB cases (XDR-TB) are resistant to more drugs than rifampicin and isoniazid (3).

Overall initial drug resistance and geographical distribution

In 2021, 99.7% (286 out of 287) of culture confirmed North West TB cases had susceptibility results for isoniazid; 98.6% (283 out of 287) had susceptibility results for rifampicin. This was in line with previous years.

The proportion of culture confirmed cases with susceptibility results for at least one first line drug was similar to previous years at 98.6% (283 out of 287). The proportion of cases with resistance to at least one first line drug increased from 14.1% (41 out of 291) in 2020 to 15.7% (45 out of 287) in 2021. This was higher than reported nationally (9.9%) (1).

The proportion of North West TB cases with isoniazid resistance (without MDR-TB) was 7.7% (22 out of 287) in 2021, lower than in the previous year (8.6%, 25 out of 291) but higher than in years 2000 to 2019 (Figure 12).This was higher than reported nationally (5.6%) (1).

In 2021, resistance to rifampicin remained low at 2.8% (8 out of 283 cases). MDR, grouped with RR for treatment purposes, was 2.8% (8 out of 287), higher than in previous years and higher than the proportion of 1.9% reported nationally (1). There were no cases of XDR TB reported in the North West in 2021.

Figure 12. Proportion of drug resistant TB cases, North West, 2000 to 2021

Description of Figure 12: a line chart showing the proportion of culture confirmed North West TB cases with isoniazid resistance (without MDR-TB), MDR-RR TB and XDR-TB from 2000 to 2021. There was a notable increase in the proportion of cases with isoniazid resistance (without MDR-TB) from 3.5% in 2019 to 8.6% in 2020, although there was a subsequent decrease to 7.7% in 2021. There was also an increasing proportion of cases with MDR/RR-TB from 0.6% in 2017 to 2.8% in 2021. The proportion of XDR-TB cases remained at 0.0% between 2013 and 2021.

Among cases of isoniazid resistance without MDR-TB, 45.5% were aged between 45 and 64 years (10 out of 22 cases), with more males (68.2%, 15 out of 22) than females. Most cases were born outside the UK (81.8%, 18 out of 22). Countries of birth varied, but the highest proportion originated in Pakistan (50.0%, 9 out of 18). The highest proportions of isoniazid resistant cases without MDR-TB occurred in Pakistani (40.9%, 9 out of 22) and White (27.3%, 6 out of 22) ethnic groups. Most cases had pulmonary disease (68.2%, 15 out of 22).

Of cases notified a year earlier in 2020, 76.0% (19 out of 25) of those resistant to isoniazid without MDR-TB had completed treatment at 12 months; 12.0% (3 out of 25) died. One further case (80.0%, 20 out of 25) had completed treatment at the last recorded outcome.

MDR or RR TB cases notified in 2021 occurred mostly in males (62.5%, 5 out of 8 cases), and mostly in the 15 to 44 years age group (62.5%, 5 out of 8). Three quarters of cases were born outside the UK (75.0%, 6 out of 8) and 62.5% (5 out of 8) had pulmonary TB. Two out of 8 cases of MDR or RR TB were clustered together (no other cases were known to be in the cluster).

Tuberculosis treatment outcome at 24 months for patients in the drug resistant (MDR or RR TB) cohort

In 2019, there were 7 cases notified in the MDR or RR TB cohort, all of which were confirmed by culture. At 24 months, 4 cases (57.1%) had completed treatment (Table 6); this increased to 5 cases at the last recorded outcome. One case died, with TB recorded as incidental to death.

Table 6. TB outcome at 24 months for culture confirmed cases with MDR or RR TB, North West, cases diagnosed in 2019

TB outcome	n	%
Treatment completed	4	57.1%
Died	1	14.3%
Lost to follow up	0	0.0%
Still on treatment	1	14.3%
Treatment stopped	0	0.0%
Blank/unknown	1	14.3%
Total	7	100.0%

Tuberculosis in under-served populations

Social risk factors

Information on SRFs (including homelessness, drug and alcohol misuse and imprisonment) for TB cases aged 15 years and over has been available since 2009. In 2021, 9.5% (44 out of 462) of North West cases had at least one SRF. Where information on individual risk factors was known, 5.0% (20 out of 400) reported drug use, 4.8% (19 out of 398) reported homelessness, 4.4% (17 out of 384) reported imprisonment, and 2.3% (9 out of 397) reported alcohol misuse (Figure 13). Over half of cases (54.5%, 24 out of 44) with at least one SRF recorded had 2 or more SRFs.

Figure 13. Social risk factors among TB cases [note 4], North West, 2012 to 2021

Note 4: For cases aged 15 years and over, where information on individual risk factors was recorded.

Description of Figure 13: a line chart showing the proportion of North West TB cases with SRFs from 2012 to 2021. Separate lines show cases with at least one SRF, recorded drug use, alcohol use, homelessness and imprisonment.

Most cases with at least one SRF were male (84.1%, 37 out of 44) and half (50.0%, 22 out of 44) were in the 15 to 44 years age group. The majority of UK born cases were in the white ethnic group (90.5%, 19 out of 21). Of non-UK born cases with at least one SRF, the highest proportion occurred in the black-African ethnic group (45.5%, 10 out of 22). Most cases with at least one SRF had pulmonary disease (70.5%, 31 out of 44).

Asylum seekers comprised 3.5% (17 out of 481) of North West TB cases in 2021 (where information was recorded); a similar level to previous years.

The prevalence of SRFs varied among county council areas. For the period 2019 to 2021, the highest proportion of cases with at least one SRF occurred in Manchester (14.9%, 18 out of 121), followed by Liverpool (14.0%, 17 out of 121).

Of cases notified in 2020, a lower proportion of drug sensitive cases with at least one SRF had completed treatment at the last recorded outcome (76.7%, 23 out of 30) compared to those with no recorded risk factors (88.5%, 308 out of 348). More cases with SRFs died before or during TB treatment (16.7%, 5 out of 30 compared with 4.3%, 15 out of 348) and more were lost to follow up (6.7%, 2 out of 30 compared with 2.0%, 7 out of 348).

Deprivation

In 2021, the incidence of TB was 11.9 per 100,000 in the 10% of the population living in the most deprived areas of the North West, compared to 2.2 per 100,000 in the 10% of the population living in the least deprived areas (Figure 14). One-fifth of TB cases were in the most socio-economically deprived decile (20.0%, 89 out of 446) compared with one in 28 in the least socio-economically decile (3.6%,16 out of 446).

Figure 14. Rate of TB by socio-economic deprivation decile, North West, 2021

Description of Figure 14: a combination line-column chart, with columns showing the proportion of 2021 North West TB cases in each deprivation decile and a line showing TB incidence for each decile. A clear trend is shown of a higher proportion of cases and higher incidence in the most deprived deciles compared with the least deprived deciles.

A greater proportion of non-UK-born cases resided in the most deprived areas, while more UK born cases were resident in areas of least deprivation.

HIV testing of tuberculosis patients

HIV testing

TB is a well-recognised and serious complication of HIV infection, but is successfully treated with a combination of highly active antiretroviral therapy (HAART) and appropriate TB antibiotic treatment). For this reason, it is essential that all patients with TB should undergo HIV testing so that if they are diagnosed as having TB-HIV co-infection they have the opportunity to start curative TB treatment and HAART as soon as possible, and in so doing reduce the risk to themselves and reduce the risk of TB or HIV transmission to others.

Information on HIV testing was available for 94.5% (451 out of 477) of North West cases reported in 2021 (excluding cases diagnosed at post-mortem). Of these, 99.3% (434 out of 437) were offered an HIV test (excluding cases where HIV status was already known). The proportion of TB cases being offered an HIV test has increased over time (Figure 15).

Figure 15. Proportion of TB cases offered an HIV test, North West, 2021

Description of Figure 15: a bar chart with columns showing the proportion of North West TB cases in each year from 2012 to 2021 that were offered an HIV test. There has been an increasing trend from 90.2% in 2012 to 99.3% in 2021.

Of cases that were offered an HIV test: 99.5% (432 out of 434) received a test; 0.2% (one out of 434) were offered a test but did not receive it; and 0.2% (one out of 434) refused testing.

BCG vaccination

BCG vaccination status   

Information on Bacillus Calmette-Guérin (BCG) vaccination status was available for 48.2% (232 out of 481) of North West cases in 2021, similar to previous years. Of these, 67.7% (157 out of 232) were reported to have received BCG vaccination.

The proportion of cases with a known BCG vaccination status was higher in younger age groups: 73.7% (14 out of 19) in cases aged 0 to 14 years, compared with 47.2% (34 out of 72) of cases aged 65 and over. Where vaccination status was known, the proportion with recorded BCG vaccination ranged from 71.4% (10 out of 14) in the 0 to 14 years age group to 47.1% (16 out of 34) in those 65 years and over. Information was recorded for 75.0% (24 out of 32) of cases aged 0 to 17 years, 75.0% (18 out of 24) of which had received BCG vaccination.

BCG vaccination data was available for 55.1% (70 out of 127) of UK born cases, compared with 47.2% (161 out of 341) of cases born outside the UK. Among cases with available information, 70.0% (49 out of 70) of UK born cases had received BCG vaccination, a slightly higher proportion than in cases born outside the UK (66.5%, 107 out of 161).

Discussion

Overall, numbers and rates of TB in North West England have gradually decreased since 2011, and incidence remains below the national level. The regional rate increased by 5.5% between 2020 and 2021. However, these data should be interpreted with caution due to the likely impact of the COVID-19 pandemic on TB detection and transmission.

The ethnic groups with the highest proportion of cases were the Pakistani, white and black-African ethnic groups. Of cases born abroad who were notified in 2021, the greatest proportion had been resident in the UK for at least 11 years. This demonstrates the importance of timely identification and treatment of TB and LTBI in migrants arriving from high incidence TB countries via an effective LTBI screening programme, and of maintaining awareness of TB among migrant populations.

Overall, the proportion of cases with SRFs has remained fairly consistent, comprising 8.9% of cases on average over the last 10 years, which indicates that underserved populations must remain a priority for intervention. The largest burden of disease falls in those populations which are socio-economically disadvantaged. Continued efforts to control TB in these groups presents an opportunity to reduce health inequalities.

Over half of pulmonary cases reported in 2021 had a sputum smear result, a higher proportion than in recent years. This is an important indication of infectiousness and should be obtained for all cases where possible.

More than two-thirds of pulmonary cases started TB treatment within 4 months of symptom onset. However, this means there were still a significant proportion of cases starting treatment more than 4 months after symptom onset, which may have increased the opportunity for TB transmission. It is important to raise awareness of TB among high risk groups and service providers, and to ensure that clinical pathways are in place to increase detection and diagnosis.

The proportion of non-severe TB cases (non-MDR or non-RR TB and without central nervous system disease) in the North West that completed treatment within 12 months was 85.9%, similar to the previous year (covering cases notified in 2020).

In 2021, 99.3% of North West TB cases were offered an HIV test. Of these, testing uptake was 99.5%. UK guidance recommends all TB cases should be offered an HIV test regardless of age, ethnic group or place of residence (2).

References

1. UKHSA. Tuberculosis in England: 2022 report March 2023. (Viewed on 13 February 2024)

2. Palfreeman A, Sullivan A, Rayment M and others. British HIV Association / British Association for Sexual Health and HIV / British Infection Association adult HIV testing guidelines 2020 HIV Medicine 2020, 21 Supplement 6, pages 1 to 26. (Viewed on 13 February 2024)

3. World Health Organization. Meeting report of the WHO expert consultation on the definition of extensively drug-resistant tuberculosis. January 2021 (Viewed on 13 February 2024)

4. World Health Organization. Definitions and reporting framework for tuberculosis 2013 revision: updated December 2014 and January 2020. (Viewed on 13 February 2024)

5. World Health Organization. Treatment of tuberculosis: guidelines, 4th edition 2010. (Viewed on 13 February 2024)

6. Public Health England. Latent TB testing and treatment for migrants: a practical guide for commissioners and practitioners 2015. (Viewed on 13 February 2024)

7.National Institute of Health and Care Excellence. Tuberculosis - NICE guideline [NG33] January 2016, updated September 2019. (Viewed on 13 February 2024)

Appendix A. Notes on the report

About the Field Service

The Field Service (FS) supports UKHSA centres and partner organisations through the application of epidemiological methods to inform public health action. It does this in 2 main ways: firstly by providing a flexible expert resource that is available, as and when needed, to undertake epidemiological investigations for key health protection work, and secondly through the expert analysis, interpretation and dissemination of surveillance information to UKHSA centres, local health partners, service providers and commissioners of services. Within the FS network, excellence and innovation is encouraged. We foster academic collaborations, taking an active part and leading in research, development and training.

Intended audience

This report is for use by healthcare professionals who diagnose and/or care for people with tuberculosis (TB), commissioners involved in planning and financing TB services, public health professionals working to improve TB control and the health of at-risk populations, researchers with an interest in TB, and government and non-governmental organisations working in the field of TB. In particular, this report is for the use of the North West TB Control Board and North West clinical leadership group.

Aim of report

This report describes the recent epidemiology of TB in the North West, providing an update on local trends, identifying areas of high burden of disease, at-risk population groups, and opportunities for interventions and prevention of future cases.

Further tuberculosis information

The national report of Tuberculosis in England is available online.

Indicators of progress towards national objectives were set out in the TB Action Plan for England (2021 to 2026). Data pertaining to several indicators are presented in Appendix D.

TB indicators at county council and clinical commissioning group level are available online.

Appendix B. Description of data sources and definition

Data sources

This report is based on TB case notifications made to the UKHSA NTBS system in England to the end of 2021. This information is updated annually to take into account denotifications (where the patient was found not to have TB), late notifications and other updates. Data presented in this report supersede data in previous reports.

Diagnostic laboratories serving acute hospitals are the first place in which TB infection-related samples are received and processed within the pathway of clinical diagnosis and management of suspected TB cases. Results for microscopy, polymerase chain reaction (PCR), histology and culture are collected in NTBS system. Appropriate referral of clinical specimens to the Mycobacterium Reference Laboratories is an important part of the routine work of the diagnostic laboratories in the investigation and management of TB cases.

The National Mycobacterium Reference Service (NMRS) receives these diagnostic materials and undertake characterisation using culture and molecular diagnostic methods to define species of Mycobacterium, TB antibiotic (drug) susceptibility and organism relatedness. Historically, organism relatedness has been determined by Mycobacterial Interspersed Repetitive Unit-Variable Number Tandem Repeats (MIRU-VNTR) typing, however this has been superseded in recent years by Whole Genome Sequencing (WGS).

Proportions

All proportions in this report are calculated among patients with known information or a known result, except where otherwise stated.

Population denominator

Tuberculosis rates by geographical area, age, sex and place of birth were calculated using ONS mid-year population estimates. Tuberculosis rates by ethnic group were calculated using population estimates from the LFS. The LFS is based on a population sample, so estimates are liable to sampling errors, particularly for small population subgroups, and should be interpreted with caution. LFS data had not yet been updated to reflect the 2021 population census data at the time of production of this report.

Appendix C. TB in North West residents

Table C1. Three-year average TB case numbers and rates by county council of residence [note 5], North West, 2019 to 2021

County council	Average annual TB notifications 2019 to 2021	Average annual rate per 100,000 population 2019 to 2021
Allerdale	1	1.0
Barrow-in-Furness	1	1.5
Blackburn with Darwen	33	21.6
Blackpool	3	2.1
Bolton	35	11.9
Burnley	7	8.1
Bury	13	7.0
Carlisle	2	1.8
Cheshire East	10	2.5
Cheshire West and Chester	8	2.3
Chorley	2	1.7
Copeland	1	1.0
Eden	1	1.9
Fylde	1	1.2
Halton	1	0.5
Hyndburn	5	6.5
Knowsley	1	0.9
Lancaster	4	3.0
Liverpool	34	6.9
Manchester	117	21.1
Oldham	40	16.7
Pendle	16	17.1
Preston	23	16.1
Ribble Valley	1	1.1
Rochdale	19	8.7
Rossendale	4	6.1
Salford	23	8.6
Sefton	7	2.5
South Lakeland	2	2.2
South Ribble	2	2.1
St. Helens	2	1.1
Stockport	6	2.0
Tameside	19	8.3
Trafford	19	7.9
Warrington	4	2.1
West Lancashire	0	0.0
Wigan	7	2.2
Wirral	9	2.7
Wyre	1	1.2
Cheshire & Merseyside	76	3.0
Cumbria & Lancashire	112	5.5
Greater Manchester	298	10.4
North West	486	6.6

Note 5: Cases with unknown county council excluded

Table C2. TB case numbers and rates by age and sex, North West, 2021

Age group	Female number	Female rate	Male number	Male rate
0 to 14	9	1.3	10	1.4
15 to 44	88	6.4	161	12.0
45 to 64	49	5.0	92	9.7
65 and over	25	3.3	47	7.3

Table C3. Drug resistance among TB cases with culture confirmed disease, North West, 2012 to 2021

	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021
Culture confirmed [note 6]	472	447	396	367	381	329	313	346	296	299
Drug resistant n	24	28	30	17	23	35	40	40	41	45
Drug resistant % [note 7]	5.1%	6.3%	7.6%	4.7%	6.1%	10.8%	12.9%	11.7%	14.1%	15.7%

Note 6: Resistant to at least one first line drug.

Note 7: Proportion of cases with known results for first line drug resistance.

Appendix D. Baseline data for TB indicators, North West and England 2000 to 2021

Indicator 1. Overall TB incidence per 100,000 population

Indicator from TB Action Plan for England, 2021 to 2026.

Year	North West: number of cases	North West: rate	North West: annual change in number of notifications (%)	North West: annual change in rate (%)	England: number of cases	England: rate	England: annual change in number of notifications (%)	England: annual change in rate (%)
2000	624	9.2	-	-	6,051	12.3	-	-
2001	638	9.4	2.2	2.3	6,171	12.5	2.0	1.6
2002	638	9.4	0.0	-0.2	6,676	13.4	8.2	7.2
2003	574	8.4	-10.0	-10.4	6,632	13.3	-0.7	-0.7
2004	570	8.3	-0.7	-1.1	6,931	13.8	4.5	3.8
2005	743	10.8	30.4	29.8	7,658	15.1	10.5	9.4
2006	696	10.1	-6.3	-6.8	7,684	15.1	0.3	0.0
2007	733	10.6	5.3	4.9	7,577	14.7	-1.4	-2.6
2008	730	10.5	-0.4	-0.8	7,809	15.1	3.1	2.7
2009	799	11.4	9.5	9.0	8,112	15.5	3.9	2.6
2010	809	11.5	1.3	0.8	7,673	14.6	-5.4	-5.8
2011	818	11.6	1.1	0.6	8,281	15.6	7.9	6.8
2012	775	10.9	-5.3	-5.6	8,087	15.1	-2.3	-3.2
2013	716	10.1	-7.6	-7.9	7,265	13.5	-10.2	-10.6
2014	642	9.0	-10.3	-10.7	6,470	11.9	-10.9	-11.9
2015	568	7.9	-11.5	-12.0	5,734	10.5	-11.4	-11.8
2016	589	8.2	3.7	3.0	5,618	10.2	-2.0	-2.9
2017	529	7.3	-10.2	-10.6	5,067	9.1	-9.8	-10.8
2018	466	6.4	-11.9	-12.3	4,610	8.2	-9.0	-9.9
2019	521	7.1	11.8	11.1	4,705	8.4	2.1	2.4
2020	455	6.2	-12.7	-13.0	4,123	7.3	-12.4	-13.1
2021	481	6.5	5.7	4.9	4,425	7.8	7.3	6.8

Indicator 2. Reduce the proportion of TB cases in those born outside of the UK in whom TB occurs within 5 years of entry

Indicator from TB Action Plan for England, 2021 to 2026.

Year	North West: proportion (%)	England: proportion (%)
2017-2019 [note 8]	41.8	29.1
2020	39.4	-
2021	44.5	32.3

Note 8: Baseline of the average proportion from 2017 to 2019.

Indicator 8. Reduce proportion of pulmonary TB cases with treatment delay of 2 to 4 months from symptom to onset

Indicator from TB Action Plan for England, 2021 to 2026.

Year	North West: 2 to 4 months delay (number of cases)	North West: 2 to 4 months delay (proportion of cases)	North West: over 4 months delay (number of cases)	North West: over 4 months delay (proportion of cases)	England: 2 to 4 months delay (number of cases)	England: 2 to 4 months delay (proportion of cases)	England: over 4 months delay (number of cases)	England: over 4 months delay (proportion of cases)
2011	78	28.2	75	27.1	863	29.9	711	24.6
2012	80	28.0	82	28.7	933	30.4	765	25.0
2013	67	27.3	83	33.9	907	30.9	805	27.4
2014	98	32.7	82	27.3	893	30.9	839	29.0
2015	84	31.8	72	27.3	847	30.4	750	26.9
2016	85	29.3	88	30.3	857	31.1	821	29.8
2017	60	29.1	70	34.0	787	30.9	775	30.4
2018	54	27.4	67	34.0	721	31.3	625	27.2
2019	63	30.0	57	27.1	665	29.1	697	30.5
2020	42	24.7	60	35.3	570	29.2	626	32.1
2021	51	32.3	48	30.4	583	30.4	607	31.6

Indicator 9: Reduce the median duration from symptom onset to diagnosis for pulmonary TB cases, and Indicator 10: Reduce the median duration from symptom onset to treatment start for pulmonary TB cases

Indicators from TB Action Plan for England, 2021 to 2026.

Year	North West: median diagnostic delay (IQR)	North West: median treatment delay (IQR)	England: median diagnostic delay (IQR)	England: median treatment delay (IQR)
2011	64 (33 to 122)	67 (36 to 128)	63 (31 to 117)	66 (33 to 120)
2012	65.5 (36.5 to 133.5)	70 (38 to 136)	63 (31 to 117)	65 (34 to 121)
2013	76 (39 to 154)	79 (42 to 160)	69 (34 to 126)	71 (36 to 129)
2014	69 (38 to 139)	70 (39 to 137)	71 (36 to 132)	73 (38 to 135)
2015	76 (30 to 129)	78 (30.5 to 134.5)	70 (33 to 127.5)	72 (36 to 130)
2016	71 (36 to 133.5)	75 (38 to 136)	74 (37 to 134)	77 (40 to 139)
2017	85.5 (43.5 to 152)	88.5 (46 to 159)	75 (36 to 136)	79 (39 to 141)
2018	80 (37 to 155)	81 (40 to 158)	70 (34 to 126)	72 (36 to 129)
2019	70 (35 to 126)	73 (37 to 129)	70 (36 to 137)	74 (38 to 144)
2020	79.5 (37 to 147.5)	82.5 (39 to 155)	76 (36 to 145)	78 (39 to 149)
2021	71 (36 to 148)	71.5 (36 to 149)	76 (37 to 149)	79 (40 to 153)

Indicator 11: Increase the proportion of TB cases that are culture confirmed

Indicator from TB Action Plan for England, 2021 to 2026.

(a) All cases

Year	North West: number culture confirmed	North West: proportion culture confirmed (%)	England: number culture confirmed	England: proportion culture confirmed (%)
2011	509	62.2	5,051	61.0
2012	472	60.9	4,904	60.6
2013	447	62.4	4,403	60.6
2014	396	61.7	3,935	60.8
2015	367	64.6	3,506	61.1
2016	381	64.7	3,586	63.8
2017	329	62.2	3,173	62.6
2018	313	67.2	2,866	62.2
2019	346	66.4	2,897	61.6
2020	296	65.1	2,537	61.5
2021	299	62.2	2,690	60.8

(b) Pulmonary cases

Year	North West: number culture confirmed	North West: proportion culture confirmed (%)	England: number culture confirmed	England: proportion culture confirmed (%)
2011	296	72.4	3,075	71.8
2012	287	73.6	2,947	70.5
2013	264	74.8	2,720	73.1
2014	257	73.2	2,491	73.3
2015	239	79.1	2,262	74.3
2016	250	74.0	2,317	76.9
2017	191	76.7	2,099	75.7
2018	195	78.9	1,927	75.2
2019	224	78.0	1,924	75.0
2020	170	81.0	1,632	75.6
2021	186	80.5	1,737	74.4

(c) Non-pulmonary cases

Year	North West: number culture confirmed	North West: proportion culture confirmed (%)	England: number culture confirmed	England: proportion culture confirmed (%)
2011	213	52.1	1,976	49.4
2012	185	48.1	1,956	50.1
2013	183	50.4	1,683	47.5
2014	139	47.8	1,444	47.0
2015	128	48.1	1,244	46.3
2016	131	52.2	1,269	48.7
2017	138	49.3	1,074	46.8
2018	118	53.9	939	45.8
2019	122	52.1	973	45.5
2020	126	51.4	905	46.1
2021	113	45.2	953	45.6

Indicator 12: Proportion of culture confirmed TB cases with drug susceptibility testing reported for the 4 first line agents

Historical indicator from Collaborative Tuberculosis Strategy for England: 2015 to 2020.

Year	North West: number of cases	North West: proportion of cases (%)	England: number of cases	England: proportion of cases (%)
2011	508	99.8	4,960	98.2
2012	470	99.6	4,850	98.9
2013	444	99.3	4,297	97.6
2014	393	99.2	3,902	99.2
2015	362	98.6	3,485	99.4
2016	376	98.7	3,540	98.7
2017	320	97.3	3,134	98.8
2018	309	98.7	2,839	99.1
2019	342	98.8	2,865	98.9
2020	287	97.0	2,476	97.6
2021	283	94.6	2,612	97.1

Indicator 13: Proportion of culture confirmed TB cases with any first line drug resistance

Historical indicator from Collaborative Tuberculosis Strategy for England: 2015 to 2020.

Year	North West: number of cases	North West: proportion of cases (%)	England: number of cases	England: proportion of cases (%)
2011	36	7.1	414	8.2
2012	31	6.6	361	7.4
2013	29	6.5	330	7.5
2014	32	8.1	294	7.5
2015	19	5.2	266	7.6
2016	24	6.3	273	7.6
2017	41	12.7	290	9.1
2018	41	13.2	343	12.0
2019	42	12.3	324	11.2
2020	43	14.8	270	10.6
2021	47	16.4	267	9.9

Indicator 14: Proportion of TB cases offered an HIV test

Historical indicator from Collaborative Tuberculosis Strategy for England: 2015 to 2020.

Year	North West: number of cases	North West: proportion of cases (%)
2012	451	90.2
2013	541	87.0
2014	547	94.6
2015	477	97.0
2016	533	96.7
2017	457	96.0
2018	393	95.4
2019	461	98.7
2020	413	99.8
2021	434	99.3

Indicator 15: Proportion of drug sensitive TB cases with at least one social risk factor who completed treatment within 12 months, and Indicator 16: Proportion of drug sensitive TB cases who completed treatment within 12 months

Indicator from TB Action Plan for England, 2021 to 2026.

Year	North West: number of cases completing treatment (all cases)	North West: proportion (%) of cases completing treatment (all cases)	North West: number of cases with at least one social risk factor completing treatment	North West: proportion (%) of cases with at least one social risk factor completing treatment
2011	621	86.0	39	73.6
2012	596	88.0	37	77.1
2013	556	87.0	36	76.6
2014	476	87.3	32	69.6
2015	419	86.2	49	81.7
2016	457	87.7	33	70.2
2017	409	86.8	26	72.2
2018	365	86.3	33	80.5
2019	398	85.2	27	73.0
2020	346	85.9	23	76.7

Indicator 17: Proportion of drug sensitive TB cases who had died at last reported outcome

Historical indicator from Collaborative Tuberculosis Strategy for England: 2015 to 2020.

Year	North West: number of cases	North West: proportion of cases (%)	England: number of cases	England: proportion of cases (%)
2011	28	3.9	276	3.8
2012	31	4.6	268	3.8
2013	30	4.7	229	3.6
2014	29	5.3	242	4.3
2015	30	6.2	230	4.6
2016	26	5.0	217	4.4
2017	19	4.0	189	4.2
2018	12	2.8	167	4.1
2019	16	3.4	161	3.9
2020	20	5.0	184	5.2

Appendix E. Local TB epidemiological summaries

Local TB epidemiological summaries provide further information about TB cases among residents of county council areas with an average of at least 50 TB cases per year over the previous 3 years. These are available from your local Field Service team on request. Please contact FES.NorthWest@phe.gov.uk.

Acknowledgements

We are grateful to all those who contribute information on people with tuberculosis in the North West, including nurses, physicians, microbiologists, scientists, outreach and social care and administrative staff. We also acknowledge colleagues at the UKHSA National Mycobacterium Reference Service for information on culture confirmation and drug susceptibility testing.

Further thanks are due to:

• the UKHSA National TB Unit for providing the cleaned, matched dataset

• the North West Health Protection Team

• the FS North West team for their work supporting Enhanced Tuberculosis Surveillance

Authors

This report was prepared by Stefanie Davies and Soeren Metelmann of Field Service North West, National Infection Service, UK Health Security Agency.

Suggested citation

UK Health Security Agency. Tuberculosis in the North West of England: Annual review 2022. December 2023.