Research and analysis

Executive summary

Published 5 December 2024

Applies to England

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

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

TB Incidence and Epidemiology in England

In 2023, a total of 4,855 people were notified with TB in England, an increase of 11% compared with 2022 and an annual TB notification rate of 8.5 per 100,000. England therefore remained a low TB incidence country below the WHO threshold of less than or equal to 10 per 100,000. Provisional data for the first 3 quarters of 2024 indicate a further 13.7% increase against the same period in 2023. Numbers and rates are now above the levels seen before the COVID -19 pandemic and the annual increase in 2023 is the largest in the current reporting period (1971 to 2023). However, rates are still below the peak this century, in 2011 (15.6 per 100,000). Although England remains a low incidence country, the ongoing increase in the rate of TB notifications means that England is further off-track to achieve the WHO’s end TB targets.

TB rates remain highest in urban areas, with the UKHSA London region having the highest numbers and rates (1,662 individuals, rate 18.7 per 100,000). In 2023, 2 local authority districts had a 3-year average notification rate above 40 per 100,000. These were Leicester City (East Midlands) at 40.7 per 100,000 and Newham (London) at 40.6 per 100,000.  

Individuals born outside of the UK continued to account for most TB notifications in England (79.9%; rate 40.1 per 100,000). Nearly a third (30.1%) of individuals are diagnosed within 5 years of entering the UK. This has increased since 2019, when it was around a fifth (22.1%).

For the first time since 2012, the rate of TB in people born in the UK increased, to 2.1 per 100,000.

Tuberculosis continues to be strongly associated with inequalities. The rate of TB notifications in the 10% of individuals living in the most deprived areas of England increased from 13.5 per 100,000 in 2022 to 15.7 per 100,000 in 2023. This is compared with only 3.3 per 100,000 in the 10% of the population living in the least deprived areas. One or more social risk factors (alcohol misuse, drug misuse, homelessness, imprisonment, mental health needs and asylum seeker status) were reported in 17.2% of individuals diagnosed with TB aged over 15 years in 2023, a small increase on 2022 (16.0%).

This year, for the first time, the proportion of homelessness and asylum seeker status in children (less than 18 years) diagnosed with TB is reported, revealing a significant prevalence of both, 9.6% and 20.5% respectively. The most affected group was adolescents (aged 15 to 17) in whom 19.2% (20 individuals; of whom 14 were asylum seekers) reported homelessness and 40.6% (43 individuals) asylum seeker status.

TB Prevention

Prevention of importation of individuals with active pulmonary disease is through the pre entry TB screening programme for those entering the UK on visas for at least 6 months’ stay from countries where TB incidence is more than 40 per 100,000 individuals. The number of people screened before entry to the UK doubled in 2023 to 1,059,309 compared with 2021. 505 people were diagnosed with pulmonary TB by this process.

Active TB disease can also be prevented by identifying, testing and treating people at higher risk of latent TB infection (LTBI) as a result of contact with a known infectious individual or because they have migrated from a high incidence country.

There was a 98.4% rise in the number of people tested through the NHSE Latent TB Infection (LTBI) programme in 2023 (34, 680 people) compared with 2022 (17,484); 15.1% of people tested positive for LTBI. 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).

TB Detection

Timely and accurate detection and management of TB improves disease outcomes and reduces onward transmission. Diagnostic delays, time from symptom onset to diagnosis, have not improved in England in over 5 years. The median diagnostic delay for pulmonary TB was unchanged at 75 days in 2023.

Laboratory culture confirmation of TB disease provides information on drug resistance and likely transmission. In 2023, 61.2% of individuals (2,973 out of 4,855 people) with TB had their diagnosis confirmed on culture, similar to previous years.

Numbers of rifampicin-resistant (RR) or multidrug-resistant (MDR) TB in England are low. In 2023, increases were seen in the proportion of both culture-confirmed RR or MDR TB, with 2.4% of people with positive cultures having this pattern of resistance in 2023. These are now the highest since enhanced surveillance began.

Whole genome sequencing (WGS) on culture-confirmed specimens is used to identify genetically similar TB strains, suggestive of recent transmission. 34% of individuals with a positive TB culture in England were part of a genomic cluster, down from 40.7% in 2019. The presence of any social risk factor nearly doubled the likelihood of being in a cluster (relative risk 1.88).

TB Control

The proportion of individuals who complete their treatment has not improved in the last decade, which averaged 85.4% at 12 months in people expected to complete treatment within this period. Lower treatment completion rates have continued to occur in those with social risk factors, (76.1%) and in those being treated with a regimen for MDR or RR TB (75.0%). In 2023, for all people notified in 2022 in the non MDR or RR TB cohort 4.5% of people died at their last reported treatment outcome. This is a decrease compared with the peak of 6.0% in 2021 for people notified in the peak pandemic year of 2020.

TB in children

Children are particularly vulnerable to TB, especially those aged under 5 years, who are at greatest risk of developing severe TB disease. Data is reported for children aged 15 to 17 years for the first time. In 2023, 259 children and adolescents were notified with TB, a 12.1% increase compared with 2022, resulting in an increased rate of 2.2 per 100,000 (95% confidence interval (CI) 1.9 to 2.5 per 100,000) compared with 1.9 per 100, (95% CI 1.7 to 2.2 per 100,000) in 2022, a 15.8% increase. In children and adolescents, the proportion of non-UK born individuals increased to 60.2% in 2023 compared with 45.2% in 2022.

Treatment completion rates remain higher in children than in adults; 88.9% of children diagnosed in 2022 who were expected to complete treatment by the end of 2023 did so.