Tuberculosis in Wales Annual Report 2016

Transcription

1 Tuberculosis in Wales Annual Report 2016 Author: Communicable Disease Surveillance Centre Date: 03/11/2016 Version: 1 Status: Final Intended Audience: Health Purpose and Summary of Document: This annual report summarises trends in the epidemiology of tuberculosis in Wales. Publication/Distribution: Director of Integrated Health Protection, Public Health Wales Public Health Wales TB Programme Group Public Health Wales Intranet and Internet Public Health England TB Section Version: 1 Page: 1 of 33 Intended Audience: Health

2 Acknowledgements Public Health Wales Communicable Disease Surveillance Centre would like to thank the microbiologists, clinicians, respiratory nurses and Health Protection Teams for their contributions to the running of the Enhanced Tuberculosis Surveillance Scheme in Wales. Public Health Wales greatly appreciates the support received from Public Health England in conducting tuberculosis surveillance and for coordinating the Enhanced Tuberculosis Surveillance scheme in England, Wales and Northern Ireland. Background The Enhanced Tuberculosis Surveillance Scheme commenced on the 1 st January 1999 with the aim of providing detailed and comparable information on the epidemiology of tuberculosis. The scheme is coordinated in England, Wales and Northern Ireland by Public Health England. In Wales, the scheme is administered by Public Health Wales in collaboration with Local Health Boards. This report summarises the latest annual trends in the epidemiology of tuberculosis in Wales, using data reported through the Enhanced Tuberculosis Surveillance Scheme. Wales data for the last ten years are summarised in a series of tables and graphs by demographic, geographical, clinical and microbiological characteristics. Suggested Citation: Tuberculosis in Wales Annual Report, October Public Health Wales Communicable Disease Surveillance Centre. Note: The data used in this report were derived from the Enhanced Tuberculosis Surveillance scheme. Figures for recent years should be considered provisional. Version: 1 Page: 2 of 33 Intended Audience: Health

3 Key Points The rate of tuberculosis in Wales has continued to decline steadily since In 2015, 116 cases of tuberculosis were reported in Wales (3.7 per 100,000 population), stable compared to last year. Notification rates vary geographically, with Newport and Cardiff having the highest rates. The notification rate was highest in those aged years (6.7 per 100,000 population). Between 2014 and 2015 the notification rate remained stable in most age groups apart from those aged years where the rate decreased by 1.7 per 100,000 population, and those aged years where the rate increased by 1.7 per 100,000 population. Of the 116 cases reported in 2015, 54% were male and 46% female (rates of 4.1 and 3.4 per 100,000, respectively). In 2015, 46% of tuberculosis cases were reported in the White ethnic group, 52% were in the non-white population and 3% were of an unknown ethnic group. Forty-six percent of tuberculosis cases reported in Wales were born in the UK, 53% of cases were born abroad and 2% of cases had unknown place of birth. Completeness of recording of social risk factors varied from 88% to 96% in Of those reported, 7% of cases reported a history of, or current drug abuse; 5% reported a history of, or current alcohol misuse or abuse; 4% reported they had been, or are currently, homeless; and 5% reported they had been, or are currently, in prison. The rate of tuberculosis in those who reside in the most deprived areas of Wales was 6.7 (95% CI ) per 100,000 population compared to 1.6 (95% CI ) per 100,000 population in the least deprived areas. Over half of the cases in 2015 (56%, 65/116) had pulmonary tuberculosis (with or without extra-pulmonary disease); of these, 12 (18%) also had extra pulmonary disease. In 2015 there was one case of MDR-TB reported in culture confirmed tuberculosis in Wales. There was a decrease in both isoniazid and rifampicin resistance in culture confirmed cases of tuberculosis in 2015 compared to 2014, from 12% to 8% and 4% to 1% respectively. Version: 1 Page: 3 of 33 Intended Audience: Health

4 Outcome data are available for cases newly diagnosed in The proportion of drug sensitive cases with expected treatment duration of less than 12 months who had completed treatment by 12 months increased in 2014 to 84%, compared to 83% in Treatment completion was lowest in those aged 65 years and older (57%, 8/14). Treatment completion was over 80% in all other age groups. The proportion of deaths in drug sensitive cases has increased from 5% (7/139) in 2013 to 10% (11/111) in 2014, a similar proportion to Version: 1 Page: 4 of 33 Intended Audience: Health

5 Contents 1. Geographical Distribution Demographic Characteristics Social Determinants Deprivation Clinical Characteristics Bacteriology, Speciation and Drug Susceptibility Tuberculosis case outcomes Conclusions Notes on methods References Appendix Version: 1 Page: 5 of 33 Intended Audience: Health

6 1. Geographical Distribution TB Rates in Wales and the UK In Wales, 116 cases of tuberculosis were reported in 2015 to the Enhanced Tuberculosis Surveillance (ETS) scheme, equivalent to a rate of 3.7 per 100,000 population (95% confidence interval (CI) per 100,000 population). There has been a sustained downward trend in TB since 2009, the 2015 rate remained stable compared to 2014 (Figure 1.1). Public Health England [1], reports the UK rate of tuberculosis as 9.6 (95% CI ) per 100,000 population in England continues to have the highest rate of tuberculosis in the UK, with a rate of 10.5 (95% CI ) per 100,000 population, followed by Scotland (5.7 (95% CI ) per 100,000 population), Wales (3.7 per 100,000 population), and Northern Ireland (3.2 (95% CI ) per 100,000 population). Between 2014 and 2015, the rate of tuberculosis per 100,000 population decreased in England, Northern Ireland and Scotland and remained the same in Wales. Area of Residence In 2015, the highest tuberculosis rate was observed in Cardiff and Vale University Health Board (5.8 per 100,000 population) and the lowest rate was in Cwm Taf University Health Board (1.3 per 100,000 population). Between 2014 and 2015, the rate of tuberculosis increased in Betsi Cadwaladr University (3.5 per 100,000 population compared to 2.0 per 100,000 population) and Powys Teaching Health Boards (5.3 per 100,000 population compared to 1.5 per 100,000 population), remained stable in Cardiff and Vale, Abertawe Bro Morgannwg and Hywel Dda University Health Boards and decreased in Aneurin Bevan (3.8 per 100,000 population compared to 5.3 per 100,000 population) and Cwm Taf University (1.3 per 100,000 population compared to 2.7 per 100,000 population) Health Boards (Table A1). Between 2014 and 2015 the rate of tuberculosis increased in seven of the 22 Local Authorities in Wales, remained stable in nine and decreased in six (Table A1). The rate of tuberculosis ranged from 0 per 100,000 in Monmouthshire and Blaenau Gwent to 12.2 per 100,000 population in Newport (Figure 1.3a). Figure 1.3b shows the five year average rate of tuberculosis per 100,000 population by Local Authority for the period 2011 to Tuberculosis rates continue to be highest in Cardiff and Newport. By comparing 2015 with the average in the five years 2011 to 2015, the rate in 2015 was higher in five Local Authorities, remained stable in seven Local Authorities and was lower in nine Local Authorities (Figure 1.3). Version: 1 Page: 6 of 33 Intended Audience: Health

7 Figure 1.1 Number of Cases and Rate of TB per 100,000 population in Wales, Number of cases Rate per Figure 1.2 Rate of TB per 100,000 population in the UK, 2015 England Scotland Wales Northern Ireland 95% CI Rate per 100,000 Version: 1 Page: 7 of 33 Intended Audience: Health

8 Figure 1.3 Rate of TB by Local Authority a b Crown Copyright and database right Ordnance Survey Version: 1 Page: 8 of 33 Intended Audience: Health

9 2. Demographic Characteristics Age and Sex In 2015, just over half of newly diagnosed tuberculosis cases were male (54%, 63/116), a rate of 4.1 (95% CI ) per 100,000 male population, with a lower rate of 3.4 (95% CI ) per 100,000 females (Table A2). The highest incidence was seen in people aged (6.7 per 100,000; 21% of cases). The median age at diagnosis remained stable between 2014 and 2015 at 43 years of age. During 2015 there was only one reported case of tuberculosis in a child aged under 15 years, the same as in 2014 (Table A3). Changes in the rate of tuberculosis amongst different age groups from are presented in Figure 2.1. Ethnicity Information on ethnic group was known for 97.4% (113/116) of cases notified in The largest proportions of cases were from White (45.7%, 53/116) and Pakistani (16.4%, 19/116) ethnic groups. The five year (2011 to 2015) average annual rate was highest in the Black-African ethnic group; per 100,000 population (95% CI ) and lowest in the White ethnic group, a rate of 1.7 per 100,000 population (95% CI ) (Figure 2.2, Table A4). Using 2011 census population estimates, since 2006 the rate of TB has decreased or remained stable in all ethnic groups. The rate of TB has decreased by 54% in the Black African ethnic group (201.9 per 100,000 population in 2006 compared to 92.5 per 100,000 population in 2015), 35% in the Indian ethnic group (115.9 per 100,000 population in 2006 compared to 75.3 per 100,000 population in 2015) ethnic group, 35% in the White ethnic group (2.8 per 100,000 population in 2006 compared to 1.8 per 100,000 population in 2015) and 5% in the Pakistani ethnic group (163.5 per 100,000 population in 2006 compared to per 100,000 population in 2015). Annual TB rates by ethnicity should be interpreted with caution as reliable annual denominator data are not available by ethnicity. Place of Birth Information on place of birth was known for 98.3% (114/116) of tuberculosis cases notified in Wales in Fifty-three percent of cases (61/116) were known to have been born outside of the UK whilst 45.7% of cases (53/1165) were known to have been born in the UK (Figure 2.3, Table A5). As in previous years, in 2015 the majority of cases known to be born outside the UK originated from South Asia (55.7%, 34/61) and Sub-Saharan Africa (16.4%, 10/61) (Table A6). Information on region of birth was known for all cases born outside of the UK. Version: 1 Page: 9 of 33 Intended Audience: Health

10 Rate per 100,000 population Public Health Wales Tuberculosis in Wales Annual Report 2016: Time between Entry into the UK and Diagnosis The time between entry to the UK and tuberculosis diagnosis was known for 75.4% (46/61) of non-uk born cases diagnosed in 2015 (Table A7). Where time since entry was known, the highest proportion of cases were diagnosed over ten years since UK entry (41.3%, 19/46) followed by less than two years since UK entry (23.9%, 11/46). Figure 2.1 Rate of TB per 100,000 population by Age Group and Year in Wales, Figure 2.2 Average Annual Number of TB Cases and Rate per 100,000 population in Wales by Ethnic Group, Average Number of Cases Rate Version: 1 Page: 10 of 33 Intended Audience: Health

11 Number of TB cases Public Health Wales Tuberculosis in Wales Annual Report 2016: Figure 2.3 Number of non-uk born TB Cases in Wales, Number of non-uk born TB cases Total number of TB cases During between 3-8% of cases were reported with an unknown origin for place of birth. Version: 1 Page: 11 of 33 Intended Audience: Health

12 3. Social Determinants The collection of information on social risk factors for tuberculosis was introduced to the Enhanced Tuberculosis Surveillance Scheme in In 2015, information on social risk factors was documented for between 91.4% and 95.7% of cases in Wales, depending on the risk factor investigated (Table 3.1). The completeness of recording social risk factors increased between 2014 and 2015 for all risk factors. The proportion of cases for which at least one social risk factor was recorded decreased between 2014 and 2015 from 17.2% to 11.8%. In 2015, 11.8% of cases reported at least one social risk factor. Seven percent of cases reported a history of, or current, drug use; 5.4% reported a history of, or current, alcohol misuse; 3.7% reported a history of, or current, homelessness; and 4.7% reported a history of, or current, imprisonment (Figure 3.1). Figure 3.1 History of or current social risk factors among TB patients in Wales, % 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Drug use Alcohol misuse Homelessness Imprisonment Any risk factor Table 3.1 Completeness of social risk factors among TB patients in Wales, Drug use 77.0% 72.4% 86.3% 83.1% 84.5% 85.1% 92.2% Alcohol misuse 74.2% 79.6% 91.6% 90.4% 92.3% 87.7% 95.7% Homelessness 79.3% 82.9% 90.1% 89.7% 93.7% 90.4% 92.2% Imprisonment 62.9% 70.4% 85.5% 80.1% 85.9% 77.2% 91.4% Any risk factor 62.4% 69.7% 80.2% 73.5% 79.6% 76.3% 87.9% Version: 1 Page: 12 of 33 Intended Audience: Health

13 Rate per 100,000 population Public Health Wales Tuberculosis in Wales Annual Report 2016: 4. Deprivation The Welsh Index of Multiple Deprivation (WIMD) developed for Welsh Government assigns an estimated rank of deprivation to each Lower Super Output Area (LSOA) [2]. Cases have been assigned to LSOA using postcode of residence as reported on ETS, postcode was available for all cases in There were 40 cases that reported living in LSOAs comprising the most deprived fifth of Wales, 27 in the second most deprived fifth, 20 in the middle fifth, 19 in the forth fifth and 10 in the least deprived fifth. The highest rate of tuberculosis was in the most deprived quintile at 6.7 (95% CI ) per 100,000 population compared to 1.6 (95% CI ) per 100,000 population in the least deprived quintile (Figure 4.1). Figure 4.1 Rate of TB in Wales per 100,000 population by deprivation quintile, % CI Most deprived Quintile 2 Quintile 3 Quintile 4 Least deprived Version: 1 Page: 13 of 33 Intended Audience: Health

14 5. Clinical Characteristics Site of Disease Information on site of disease was known for 98.3% (114/116) of cases notified in Over half of tuberculosis cases with a known site of disease had pulmonary disease (with or without extra-pulmonary disease) (56.1%, 65/114). Eighteen percent (12/65) of pulmonary cases were reported to also have extra pulmonary disease in at least one additional site. Many cases reported disease at multiple sites. For those where site of disease was known, the extra thoracic lymph nodes were the most common extra-pulmonary site of infection (19.3%, 22/114) (Table A8). Planned Course of Treatment In 2015, planned course of treatment was known for 95.7% (111/116) of cases. Of these 111 cases, 91.9% (102) were assigned to a standard six month course of treatment. It was known whether a patient was assigned to directly observed therapy (DOT) treatment in 94.0% of cases (109/116). Sixteen percent of these cases (17/109) were assigned DOT treatment. In 2015, 66.7% (8/12) of cases reporting at least one social risk factor were known to be assigned DOT. Vaccination Status The collection of data on Bacillus Calmette-Guérin (BCG) vaccination was introduced to the Enhanced Tuberculosis Surveillance Scheme in In 2015, BCG vaccination status was known for 58.6% (68/116) of tuberculosis cases, slightly higher completeness compared to 2014 (50.0%, 57/114). Of the 68 cases with known BCG vaccination status, 76.5% (52) were vaccinated, stable compared to 2014 (77.2%, 44/57). Coverage was highest in those aged and 55-64, being 90.0% (9/10) in both age groups, and lowest in those aged 5-24 where coverage was 50.0% (5/10) (Table A9). Previous Diagnosis Information on previous tuberculosis diagnosis was known for 96.6% (112/116) of cases, of which two had a previous diagnosis of tuberculosis (Table A10). Version: 1 Page: 14 of 33 Intended Audience: Health

15 6. Bacteriology, Speciation and Drug Susceptibility Bacteriology Sixty nine percent (80/116) of all cases in 2015 were culture confirmed, and 90.8% (59/65) of pulmonary cases (with or without extra pulmonary disease) were culture confirmed. This is higher than the 73.4% UK average reported by Public Health England as well as compared to other UK counterparts [1] and 11% above the European Centre for Disease Prevention and Control (ECDC) target of 80% for culture confirmation of pulmonary tuberculosis [3]. For 61.5% (40/65) of pulmonary cases in 2015 a sputum smear result was recorded, of which 65.0% (26/40) were positive (Table A11). Forty percent (20/50) of cases which reported extra pulmonary disease only were culture confirmed. Among 80 culture-confirmed cases reported through the Enhanced Tuberculosis Surveillance scheme in 2015, 95.0% (76) of cases were due to infection by Mycobacterium tuberculosis, 3.8% (3) were due to Mycobacterium bovis and 1.3% (1) Mycobacterium africanum (Table A12). Mycobacterium bovis During 2015 there were three confirmed cases of M. bovis in Wales, more cases than seen in the previous two years. All were UK born and aged between 25 and 54. An additional questionnaire is completed when an isolate is identified as Mycobacterium bovis, this questionnaire collects information on work and travel history, contact with animals and consumption of unpasteurised milk. All cases had history of occupational risk factors; two were part of a cluster. Antimicrobial Resistance Drug susceptibility results for the first line drugs isoniazid and rifampicin were reported for 100% (80/80) of culture confirmed tuberculosis cases. As with previous years, surveillance data continues to show that resistance to first line antimicrobials is low. Compared to 2014 there was a decrease in both isoniazid resistance and rifampicin resistance from 12.3% (10/81) to 7.5% (6/80) and 3.7% (3/81) to 1.3% (1/80), respectively. These resistance levels are similar to those reported elsewhere in the UK [4]. In 2015, there was one case of multidrug resistant (MDR) TB. These are TB strains that are resistant to both isoniazid and rifampicin. There were no cases of extensively drug resistant TB (XDR-TB). XDR-TB is resistant to at least one fluoroquinolone and at least one second line injectable drug (amikacin, capreomycin or kanamycin) [3]. Version: 1 Page: 15 of 33 Intended Audience: Health

16 Table 6.1: Number and proportion of TB cases with first line drug resistance 1, Wales, Any resistance to Isoniazid Rifampicin Ethambutol Pyrazinamide Year resistant resistant 2 one or more first resistant resistant line drug 1 Includes culture confirmed cases with drug susceptibility results for at least isoniazid and rifampicin 2 Excludes M. bovis cases n % n % n % n % n % Tuberculosis case outcomes Drug sensitive cohort, In accordance with the revised World Health Organization (WHO) TB outcome definitions, the drug sensitive cohort is defined as all TB cases excluding those with rifampicin resistant TB or MDR-TB (initial or amplified), or non-culture confirmed cases treated as MDR-TB [3]. In this report, treatment outcomes at 12 months for drug sensitive TB cases are reported for cases with an expected duration of treatment less than 12 months. This group excludes cases with central nervous system (CNS) disease who have an expected treatment duration of 12 months. Cases with spinal, cryptic disseminated or miliary disease are also excluded from this group, as CNS involvement cannot be reliably ruled out for the purposes of reporting. TB outcomes, loss to follow up and deaths in the entire drug sensitive cohort (including cases with CNS, spinal, cryptic disseminated or miliary TB disease) are presented by last recorded outcome. TB outcomes reported using these new cohort definitions will not be directly comparable with outcome data presented in previous reports. Treatment outcomes for all cases notified from have been calculated using these new definitions, so that trends can be monitored. TB outcomes at 12 months for drug sensitive cohort with expected duration of treatment less than 12 months Information on the outcome of treatment, 12 months after treatment commenced, was reported for 98.9% (91/92) of cases in this cohort notified in 2014 (Table A13). Version: 1 Page: 16 of 33 Intended Audience: Health

17 Eighty-four percent (77/92) of cases completed treatment within 12 months within this cohort notified in 2014, compared to 82.6% (100/121) in 2013 (Table A13, Figure 7.1). The proportion of cases who completed treatment within 12 months varied with age (Table A14). Treatment completion was highest in year olds (90.9%, 10/11) and year olds (90.0%, 18/20), and lowest in those aged 65 years and older (57.1%, 8/14). The proportion of cases that completed treatment was higher in females (93.9%, 31/33) compared to males (78.0%, 46/59, Table A15). The proportion of cases with a known site of disease and who completed treatment within 12 months was higher in those with extra-pulmonary disease only (94.4%, 34/36) compared to those with pulmonary disease only (79.5%, 35/44, Table A16). In 2014, treatment completion at 12 months varied by Health Board ranging from 64.3% (Hywel Dda UHB) to 100.0% (Cwm Taf UHB and Powys THB) (Table A17). TB outcomes at last reported outcome Information on the outcome of treatment based on the last reported outcome was reported for 99.1% (110/111) of cases in this cohort notified in 2014 (Table A18). The proportion of cases in this cohort notified in 2014 who completed treatment was 82.0% (91/111) (Table A18, Figure 7.1). In 2014, treatment completion in the entire drug sensitive cohort varied by Health Board from 70.6% (Hywel Dda UHB) to 100.0% (Powys THB) (Table A19). Deaths at last reported outcome In 2014, the proportion of cases who were reported to have died at the last reported outcome among all drug sensitive TB cases was 9.9% (11/111), an increase from the proportion of deaths in cases reported in 2013 (5.0%, 7/139) (Table A20). Of the 11 deaths in 2014, tuberculosis caused or contributed to death in 27.3% (3), was incidental in 18.2% (2) and the relationship between tuberculosis and death was unknown for the remaining 54.4% (6). Among those reported to have died, 18.2% (2/11) were diagnosed post-mortem. For cases where TB caused or contributed to death, or the relationship between TB and death was unknown, 55.6% (5/9) were aged over 65 years and 44.4% (4/9) were aged 65 years or under. Wales had the highest proportion of deaths in drug sensitive cases notified in 2014 (9.9%) compared to other countries in the UK (Scotland: 5.9%, England: 5.5% and Northern Ireland: 5.3%) [1]. Loss to follow up at last reported outcome In 2014, 2.7% (3/111) of all drug sensitive TB cases were lost to follow up at the last reported outcome (Table A18). For all three cases the reason for loss to follow up was leaving the UK. Version: 1 Page: 17 of 33 Intended Audience: Health

18 Figure 7.1: TB outcome percentages at 12 months for drug sensitive cases with expected treatment duration <12 months 1, Wales, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 77 Completed Died Lost to follow up Still on treatment Stopped Not evaluated 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB cases and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB. 2 Not evaluated includes missing, unknown and transferred out. Figure 7.2: Last recorded TB outcome percentages for the entire drug sensitive cohort 1, Wales % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Completed Died Lost to follow up 3 5 Still on treatment 0 1 Stopped Not evaluated 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB cases and MDR-TB treated cases. 2 Not evaluated includes missing, unknown and transferred out Version: 1 Page: 18 of 33 Intended Audience: Health

19 8. Conclusions The rate of tuberculosis in Wales continues to decline steadily and reached the lowest ever recorded incidence of 3.7 per 100,000 population in TB incidence in 2015 was identical to 2014, with the majority of cases in the urban centres of Newport and Cardiff. The age distribution of cases remains similar to last year, although there has been a decrease in the rate of tuberculosis in older teenagers and younger adults and an increase in those in the middle-aged groups. There was only one case of TB in a child. The rate of tuberculosis continues to be higher in males. TB incidence rates remain highest in people of Black African origin followed by those of Pakistani or Indian origin. TB rates have declined in most ethnic groups, but there has been little change in rates among people of Pakistani origin. In those born outside of the UK, the majority of cases were diagnosed over ten years after they entered the country. Although there are agreed protocols in place to screen people from high risk countries who enter Wales through formal asylum seeker or refugee routes, there are many other routes by which people can relocate to reside in Wales. There is scope for developing collaborative approaches between primary care and health boards in order to raise awareness about TB in these communities. The proportion of TB cases in the UK-born population remains slightly higher in Wales (3.7 per 100,000 population) compared to England (3.4 per 100,000 population) [4]. Contact tracing continues to be an important measure for reducing the number of TB cases in Wales. There is a need to work with cases to encourage full and honest disclosure about their contacts, to minimise any perception of stigma associated with a diagnosis of TB and to emphasise the importance of contact tracing in preventing illness in other people. The proportion of TB cases with pulmonary disease has remained stable, and this year the proportion of cases culture confirmed was well above the ECDC target of 80% for culture confirmation of pulmonary tuberculosis [4]. The proportion of cases completing treatment by 12 months has increased for the second year in a row and is nearing the 85% target for the proportion of newly detected infectious TB cases successfully completing treatment [6]. However, compared to the other regions of the UK, Wales has the highest proportion of TB outcomes reported as death. As the number of tuberculosis cases in Wales is small, proportions can be difficult to interpret and can fluctuate over time. The highest proportion of deaths are in those aged over 65 years of age, the introduction of the annual TB death review aims to improve outcomes for patients diagnosed with TB. Rates of MDR TB remain low in Wales, with only one case reported in Version: 1 Page: 19 of 33 Intended Audience: Health

20 Notes on Methods All analysis was conducted using Stata Rates were calculated using mid-year population estimates for Wales obtained from the Office of National Statistics (ONS). Rates for ethnic groups were calculated using ONS 2011 population estimates for ethnic groups resident in Wales. The 2014 Welsh Index of Multiple Deprivation (WIMD) was used to assign cases to deprivation fifth using postcode of residence and Lower Super Output Area (LSOA). Rates by deprivation fifth were calculated using ONS 2014 population estimates for LSOAs. Deprivation scores from the 2014 index are not comparable to previous indices. The WIMD is an ecological measure and not all deprived people live in deprived areas and not all people in deprived areas are deprived. This report only includes tuberculosis cases which have been notified to ETS. All Local Health Board and Local Authority figures are based on the area of residence of tuberculosis cases. Miliary tuberculosis is classified as pulmonary tuberculosis in accordance with the WHO s recommendation and international reporting definitions [5]. Data presented in this report are correct as at April As treatment outcomes are reported at 12 months, treatment outcomes are only available to be reported on for cases notified in the previous year, at the time data are extracted for the report. References [1] Reports of cases of tuberculosis to enhanced tuberculosis surveillance systems: United Kingdom, 2000 to Public Health England B_Official_Statistics_2016_GTW2309.pdf [2] Welsh Index of Multiple Deprivation (WIMD). Welsh Government [3] European Centre for Disease Control and Prevention (ECDC), Progress towards TB elimination, TB_elimination.pdf [4] Public Health England. (2016) Tuberculosis in England: Public Health England, London. B_Annual_Report_2016_GTW2309.pdf [5] Definitions and reporting framework for tuberculosis 2013 revision. WHO [6] Royal College of Nursing, Tuberculosis case management and cohort review, guidance for health professionals. data/assets/pdf_file/0010/439129/ pdf Version: 1 Page: 20 of 33 Intended Audience: Health

21 Appendix Table A1. Number of Cases and Rate 1 of Tuberculosis in Wales by LHB and LA, HB and LA Year Average 2 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Abertawe Bro Morgannwg University Bridgend Neath Port Talbot Swansea Aneurin Bevan University Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen Betsi Cadwaladr University Anglesey Conwy Denbighshire Flintshire Gwynedd Wrexham Cardiff and Vale University Cardiff Vale of Glamorgan Cwm Taf University Merthyr Tydfil Rhondda Cynon Taff Hywel Dda University Carmarthenshire Ceredigion Pembrokeshire Powys Teaching Powys Not known Total Rate per 100,000 using ONS Mid-Year population estimates 2 Average number of cases and rate calculated using the last 5 years data (2011 to 2015) Version: 1 Page: 21 of 33 Intended Audience: Health

22 Table A2. Number of Cases and Rate 1 of Tuberculosis in Wales by Sex, Sex Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Male Female Unknown Total Rate per 100,000 using ONS Mid-Year population estimates Table A3. Number of Cases and Rate 1 of Tuberculosis in Wales by Age Group, Age Group Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Rate per 100,000 using ONS Mid-Year population estimates Version: 1 Page: 22 of 33 Intended Audience: Health

23 Table A4. Number and Percentage of Tuberculosis Cases in Wales by Ethnic Group, Ethnic Group year Average 2 cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Cases Rate White Black-Caribbean Black-African Black-Other Indian Pakistani Bangladeshi Chinese Mixed/Other Unknown Total Average number of cases and rates calculated using the last 5 years data (2011 to 2015) 2 Rate per 100,000 using ONS 2011 population estimates by ethnic group Table A5. Number and Percentage of Tuberculosis Cases in Wales by Place of Birth, Place of Birth cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Born in UK Born Abroad Not Known Total Version: 1 Page: 23 of 33 Intended Audience: Health

24 Table A6. Number and Percentage of Tuberculosis Cases in Wales by World Region of Birth for Non-UK Born Cases, Region of Birth cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % North Africa Sub-Saharan Africa East Asia South Asia South East Asia Central Europe East Europe West Europe East Mediterranean North America South & Central America Not Known Total Table A7. Time between UK Entry and Tuberculosis Diagnosis for Non-UK Born Cases, Time between UK Entry and Diagnosis cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % < 2 years years years >10 years Not Recorded Total Version: 1 Page: 24 of 33 Intended Audience: Health

25 Table A8. Number and Percentage of Tuberculosis Cases in Wales by Site of Disease, Site of Disease Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Pulmonary Extra thoracic lymph nodes Intra thoracic lymph nodes Pleural Gastrointestinal CNS-meningitis CNS-other Bone-Spine Bone-other Genitourinary Laryngeal Cryptic Other extra pulmonary Unknown extra pulmonary Total cases Patients may have disease at more than one site 2 Pulmonary TB includes miliary TB in accordance with the WHO s recommendation and international reporting definitions [5]. Revised trends in site of disease are presented for previous years using the revised WHO definitions. Table A9. Number and Percentage of Cases in Wales with a History of BCG Vaccination by Age Group, 2015 Age Group Vaccinated Known Status Vaccinated % Known Status % Total Version: 1 Page: 25 of 33 Intended Audience: Health

26 Table A10. Number and Percentage of Tuberculosis Cases in Wales with Previous Tuberculosis Diagnosis, Previous Diagnosis cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Yes No Not Reported Total Table A11. Number and Percentage of Tuberculosis Cases in Wales with Bacteriological Confirmation, Bacteriological Results cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Culture Confirmed Culture Confirmed Pulmonary Cases Pulmonary Cases with Sputum Smear Taken Positive Sputum Smear Pulmonary Cases Denominator for percentage is total number of TB cases 2 Denominator for percentage is total number of pulmonary TB cases 3 Denominator for percentage is number of pulmonary cases with sputum smear taken Version: 1 Page: 26 of 33 Intended Audience: Health

27 Table A12. Species Identification in Culture Confirmed Tuberculosis Case, Wales, Species Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % M. africanum M. bovis M. tuberculosis M. tuberculosis complex Total Table A13. TB outcome at 12 months after treatment start for drug sensitive cases with expected treatment duration <12 months 1, Wales, Completed Died Lost to follow-up Still on treatment Stopped Not evaluated 2 Total Year n % n % n % n % n % n % n Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB 2 Not evaluated includes missing, unknown and transferred out. Version: 1 Page: 27 of 33 Intended Audience: Health

28 Table A14. Treatment completion at 12 months by age group for drug sensitive cases with expected treatment duration <12 months 1, Wales, Year n % n % n % n % n % n % n % n % Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB Table A15. Treatment completion at 12 months by sex for drug sensitive cases with expected treatment duration <12 months 1, Wales, Male Female Year n % n % Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB Version: 1 Page: 28 of 33 Intended Audience: Health

29 Table A16. TB outcome at 12 months by site of disease for drug sensitive cases with expected treatment duration < 12 months, Completed Died Lost to follow-up Still on treatment Stopped Not evaluated 2 Total 3 Site of disease n % n % n % n % n % n % n Pulmonary only Pulmonary, with or without EP Extrapulmonary only Extra-thoracic lymph nodes Intra-thoracic lymph nodes Pleural Bone Other All other EP sites Total Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB 2 Not evaluated includes missing, unknown and transferred out 3 Multiple sites of disease can be reported so the total does not add up to the total number of cases 4 All other extra-pulmonary sites includes gastrointestinal, genitourinary, laryngeal, other and unknown extra-pulmonary disease Version: 1 Page: 29 of 33 Intended Audience: Health

30 Table A17. TB outcome at 12 months after treatment start for drug sensitive cases with expected treatment duration <12 months by LA and LHB, Wales, LHB and LA Total Treatment completed Total Treatment completed n n % n n % Abertawe Bro Morgannwg University Bridgend Neath Port Talbot Swansea Aneurin Bevan Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen Betsi Cadwaladr University Anglesey Conwy Denbighshire Flintshire Gwynedd Wrexham Cardiff and Vale University Cardiff Vale of Glamorgan Cwm Taf Merthyr Tydfil Rhondda Cynon Taf Hywel Dda Carmarthenshire Ceredigion Pembrokeshire Powys Teaching Powys Total Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB Version: 1 Page: 30 of 33 Intended Audience: Health

31 Table A18. Last recorded TB outcome for entire drug sensitive cohort, Wales, Completed Died Lost to follow-up Still on treatment Stopped Not evaluated 2 Total Year n % n % n % n % n % n % n Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases 2 Not evaluated includes missing, unknown and transferred out Version: 1 Page: 31 of 33 Intended Audience: Health

32 Table A19. Last recorded TB outcome for entire drug sensitive cohort by LHB and LA, Wales, LHB and LA Total Treatment completed Total Treatment completed n n % n n % Abertawe Bro Morgannwg University Bridgend Neath Port Talbot Swansea Aneurin Bevan Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen Betsi Cadwaladr University Anglesey Conwy Denbighshire Flintshire Gwynedd Wrexham Cardiff and Vale University Cardiff Vale of Glamorgan Cwm Taf Merthyr Tydfil Rhondda Cynon Taf Hywel Dda Carmarthenshire Ceredigion Pembrokeshire Powys Teaching Powys Total Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases Version: 1 Page: 32 of 33 Intended Audience: Health