Tuberculosis in Wales Annual Report 2013

Transcription

1 Tuberculosis in Wales Annual Report 2013 Author: Communicable Disease Surveillance Centre Date: 16/12/13 Version: 1 Status: Final Intended Audience: Health Purpose and Summary of Document: This report summarises the latest annual trends in the cases of tuberculosis in Wales reported through the enhanced tuberculosis surveillance system. Publication/Distribution: Head of Public Health Wales Health Protection Division Public Health Wales TB Programme Group Public Health Wales Intranet and Internet Public Health England TB Section Version: 1 Page: 1 of 26 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 England coordinates the UK wide Enhanced Tuberculosis Surveillance scheme and provides Public Health Wales with support in conducting tuberculosis surveillance. 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 colleagues in Local Health Boards. This report summarises the latest annual trends in the cases of tuberculosis in Wales 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, December 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 26 Intended Audience: Health

3 Key Points In 2012, 136 cases of tuberculosis were reported in Wales (4.4 per 100,000 population). This represents a small increase in the number of cases reported in However, rates of infection remain low in Wales relative to other areas of the UK. The rate per 100,000 population was highest in those aged 25 to 34 years (10.7); continuing the trend identified in the last six years. The rate per 100,000 population decreased in all the age groups between 2011 and 2012; with the exception of those aged 25 to 34, 45 to 54 and 65 years and older, where increases were observed. Of the 136 cases reported in 2012, 68% were male and 32% female (rates of 6.1 and 2.8 per 100,000 respectively). In 2012, 43% of tuberculosis cases were reported in the White ethnic group, 52% were in the non-white population and 5% were of an unknown ethnic group. Forty one percent of tuberculosis cases reported in Wales were born in the UK, 54% of cases were born abroad and 5% of cases had unknown place of birth. Completeness of recording of social risk factors varied from 81% to 90% in Of those reported, a history of alcohol misuse or abuse, have been or are currently homeless or have been or are currently in prison were reported for 2% of cases. No cases reported a history or current drug abuse problem. Over half of the cases in 2012 (57%) were diagnosed with pulmonary tuberculosis; of which 11 (14%) of these cases also had extra pulmonary disease. Isoniazid resistance in culture confirmed tuberculosis cases increased to 10% in 2012 from 2% in Information on the outcome of treatment at 12 months was received for 124 (97%) of the 128 tuberculosis cases reported in 2011, excluding patients with rifampicin resistance or multi-drug resistance. Of the treatment outcomes reported, 98 (79%) cases were reported as having completed treatment within 12 months. Completion was lowest in over 65 year olds (52%, 13/25). Version: 1 Page: 3 of 26 Intended Audience: Health

4 Contents 1. Geographical Distribution TB Rates in Wales and the UK 1.2. Area of Residence 2. Demographic Characteristics of TB in Wales Age and Sex 2.2. Ethnicity 2.3. Place of Birth 2.4. Time Since Entry into the UK to Diagnosis 3. Social Determinants Clinical Characteristics Site of Disease 4.2. Planned Course of Treatment 4.3. Vaccination Status 4.4. Previous Diagnosis 5. Bacteriology, Speciation and Drug Susceptibility Bacteriology 5.2. Species Identification 5.3. Antimicrobial Resistance 6. Treatment Outcomes Conclusion Notes on Methods References Appendix Version: 1 Page: 4 of 26 Intended Audience: Health

5 1 Geographical Distribution 1.1 TB Rates in Wales and the UK In Wales in 2012, 136 cases of tuberculosis were reported to the Enhanced Tuberculosis Surveillance (ETS) scheme, a rate of 4.4 per 100,000 population (95% confidence interval (CI) per 100,000 population). This represents a 5% increase in the number of cases reported in 2011 (130, 4.2 (95% CI ) per 100,000 population) which recorded the lowest annual number of cases since enhanced surveillance commenced in 1999 (Fig 1). Provisionally, for 2013, there have been 129 cases reported on ETS that reside in Wales at 16/12/2013. Fig 1. Number of Cases and Rate of TB per 100,000 population in Wales, Number of cases Rate per Figures published by Public Health England (August 2013) [1], report the total UK rate per 100,000 population was 13.9 (95% CI ) in For the first time, Wales reported the lowest rate of tuberculosis in the UK (Fig 2). England continues to account for the highest rate of tuberculosis in the UK, a rate of 15.2 (95% CI ) per 100,000 population, followed by 7.5 (95% CI ) per 100,000 population in Scotland and 4.8 (95% CI ) per 100,000 population in Northern Ireland. Between 2011 and 2012, the rate of tuberculosis per 100,000 population increased in Northern Ireland and Wales but decreased in Scotland and England. Version: 1 Page: 5 of 26 Intended Audience: Health

6 Fig 2. Rate of TB per 100,000 population in the UK, Rate per 100,000 England Scotland Northern Ireland Wales Version: 1 Page: 6 of 26 Intended Audience: Health

7 1.2 Area of Residence Between 2011 and 2012, the rate of tuberculosis increased in Powys Teaching, Cwm Taf and Aneurin Bevan Local Health Boards, remained stable in Betsi Cadwaladr University Health Board and decreased in the remaining three Local Health Boards (Table 1). In 2012, the highest tuberculosis rate of 7.6 per 100,000 population was found in Cardiff and Vale Health Board and the lowest rate was in Powys Teaching Health Board at 2.3 per 100,000 population. Between 2011 and 2012 the rate of tuberculosis increased in eight of the 22 Local Authorities, remained stable in five and decreased in nine (Table 1). The rate of tuberculosis ranged from 0.0 per 100,000 in Conwy, where no cases were reported in 2012, to 10.3 per 100,000 population in Newport (Fig 3a). Figure 3b shows the five year average rate of tuberculosis per 100,000 population by Local Authority over the period of 2008 to Comparison of the five year average rate per 100,000 with the rate of tuberculosis in 2012 highlights that rates continue to be highest in Cardiff and Newport. However, in Pembrokeshire the rate of tuberculosis per 100,000 in 2012 was higher than the five year average rate whereas the rate of tuberculosis per 100,000 in 2012 was lower in Powys, Conwy and Flintshire than the average rate from 2008 to Fig 3. Rate of TB by Local Authority a b Crown Copyright and database right Ordnance Survey Version: 1 Page: 7 of 26 Intended Audience: Health

8 2 Demographic Characteristics of Tuberculosis in Wales 2.1 Age and Sex Over two thirds of the cases reported in 2012 were male (68%, 92/136), a rate of 6.1 (95% CI ) per 100,000 male population, with a lower rate of 2.8 (95% CI ) per 100,000 females (Table 2). Cases were most frequently aged 25 to 34 years of age (29%, 39/136) and 65 years of age and older (23%, 31/136). In comparison to 2003 the highest proportion (29%) of active tuberculosis disease identified amongst the Welsh population was found in those aged 65 years and over (Table 3). Changes in the rate of tuberculosis amongst different age groups from are presented in Figure Ethnicity In 2012, 43% (59/136) of tuberculosis cases reported were in the White ethnic group compared to 57% in This decrease has been accompanied by a rise in tuberculosis amongst those of Indian ethnic origin. The five year (2008 to 2012) average annual rate was highest in the Black-African ethnic group; (95% CI ) per 100,000 population and lowest in the White ethnic group, a rate of 2.4 (95% CI ) per 100,000 population (Fig 6, Table 4). Version: 1 Page: 8 of 26 Intended Audience: Health

9 Fig 5. Rate of TB per 100,000 population by Age Group and Year in Wales, Age Group 5-14 Age Group Age Group Age Group Age Group Age Group Age Group 65+ Age Group Version: 1 Page: 9 of 26 Intended Audience: Health

10 Fig 6. Average Annual Number of TB Cases and Rate per 100,000 population in Wales by Ethnic Group, < Average Number of Cases Rate 2.3 Place of Birth In 2012, 41% (56/136) of tuberculosis cases reported in Wales were born in the UK, 54% (73/136) were born abroad and 5% (7/136) of unknown origin (Fig 7, Table 5). In comparison, 35% of cases in 2003 were reported to be born abroad. However, it should be noted that the reporting of place of birth has improved over the last decade; in % of cases had unknown origins. As with previous years, in 2012 the majority of cases born outside the UK originated from South Asia (55%, 40/73) and Sub-Saharan Africa (21%, 15/73) (Table 6). 2.4 Time between Entry into the UK and Diagnosis The time between entry to the UK and tuberculosis diagnosis was known for 89% (65/73) of non-uk born cases diagnosed in 2012, comparable to 2011 (Table 7). Where time since entry was known, the proportion of cases varied across the classifications: less than two years of entry and between two and four years (26% each), between five and nine years (19%) and over ten years (18%) since UK entry. Version: 1 Page: 10 of 26 Intended Audience: Health

11 Number of TB cases Public Health Wales Tuberculosis in Wales Annual Report 2013: Fig 7. Number of TB Cases in Wales born abroad, Number of TB cases born abroad Total number of TB cases During between 4-15% of cases were reported with an unknown origin for place of birth. Version: 1 Page: 11 of 26 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 2012, information on social risk factors was known for between 81% and 90% of cases in Wales, depending on the risk factor investigated (Fig 8). The completeness of recording social risk factors increased between 2011 and 2012, but the proportion of cases for which a social risk factor was implicated remained stable or decreased between this time period: History or current drug use 3% 0% History or current alcohol misuse 2% 2% History or current homelessness 3% 2% History or current imprisonment 2% 2% Fig. 8 Completeness (%) of Recording Risk Factors, % 80% 83% 71% 87% 92% 91% 86% 82% 90% 89% 81% History of Drug Abuse History of Homelessness History of Alcohol Abuse History of Prison Overall 4% (6/136) of cases had at least one social risk factor. Of those, 33% (2/6) were on Directly Observed Therapy (DOT). Version: 1 Page: 12 of 26 Intended Audience: Health

13 4 Clinical Characteristics 4.1 Site of Disease Miliary tuberculosis is now classified as pulmonary tuberculosis in accordance with the WHO s recommendation and international reporting definitions [2]. In 2012, over half of tuberculosis cases had pulmonary disease (57%, 77/136). Fourteen percent (11/77) of pulmonary cases were reported to also have extra pulmonary disease. Many cases reported disease at multiple sites. For cases with extra pulmonary disease, the extra thoracic lymph nodes were the most common site of infection (22%, 32/148) (Table 8). 4.2 Planned Course of Treatment In 2012, planned course of treatment was known for 93% (126/136) of cases; of these 94% (118/126) were assigned to a standard six month course of treatment. In 90% of cases (122/136), it was known whether a patient was assigned to DOT, which is similar to the 88% of cases reported in last year s report. Of these 7% (8/122) were assigned DOT treatment. 4.3 Vaccination Status The collection of data on Bacillus Calmette-Guérin (BCG) vaccination was introduced to the Enhanced Tuberculosis Surveillance scheme in In 2012, BCG vaccination status was known for 51% (69/136) of tuberculosis cases. Of these, 74% (51/69) were vaccinated. Vaccination coverage varied between age groups ranging from 33% (1/3) for 5 to 14 year olds to 100% (4/4) in 55 to 64 year olds (Table 9). 4.4 Previous Diagnosis Information on previous tuberculosis diagnosis was known for 93% (127/136) of cases, of which seven had a previous diagnosis of tuberculosis (Table 10). Of these seven patients, one was assigned to DOT with the remaining patients either not assigned to DOT (5/7) or it was not reported whether they were assigned to DOT (1/7). Version: 1 Page: 13 of 26 Intended Audience: Health

14 5 Bacteriology, Speciation and Drug Susceptibility 5.1 Bacteriology Seventy-four percent (100/136) of all cases in 2012 were culture confirmed, and 77% (59/77) of pulmonary cases (with or without additional extra pulmonary disease) were culture confirmed. This is higher than the 69% UK average reported by Public Health England as well as compared to other UK counterparts [1] but is slightly below the European Centre for Disease Prevention and Control (ECDC) target of 80% for culture confirmation of pulmonary tuberculosis [3]. For 53% (41/77) of pulmonary cases in 2012 a sputum smear result was recorded, of which 78% (32/41) were positive (Table 11). Seventy-four percent (40/54) of cases which reported extra pulmonary disease only were culture confirmed. 5.2 Species Identification The Enhanced Tuberculosis Surveillance scheme collates data on species identification, including an additional questionnaire for completion when an isolate is identified as Mycobacterium bovis. However, the completeness of these data is unclear. Therefore, more detailed analysis of all M.bovis cases reported between 2001 and 2010 in Wales can be found on Public Health Wales website ( Among culture-confirmed cases reported through the Enhanced Tuberculosis Surveillance scheme in 2012, 96% (96/100) were due to infection by Mycobacterium tuberculosis (Table 12). 5.3 Antimicrobial Resistance Drug susceptibility results for isoniazid and rifampicin were reported for 100% (100/100) of culture confirmed tuberculosis cases. As with previous years, surveillance data continues to show that resistance to first line antimicrobials is low, however, isoniazid resistance has increased from 2% in 2011 to 10% in 2012, comparable to the highest reported in 2007 (10%). Isoniazid 10% Rifampicin 1% Ethambutol 1% Pyrazinamide 0% One culture confirmed sample was resistant to isoniazid, rifampicin and ethambutol. Version: 1 Page: 14 of 26 Intended Audience: Health

15 6 Treatment Outcomes Treatment outcomes in 2012 are reported in accordance with the revised 2013 World Health Organisation (WHO) treatment outcome definitions [2]. Under these revised definitions, treatment outcome at 12 months is reported for the cohort of patients with drug sensitive TB (excluding patients with rifampicin resistance or multi-drug resistance). Revised trends in treatment outcomes are presented for previous years using the revised WHO definitions. Cases where treatment outcome is missing or were transferred to another clinic outside Wales and a treatment outcome form was not received are assigned the outcome unknown outcome. Information on the outcome of treatment, 12 months after treatment commenced, was reported for 97% (124/128) of drug sensitive TB cases notified in 2011 (Table 13). Treatment outcome was missing for 3% (4/128) of cases. Seventy-nine percent (98/124) of cases completed treatment within 12 months. The most common reasons for not completing treatment were lost to follow-up and death (6.5%, 8/124 for both). Moving outside the UK was most frequently the reason provided for cases lost to follow-up. The cessation of treatment was reported for 5% (6/124) of cases, the highest reported in Wales compared to previous years and to the UK. Of the eight deaths, tuberculosis was incidental to death in 38% (3/8), contributed to death in 25% (2/8) and the relationship between tuberculosis and death was unknown for 33% (3/8) of deaths. Amongst those reported to have died, 25% (2/8) were diagnosed with tuberculosis postmortem. Treatment completion at 12 months varied between Local Health Boards (Table 14); Hywel Dda 81% Aneurin Bevan 83% Cardiff and Vale University 81% Betsi Cadwaladr University 72% Cwm Taf 67% Abertawe Bro Morgannwg 78% Powys 100% 1 Treatment completion differed between age groups; with 100% completion reported in cases aged less than 15 years (7/7) and those aged between 45 and 64 years old (19/19) but only 52% (13/25) treatment completion in those aged 65 and older (Table 15). Death was the most frequent reason (58%, 7/12) for those over 65 years of age not completing treatment. The majority of deaths (88%, 7/8) occurred in those aged 65 and older (Table 15). 1 Interpret with caution as small number of cases in Powys Version: 1 Page: 15 of 26 Intended Audience: Health

16 Completion was higher in non-uk born cases (81%, 61/75) compared to UK born cases (75%, 33/44). A higher proportion of UK born cases died (9%, 4/44) compared to non-uk born cases (4%, 3/75). 7 Conclusion In 2012, the annual number of tuberculosis cases in residents of Wales increased by 5% to 136 but rates remain low relative to other parts of the UK. In 2012, Wales reported the lowest rate of tuberculosis in the UK (4.4 per 100,000 cases) [4]. Consistent with the rest of the UK, the majority of cases in Wales were reported from urban areas, with over 50% of cases born outside the UK, originating from high tuberculosis burden countries. Encouragingly, in Wales the proportion of pulmonary cases that were culture confirmed exceeded the UK average and other UK countries. The introduction of the Cohort Review in 2012 by Public Health Wales to improve tuberculosis management by systematically reviewing case management and contact investigation may have led to the observed improvements [5]. It is important that every effort should be made to maintain these achievements. Of concern, is the increase in isoniazid resistance which is higher than that recorded for the UK and is on par with the highest ever recorded in Wales. Drug resistance is a worldwide concern and identification of an increase in first line drug resistance is important to monitor. Consequently, obtaining drug susceptibility results is imperative for tackling any further rise. The proportion of cases completing treatment at 12 months in Wales remained stable in comparison to 2011 but is slightly lower than that reported for the UK and remains below the Department of Health s recommended 85% completion target [6]. In 2012, Wales reported the highest proportion of cases that stopped treatment since This is of concern as these patients may continue to transmit tuberculosis within the community. Further efforts should be made to encourage patients to complete treatment in order to reduce transmission. The cohort review should be continued as a platform to discuss difficulties in treatment completion with the aim to improve case management. Version: 1 Page: 16 of 26 Intended Audience: Health

17 Notes on Methods All analysis was conducted using Stata 12.1, using 95% confidence intervals. Population figures were obtained from the Office of National Statistics (ONS) mid-year estimates for Wales and used as the denominator to calculate rates. Rates for ethnic groups were calculated using ONS estimates by ethnic group in Wales. Five year average rates for ethnic groups were calculated using a combination of 2008, 2009 and 2011 ONS estimates. This report only includes tuberculosis cases which have been reported on ETS. All Local Health Board and Local Authority figures are based on the area of residence of tuberculosis cases. References [1] Public Health England, Tuberculosis in the UK: Annual report on tuberculosis surveillance in the UK, [2] Definitions and reporting framework for tuberculosis 2013 revision. WHO [3]European Centre for Disease Control and Prevention (ECDC), Progress towards TB elimination, wards_tb_elimination.pdf [4] Public Health England, Annual report on Tuberculosis surveillance in the UK 2013 Slideset [5] Health Protection Agency and London TB Service, Evaluation of cohort review in North Central London, [6] Department of Health, Stopping Tuberculosis in England: An action plan from the Chief Medical Officier, uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/ dh_ pdf Version: 1 Page: 17 of 26 Intended Audience: Health

18 Appendix Table 1. Number of Cases and Rate 1 of Tuberculosis in Wales by LHB and LA, LHB 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 Betsi Cadwaladr University Anglesey Conwy Denbighshire Flintshire Gwynedd Wrexham Powys Teaching Powys Hywel Dda Carmarthenshire Ceredigion Pembrokeshire Abertawe Bro Morgannwg University Bridgend Neath Port Talbot Swansea Cwm Taf Merthyr Tydfil Rhondda, Cynon, Taff Cardiff and Vale University Cardiff Vale of Glamorgan Aneurin Bevan Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen 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 (2008 to 2012) Version: 1 Page: 18 of 26 Intended Audience: Health

19 Table 2. 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 3. 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 Rate per 100,000 using ONS Mid-Year population estimates Version: 1 Page: 19 of 26 Intended Audience: Health

20 Table 4. Number and Percentage of Tuberculosis Cases in Wales by Ethnic Group, Ethnic Group 5 year Average 1 cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Cases Rate 2 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 (2008 to 2012) 2 Rate per 100,000 using ONS 2008, 2009 and 2011 population estimates by ethnic group Table 5. 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: 20 of 26 Intended Audience: Health

21 Table 6. 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 7. 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 Version: 1 Page: 21 of 26 Intended Audience: Health

22 Table 8. 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 Patients may have disease at more than one site 2 Miliary TB is now classified as pulmonary TB in accordance with the WHO s recommendation and international reporting definitions [2]. Revised trends in site of disease are presented for previous years using the revised WHO definitions. Table 9. Number and Percentage of Cases in Wales with a History of BCG Vaccination by Age Group, 2012 Age Group Vaccinated Known Status Vaccinated % Known Status % Total Version: 1 Page: 22 of 26 Intended Audience: Health

23 Table 10. 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 Table 11. Number and Percentage of Tuberculosis Cases in Wales with Bacteriological Confirmation, Previous Diagnosis 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: 23 of 26 Intended Audience: Health

24 Table 12. Species Identification in Culture Confirmed Tuberculosis Case, Wales Species Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % M.african M.bovis M.tuberculosis M.tuberculosis complex Table 13. Number and Percentage of Tuberculosis Cases in Wales with Treatment Outcome 1 Reported at 12 Months, Year Total TB cases Excluded cases 2 Unknown Outcome 3 Total for Evaluation 4 Completed Treatment Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Died Lost to Follow-up Still on Treatment Stopped Not completed (reason unknown) Treatment outcomes are reported in accordance with revised 2013 World Health Organization (WHO) treatment outcome definitions [2]. Under these revised definitions, treatment outcome is reported for the cohort of patients with drug sensitive TB (excluding patients with rifampicin resistance or multi-drug resistance) at 12 months. Revised trends in treatment outcomes are presented for previous years using the revised WHO definitions. 2 Excludes multi-drug resistant and rifampicin resistant patients. 3 Refers to cases where treatment outcome is missing or were transferred to another clinic outside Wales. 4 Refers to drug sensitive TB cases excluding patients with rifampicin resistance or multi-drug resistance and that that an unknown outcome. Version: 1 Page: 24 of 26 Intended Audience: Health

25 Table 14. Number and Percentage of Tuberculosis Cases in Wales Completing Treatment 1 by 12 Months by LA, LHB and LA Total TB cases Excluded cases Unknown Total for Treatment Total TB Excluded Unknown Outcome 3 Evaluation 4 Completed cases cases 2 Outcome 3 Version: 1 Page: 25 of 26 Intended Audience: Health Total for Evaluation 4 Treatment Completed Betsi Cadwaladr University (92.9) 21 (80.8) (94.7) 13 (72.2) Anglesey (75.0) 2 (66.7) Conwy (80.0) 4 (100.0) (100.0) 2 (100.0) Denbighshire (100.0) 2 (100.0) (100.0) 2 (66.7) Flintshire (100.0) 2 (100.0) (100.0) 4 (80.0) Gwynedd (100.0) 8 (80.0) (75.0) 0 (0.0) Wrexham (100.0) 3 (60.0) (100.0) 5 (100.0) Powys Teaching (100.0) 2 (50.0) (100.0) 1 (100.0) Powys (100.0) 2 (50.0) (100.0) 1 (100.0) Hywel Dda (100.0) 11 (91.7) (88.9) 13 (81.3) Carmarthenshire (100.0) 8 (88.9) (100.0) 7 (77.8) Ceredigion (100.0) 1 (100.0) (80.0) 3 (75.0) Pembrokeshire (100.0) 2 (100.0) (75.0) 3 (100.0) Abertawe Bro Morgannwg University (100.0) 16 (69.6) (94.7) 14 (77.8) Bridgend (100.0) 1 (33.3) (80.0) 2 (50.0) Neath Port Talbot (100.0) 4 (80.0) (100.0) 5 (100.0) Swansea (100.0) 11 (73.3) (100.0) 7 (77.8) Cwm Taf (100.0) 12 (75.0) (100.0) 4 (66.7) Merthyr Tydfil (100.0) 3 (100.0) (100.0) 1 (50.0) Rhondda, Cynon, Taff (100.0) 9 (69.2) (100.0) 3 (75.0) Cardiff and Vale University (100.0) 37 (80.4) (97.7) 34 (81.0) Cardiff (100.0) 34 (81.0) (97.1) 26 (76.5) Vale of Glamorgan (100.0) 3 (75.0) (100.0) 8 (100.0) Aneurin Bevan (100.0) 20 (83.3) (95.8) 19 (82.6) Blaenau Gwent (100.0) 2 (50.0) (100.0) 1 (100.0) Caerphilly (100.0) 3 (100.0) (100.0) 4 (80.0) Monmouthshire (100.0) 1 (50.0) (80.0) 3 (75.0) Newport (100.0) 14 (93.3) (100.0) 10 (83.3) Torfaen (100.0) 1 (100.0) Total (98.7) 119 (78.8) (95.4) 98 (79.0) 1 Treatment outcomes are reported in accordance with revised 2013 WHO treatment outcome definitions [2]. Under these revised definitions, treatment outcome is reported for the cohort of patients with drug sensitive TB (excluding patients with rifampicin resistance or multi-drug resistance) at 12 months. Revised trends in treatment outcomes are presented for previous years using the revised WHO definitions. 2 Excludes multi-drug resistant and rifampicin resistant patients. 3 Refers to cases where treatment outcome is missing or were transferred to another clinic outside Wales. 4 Refers to drug sensitive TB cases excluding patients with rifampicin resistance or multi-drug resistance and that that an unknown outcome.

26 Table 15. Number and Percentage of Tuberculosis Cases in Wales Completing Treatment 1 by 12 Months by Age Group, Age Group Total for Evaluation Treatment Completed Died Total for Evaluation Treatment Completed Died cases % cases % cases % cases % cases % cases % Treatment outcomes are reported in accordance with revised 2013 WHO treatment outcome definitions [2]. Under these revised definitions, treatment outcome is reported for the cohort of patients with drug sensitive TB (excluding patients with rifampicin resistance or multi-drug resistance) at 12 months. Revised trends in treatment outcomes are presented for previous years using the revised WHO definitions. 2 Refers to drug sensitive TB cases excluding patients with rifampicin resistance or multi-drug resistance and that that an unknown outcome. Version: 1 Page: 26 of 26 Intended Audience: Health