Tuberculosis in Wales Annual Report 2014

Transcription

1 Tuberculosis in Wales Annual Report 2014 Author: Communicable Disease Surveillance Centre Date: 20/03/2015 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 32 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, March 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 32 Intended Audience: Health

3 Key Points In 2013, 140 cases of tuberculosis were reported in Wales (4.5 per 100,000 population) compared to 138 cases in 2012, representing a relatively stable trend of TB incidence. 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 (10.0); continuing the trend identified in the last seven years. The rate per 100,000 population between 2012 and 2013 decreased in those aged between years and 65 years and older but increases were observed in those aged 0-4, and years. Of the 140 cases reported in 2013, 64% were male and 36% female (rates of 5.9 and 3.2 per 100,000, respectively). In 2013, 44% of tuberculosis cases were reported in the White ethnic group, 54% were in the non-white population and 3% were of an unknown ethnic group. Forty-one percent of tuberculosis cases reported in Wales were born in the UK, 58% of cases were born abroad and 1% of cases had unknown place of birth. Completeness of recording of social risk factors varied from 85% to 93% in Of those reported, seven percent of cases reported a history or current drug abuse problem, five percent of cases reported a history of alcohol misuse or abuse, three percent of cases reported they had been or are currently homeless and a further three percent of cases reported they had been or are currently in prison. Over half of the cases in 2013 (59%, 83/140) had pulmonary tuberculosis (with or without extra-pulmonary disease); of which 17 (20%) of these cases also had extra pulmonary disease. Isoniazid resistance in culture confirmed tuberculosis cases decreased to 8% in 2013 from 10% in The proportion of drug sensitive cases with expected treatment duration of less than 12 months who had completed treatment by 12 months has improved gradually over the last decade. However, a treatment completion of 72.1% was reported in 2012 cases, the lowest since Treatment completion was lowest in cases aged 65 years and over (58%, 15/26). Wales has the highest proportion of deaths in drug sensitive cases notified in 2012 (12%) compared to other countries in the UK (Northern Ireland: 6.9%, Scotland: 6.7% and England: 4.8%). Although the number of deaths caused or contributed by TB appears to be decreasing, in people who were known to have TB and who subsequently died, the contribution of TB to those deaths was unknown in 11 of 16 deaths (69%) in Version: 1 Page: 3 of 32 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. Tuberculosis case outcomes Conclusion Notes on Methods References Appendix Version: 1 Page: 4 of 32 Intended Audience: Health

5 1 Geographical Distribution 1.1 TB Rates in Wales and the UK In Wales in 2013, 140 cases of tuberculosis were reported to the Enhanced Tuberculosis Surveillance (ETS) scheme, a rate of 4.5 per 100,000 population (95% confidence interval (CI) per 100,000 population). This represents a stable trend in the number and rate of tuberculosis cases compared to previous years (Fig 1). Provisionally, for 2014, there have been 92 cases reported on ETS that reside in Wales at 28/10/2014. 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 (September 2014) [1], report the total UK rate of tuberculosis per 100,000 population was 12.3 (95% CI ) in England continues to account for the highest rate of tuberculosis in the UK, a rate of 13.5 (95% CI ) per 100,000 population, followed by 7.3 (95% CI ) per 100,000 population in Scotland. The lowest rate of tuberculosis was in Northern Ireland at 4.0 (95% CI ) per 100,000 population. Between 2012 and 2013, the rate of tuberculosis per 100,000 population decreased in England, Northern Ireland and Scotland and remained stable in Wales. Version: 1 Page: 5 of 32 Intended Audience: Health

6 Fig 2. Rate of TB per 100,000 population in the UK, 2013 England Scotland Northern Ireland Wales Rate per 100,000 Version: 1 Page: 6 of 32 Intended Audience: Health

7 1.2 Area of Residence Between 2012 and 2013, the rate of tuberculosis increased in Betsi Cadwaladr University, Abertawe Bro Morgannwg University and Cardiff and Vale University Health Boards, remained stable in Powys Teaching and Aneurin Bevan University Health Boards and decreased Hywel Dda and Cwm Taf University Health Boards (Table 1). In 2013, the highest tuberculosis rate of 8.1 per 100,000 population was found in Cardiff and Vale University Health Board and the lowest rate was in Powys Teaching and Hywel Dda University Health Boards at 2.3 per 100,000 population. Between 2012 and 2013 the rate of tuberculosis increased in nine of the 22 Local Authorities, remained stable in three and decreased in ten (Table 1). The rate of tuberculosis ranged from 1.1 per 100,000 in Torfaen to 10.5 per 100,000 population in Cardiff (Fig 3a). Figure 3b shows the five year average rate of tuberculosis per 100,000 population by Local Authority over the period of 2009 to From comparing the five year average rate per 100,000 with the rate of tuberculosis in 2013, it highlights that rates continue to be highest in Cardiff and Newport. The rate of tuberculosis per 100,000 in 2013 was higher in seven Local Authorities, remained stable in Flintshire and was lower in fourteen Health Boards compared to the five year average rate from 2009 to Fig 3. Rate of TB by Local Authority a b Crown Copyright and database right Ordnance Survey Version: 1 Page: 7 of 32 Intended Audience: Health

8 2 Demographic Characteristics of Tuberculosis in Wales 2.1 Age and Sex In 2013, just below two thirds of all cases were male (64%, 90/140), a rate of 5.9 (95% CI ) per 100,000 male population, with a lower rate of 3.2 (95% CI ) per 100,000 females (Table 2). Cases aged 25 to 34 years of age accounted for 26% of all cases, with 19% aged 15 to 24 years of age. In contrast to 2004, the highest proportion (33%) of 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 Information on ethnic group was known for 97% (136/140) of cases notified in The largest proportions of cases were from White (43.6%, 61/140), Indian (15.7%, 22/140) and Black-African (12.1%, 17/140) ethnic groups. In these three ethnic groups, the proportion of cases have increased in the Black-African ethnic group and declined in the White and Indian ethnic groups compared to The five year (2009 to 2013) 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 2.2 per 100,000 population (95% CI ) (Fig 6, Table 4). Version: 1 Page: 8 of 32 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 32 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 Information on place of birth (UK born/non-uk born) was known for 99% (138/140) of tuberculosis cases notified in Wales in Fifty-eight percent of cases (81/140) were born outside of the UK whilst 41% of cases (57/140) were born in the UK (Fig 7, Table 5). The reporting of place of birth has improved over the last decade with cases of unknown origins declining from 14% (27/187) in 2004 to 1% (2/140) in As in previous years, in 2013 the majority of cases known to be born outside the UK originated from South Asia (49%, 40/81) and Sub-Saharan Africa (22%, 18/81) (Table 6). Version: 1 Page: 10 of 32 Intended Audience: Health

11 Fig 7. Number of non-uk born TB Cases in Wales, Number of non-uk born TB cases Total number of TB cases Number of TB cases During between 1-15% of cases were reported with an unknown origin for place of birth. 2.4 Time between Entry into the UK and Diagnosis The time between entry to the UK and tuberculosis diagnosis was known for 81% (66/81) of non-uk born cases diagnosed in 2013, a decline from 89% (66/74) in 2012 (Table 7). Where time since entry was known, the highest proportion of cases were diagnosed within 2 years of UK entry (33%, 22/66) followed by between five and nine years and over 10 years since UK entry (24%, 16/66 each). Version: 1 Page: 11 of 32 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 2013, information on social risk factors was known for between 85% and 93% of cases in Wales, depending on the risk factor investigated (Fig 8). The completeness of recording social risk factors increased between 2012 and 2013 for all risk factors other than the recording of history of alcohol misuse which remained stable. The proportion of cases for which a social risk factor was implicated increased between 2012 and 2013: History or current drug use 0% 7% History or current alcohol misuse 2% 5% History or current homelessness 2% 3% History or current imprisonment 2% 3% Fig. 8 Completeness (%) of Recording Risk Factors, % 91% 91% 90% 90% 93% 86% 85% 85% 86% 83% 80% History of Drug Abuse History of Homelessness History of Alcohol Abuse History of Prison Overall 9% (13/140) of cases had at least one social risk factor, of which 38% (5/13) were known to be on Directly Observed Therapy (DOT). Version: 1 Page: 12 of 32 Intended Audience: Health

13 4 Clinical Characteristics 4.1 Site of Disease Miliary tuberculosis is classified as pulmonary tuberculosis in accordance with the WHO s recommendation and international reporting definitions [2]. Information on site of disease was known for 99% (138/140) of cases notified in Over half of tuberculosis cases with a known site of disease had pulmonary disease (with or without extra-pulmonary disease) (60%, 83/138). Twenty percent (17/83) of pulmonary cases were reported to also have extra pulmonary disease in at least one additional site. Many cases reported disease at multiple sites. The extra thoracic lymph nodes were the most common extra-pulmonary site of infection (35%, 25/140 (Table 8). 4.2 Planned Course of Treatment In 2013, planned course of treatment was known for 92% (129/140) of cases. Of these 129 cases, 91% (118) were assigned to a standard six month course of treatment. It was known whether a patient was assigned to DOT treatment in 89% of cases (125/140). Nine percent of cases (11/125) 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 2013, BCG vaccination status was known for 51% (72/140) of tuberculosis cases, the same as Of the 72 cases with known BCG vaccination status, 75% (54) were vaccinated, an increase from 72% in Vaccination coverage varied between age groups ranging from 25% (1/4) in 65 years and older to 100% (2/2) in under five year olds (Table 9). 4.4 Previous Diagnosis Information on previous tuberculosis diagnosis was known for 93% (130/140) of cases, of which eight had a previous diagnosis of tuberculosis (Table 10). Of these eight patients, two were assigned to DOT with the remaining patients not assigned to DOT (6/8). Version: 1 Page: 13 of 32 Intended Audience: Health

14 5 Bacteriology, Speciation and Drug Susceptibility 5.1 Bacteriology Sixty percent (84/140) of all cases in 2013 were culture confirmed, and 73% (61/83) of pulmonary cases (with or without extra pulmonary disease) were culture confirmed. This is higher than the 71% 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 51% (42/83) of pulmonary cases in 2013 a sputum smear result was recorded, of which 86% (36/42) were positive (Table 11). Forty-two percent (23/55) 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 84 culture-confirmed cases reported through the Enhanced Tuberculosis Surveillance scheme in 2013, all cases were due to infection by Mycobacterium tuberculosis (Table 12). 5.3 Antimicrobial Resistance Drug susceptibility results for isoniazid and rifampicin were reported for 100% (84/84) of culture confirmed tuberculosis cases. As with previous years, surveillance data continues to show that resistance to first line antimicrobials is low. Isoniazid resistance has decreased from 10% in 2012 to 8% in 2013, although remains higher than most previous years. Isoniazid 8% Rifampicin 2% Ethambutol 0% Pyrazinamide 1% One culture confirmed sample was resistant to isoniazid, rifampicin and pyrazinamide, whilst another culture confirmed sample was resistant to isoniazid and rifampicin. Version: 1 Page: 14 of 32 Intended Audience: Health

15 6 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 [2]. 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 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 96.7% (118/122) of cases in this cohort notified in 2012 (Table 13). Seventy-two percent (88/122) of cases completed treatment within 12 months within this cohort notified in 2012, compared to 76.3% (90/118) in 2011 (Table 13, Fig 9). In comparison to 2003 there has largely been a decrease in the proportion of outcomes not evaluated in recent years. Version: 1 Page: 15 of 32 Intended Audience: Health

16 Figure 9: TB outcome percentages at 12 months for drug sensitive cases with expected treatment duration <12 months 1, Wales, % 9.8% 4.9% 8.2% 1.6% 3.3% 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. 2 The proportion of cases who completed treatment within 12 months largely decreased with age in 2012 (Table 14). Treatment completion was highest in 5-14 year olds (100%, 2/2) and lowest in those aged 65 years and older (57.7%, 15/26). The proportion of cases that completed treatment was higher for females (82.5%, 33/40) than males (67.1%, 55/82, Table 15). 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 (71.4%, 35/49) compared to those with pulmonary disease only (69.6%, 39/56, Table 16). In those with a known site of disease, completion was highest in those with lymph node TB (intra-thoracic lymph node 80.0%, 4/5 and extra-thoracic lymph node 79.3% 23/29). In 2012, treatment completion at 12 months varied by Health Board ranging from 61.1% (Hywel Dda UHB) to 100% (Powys THB) (Table 17); Abertawe Bro Morgannwg UHB 75.0% Aneurin Bevan UHB 68.2% Betsi Cadwaladr UHB 68.8% Cardiff and Vale UHB 80.6% Cwm Taf UHB 68.8% Hywel Dda UHB 61.1% Powys THB % 1 Interpret with caution as small number of cases in Powys Version: 1 Page: 16 of 32 Intended Audience: Health

17 TB outcomes at last reported outcome in the entire drug sensitive cohort (including cases with CNS, spinal, miliary or cryptic disseminated TB) Information on the outcome of treatment based on the last reported outcome, was reported for 96% (132/137) of cases in this cohort notified in 2012 (Table 18). The proportion of cases in this cohort notified in 2012 who completed treatment was 73.7% (101/137) (Table 18, Fig 10). Figure 10: Last recorded TB outcome percentages for the entire drug sensitive cohort 1, Wales % 11.7% 4.4% 3.6% 2.9% 3.6% Completed Died Lost to follow up Still on treatment Stopped Not evaluated 2 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 In 2012, treatment completion in the entire drug sensitive cohort varied by Health Board from 64.7% (Cwm Taf UHB) to 100% (Powys THB) (Table 19); Abertawe Bro Morgannwg UHB 72.2% Aneurin Bevan UHB 72.0% Betsi Cadwaladr UHB 72.2% Cardiff and Vale UHB 80.6% Cwm Taf UHB 64.7% Hywel Dda UHB 70.0% Powys THB % 1 Interpret with caution as small number of cases in Powys Version: 1 Page: 17 of 32 Intended Audience: Health

18 Deaths at last reported outcome in the entire drug sensitive cohort (including cases with CNS, spinal, miliary or cryptic disseminated TB) In 2012, the proportion of cases who were reported to have died at the last reported outcome among all drug sensitive TB cases was 11.7% (16/137), the second highest proportion since 2003 and the highest amongst other countries in the UK (Table 20, [1]). Of the 16 deaths in 2012, tuberculosis caused or contributed to death in 18.8% (3), was incidental in 12.5% (2) and the relationship between tuberculosis and death was unknown for the remaining 68.8% (11). Among those reported to have died, 37.5% (6/16) were diagnosed post-mortem. Loss to follow up at last reported outcome in entire drug sensitive cohort (including cases with CNS, spinal, miliary or cryptic disseminated TB) In 2012, 4.4% (6/137) of all drug sensitive TB cases were lost to follow up at the last reported outcome (Table 18). Of the six cases and where reason for loss to follow up was recorded, 80% (4/5) of cases had left the UK. 7 Conclusion Annual TB incidence in Wales has remained relatively stable since As with previous years, TB continues to concentrate in urban areas, with nearly 60% of all TB cases in Wales occurring in those born abroad, mainly originating from high tuberculosis countries. As in 2012, the proportion of pulmonary cases that were culture confirmed in Wales exceeded the UK average and other UK countries, despite being lower than previous years [1]. However, a large decrease was observed in the proportion of all TB cases being culture confirmed in Wales from 76% in 2012 to 60% in It is important that culture specimens are obtained from both pulmonary and extra-pulmonary cases, when able, to confirm TB diagnosis and to provide drug susceptibility results for treatment plan management, particularly when isoniazid resistance remains higher in Wales than recorded for the UK. Encouragingly, the proportion of drug sensitive TB cases that have completed treatment by 12 months has gradually improved over the past decade in Wales. However in 2012, treatment completion at 12 months in drug sensitive cases was lower than reported in previous years. Of concern, is that nearly 12% of all drug sensitive cases notified in Wales in 2012 were reported to have died at the last recorded outcome, the highest proportion of deaths reported in the UK. It is known that almost 40% of deaths were diagnosed post mortem indicating that some TB cases may not be identified early by the TB services in Wales. Further investigation is required to gain understanding into the reasons contributing to Version: 1 Page: 18 of 32 Intended Audience: Health

19 TB deaths in Wales. The number of deaths in Wales from this disease emphasises that TB remains a serious disease and efforts to control TB and improve treatment outcome in Wales must be sustained. Notes on Methods All analysis was conducted using Stata 13.0, 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 2011 ONS estimates. This report only includes tuberculosis cases which have been notified on ETS. All Local Health Board and Local Authority figures are based on the area of residence of tuberculosis cases. Data presented in this report are correct as at May As treatment outcomes are reported at 12 months, treatment outcomes are only available to be reported on for cases notified in the previous year, by the time data is extracted for the report. References [1] Public Health England, Tuberculosis in the UK: 2014 report, London /TB_Annual_report 4_0_ pdf [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 Version: 1 Page: 19 of 32 Intended Audience: Health

20 Appendix Table 1. 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 (2009 to 2013) Version: 1 Page: 20 of 32 Intended Audience: Health

21 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: 21 of 32 Intended Audience: Health

22 Table 4. Number and Percentage of Tuberculosis Cases in Wales by Ethnic Group, Ethnic Group year Average 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 (2009 to 2013) 2 Rate per 100,000 using ONS 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: 22 of 32 Intended Audience: Health

23 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: 23 of 32 Intended Audience: Health

24 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 Pulmonary TB includes miliary 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, 2013 Age Group Vaccinated Known Status Vaccinated % Known Status % Total Version: 1 Page: 24 of 32 Intended Audience: Health

25 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: 25 of 32 Intended Audience: Health

26 Table 12. 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 Table 13. 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: 26 of 32 Intended Audience: Health

27 Table 14. 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 15. 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: 27 of 32 Intended Audience: Health

28 Total 3 Table 16. TB outcome at 12 months by site of disease for drug sensitive cases with expected treatment duration < 12 Completed Died Lost to follow-up Still on treatment Stopped Not evaluated 2 months, 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 Unknown site 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: 28 of 32 Intended Audience: Health

29 Table 17. 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: 29 of 32 Intended Audience: Health

30 Table 18. 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: 30 of 32 Intended Audience: Health

31 Table 19. 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: 31 of 32 Intended Audience: Health

32 Table 20. All drug sensitive TB cases reported to have died at last recorded outcome, Wales, Cases reported Total deaths TB caused or contributed to death Year n n % n % n % n % n % Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases TB incidental to death Unknown Post mortem Version: 1 Page: 32 of 32 Intended Audience: Health