Tuberculosis in Wales Annual Report 2015

Transcription

1 Tuberculosis in Wales Annual Report 2015 Author: Communicable Disease Surveillance Centre Date: 10/03/2016 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: 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 Enhanced Tuberculosis Surveillance scheme in England, Wales and Northern Ireland 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 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, 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 Notification rates for tuberculosis remain low in Wales relative to other countries in the UK. In 2014, 115 cases of tuberculosis were reported in Wales (3.7 per 100,000 population), a decrease on recent years. Notification rates vary geographically, with rates highest in the urban centres of South East Wales. The notification rate was highest in those aged 25 to 34 years (6.4 per 100,000 population). Between 2013 and 2014 the notification rate decreased in all age groups apart from those aged years where the rate remained stable, and those aged years where the rate increased. Of the 115 cases reported in 2014, 63% were male and 37% female (rates of 4.8 and 2.7 per 100,000, respectively). In 2014, 37% of tuberculosis cases were reported in the White ethnic group, 59% were in the non-white population and 4% were of an unknown ethnic group. Thirty-eight percent of tuberculosis cases reported in Wales were born in the UK, 57% of cases were born abroad and 5% of cases had unknown place of birth. Completeness of recording of social risk factors varied from 77% to 90% in Of those reported, seven percent of cases reported a history of, or current drug abuse, seven percent reported a history of, or current alcohol misuse or abuse, eight percent reported they had been, or are currently, homeless and six percent reported they had been, or are currently, in prison. Over half of the cases in 2014 (57%, 65/115) had pulmonary tuberculosis (with or without extra-pulmonary disease); of which 16 (25%) also had extra pulmonary disease. In 2014 there was one case of XDR-TB and two further cases of MDR-TB reported in culture confirmed tuberculosis in Wales. There was an increase in both isoniazid and rifampicin resistance in culture confirmed cases of tuberculosis in 2014 compared to 2013, from 9% to 11% and 2% to 4% respectively. 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 2013 to 79.3%, compared to 73.3% in Treatment completion was lowest in those aged 65 years and older (66.7%, 10/15) and those aged 5-14 years (66.7%, 2/3). The proportion of deaths in drug sensitive cases has decreased from 11% in 2012 to 5% in 2013, the lowest reported since ETS was introduced. The proportion of cases not evaluated was three times higher in 2013 (9%, 13/139) compared to 2012 (3%, 4/135), the highest proportion of cases not evaluated since 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 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, 115 cases of tuberculosis were reported in 2014 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). This represents a decrease as compared to 2013 and the lowest rate reported since ETS was introduced (Figure 1). Provisionally, for 2015, there have been 115 cases reported on ETS that reside in Wales at 09/03/2016. Figure 1. Number of Cases and Rate of TB per 100,000 population in Wales, Number of cases Rate per Public Health England [1], reports the UK rate of tuberculosis as 11.0 per 100,000 population in England continues to have the highest rate of tuberculosis in the UK, with a rate of 12.0 (95% CI ) per 100,000 population, followed by Scotland (6.5 (95% CI ) per 100,000 population) and Northern Ireland (5.2 (95% CI ) per 100,000 population). Of the UK countries, Wales had the lowest rate of tuberculosis in Between 2013 and 2014, the rate of tuberculosis per 100,000 population decreased in Wales, England and Scotland and increased in Northern Ireland. Version: 1 Page: 5 of 32 Intended Audience: Health

6 Figure 2. Rate of TB per 100,000 population in the UK, 2014 England Scotland Northern Ireland Wales Rate per 100,000 Version: 1 Page: 6 of 32 Intended Audience: Health

7 1.2 Area of Residence In 2014, 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 Powys Teaching University Health Board (1.5 per 100,000 population). Between 2013 and 2014, the rate of tuberculosis increased in Aneurin Bevan University and Hywel Dda Health Boards, remained stable in Powys Teaching Health Board and decreased in Abertawe Bro Morgannwg University, Betsi Cadwaladr University, Cardiff and Vale University and Cwm Taf University Health Boards (Table A1). Between 2013 and 2014 the rate of tuberculosis increased in three of the 22 Local Authorities in Wales, remained stable in nine and decreased in ten (Table A1). The rate of tuberculosis ranged from 0 per 100,000 in Merthyr Tydfil to 16.3 per 100,000 population in Newport (Figure 3a). Figure 3b shows the five year average rate of tuberculosis per 100,000 population by Local Authority for the period 2010 to Tuberculosis rates continue to be highest in Cardiff and Newport. By comparing 2014 with the average in the five years 2010 to 2014, the rate in 2014 was higher in Newport, remained stable in eleven Local Authorities and was lower in ten Local Authorities (Figure 3). Figure 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 Cases in Wales 2.1 Age and Sex In 2014, around two thirds of newly diagnosed tuberculosis cases were male (63%, 73/115), a rate of 4.8 (95% CI ) per 100,000 male population, with a lower rate of 2.7 (95% CI ) per 100,000 females (Table A2). The highest incidence was seen in people aged (6.4 per 100,000; 21% of cases). During 2014 there was only one reported case of tuberculosis in a child aged under 15 years, the lowest proportion in this age group in over ten years (Table A3). Changes in the rate of tuberculosis amongst different age groups from are presented in Figure Ethnicity Information on ethnic group was known for 97% (111/115) of cases notified in The largest proportions of cases were from White (37.4%, 43/115) and Indian (18.3%, 21/115) ethnic groups. Compared to 2013, the number of cases has decreased in all ethnic groups apart from Pakistani and Black-Other. The five year (2010 to 2014) 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 1.8 per 100,000 population (95% CI ) (Figure 5, Table A4). Version: 1 Page: 8 of 32 Intended Audience: Health

9 Figure 4. Rate of TB per 100,000 population by Age Group and Year in Wales, Age Group 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 Figure 5. 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 was known for 95% (109/115) of tuberculosis cases notified in Wales in Fifty-seven percent of cases (65/115) were known to have been born outside of the UK whilst 38% of cases (44/115) were known to have been born in the UK (Figure 6, Table A5). As in previous years, in 2014 the majority of cases known to be born outside the UK originated from South Asia (55.4%, 36/65) and Sub-Saharan Africa (16.9%, 11/65) (Table A6). Information on region of birth was unknown for 4.6% (3/65) of cases born outside of the UK. Version: 1 Page: 10 of 32 Intended Audience: Health

11 Number of TB cases Public Health Wales Tuberculosis in Wales Annual Report 2015: Figure 6. Number of non-uk born TB Cases in Wales, Number of non-uk born TB cases Total 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 79% (51/65) of non-uk born cases diagnosed in 2014 (Table A7). Where time since entry was known, the highest proportion of cases were diagnosed within 2 years of UK entry (31%, 16/51) followed by over 10 years since UK entry (29%, 15/51). 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 2014, information on social risk factors was known for between 77% and 90% of cases in Wales, depending on the risk factor investigated (Figure 7). In 2014, 19% of cases reported at least one social risk factor. Seven percent of cases reported a history of, or current, drug use, 7% reported a history of, or current, alcohol misuse, 8% reported a history of, or current, homelessness, and 6% reported a history of, or current, imprisonment (Table 1). The proportion of cases for which a social risk factor was recorded increased between 2013 and However, the completeness of recording social risk factors decreased between 2013 and 2014 for all risk factors. Table 1. Social risk factors among TB patients in Wales, History or current drug use 3% 11% 3% 0% 7% 7% History or current alcohol misuse 5% 5% 2% 2% 5% 7% History or current homelessness 8% 5% 3% 2% 4% 8% History or current imprisonment 4% 5% 2% 1% 3% 6% Any risk factor 17% 17% 8% 6% 12% 19% Figure. 7 Completeness (%) of Recording Risk Factors, % 79% 74% 83% 80% 72% 70% 92% 90% 92% 94% 90% 90% 90% 86% 88% 85% 83% 85% 86% 84% 80% 77% 63% History of Drug Abuse History of Homelessness History of Alcohol Abuse History of Prison Version: 1 Page: 12 of 32 Intended Audience: Health

13 4 Clinical Characteristics 4.1 Site of Disease Information on site of disease was known for 99% (114/115) of cases notified in Over half of tuberculosis cases with a known site of disease had pulmonary disease (with or without extra-pulmonary disease) (57%, 65/114). Twenty five percent (16/65) of pulmonary cases were reported to also have extra pulmonary disease in at least one additional site. Many cases reported disease at multiple sites. The extra thoracic lymph nodes were the most common extra-pulmonary site of infection 17%, 19/114 (Table A8). 4.2 Planned Course of Treatment In 2014, planned course of treatment was known for 94% (108/115) of cases. Of these 108 cases, 85% (92) were assigned to a standard six month course of treatment. It was known whether a patient was assigned to DOT treatment in 92% of cases (106/115). Thirteen percent of these cases (14/106) were assigned DOT treatment. In 2014, 47% (8/17) of cases reported at least one social risk factor were known to be on Directly Observed Therapy (DOT). 4.3 Vaccination Status The collection of data on Bacillus Calmette-Guérin (BCG) vaccination was introduced to the Enhanced Tuberculosis Surveillance Scheme in In 2014, BCG vaccination status was known for 50% (57/115) of tuberculosis cases, a similar level of completeness to Of the 57 cases with known BCG vaccination status, 79% (45) were vaccinated, an increase from 74% (54/73) in Coverage was over 77% in all age groups apart from those aged 65 years and older where coverage was 50% (3/6) (Table A9). 4.4 Previous Diagnosis Information on previous tuberculosis diagnosis was known for 88% (101/115) of cases, of which eight had a previous diagnosis of tuberculosis (Table A10). Of these eight patients, three were assigned to DOT with the remaining patients not assigned to DOT (5/8). Version: 1 Page: 13 of 32 Intended Audience: Health

14 5 Bacteriology, Speciation and Drug Susceptibility 5.1 Bacteriology Sixty nine percent (79/115) of all cases in 2014 were culture confirmed, and 83% (54/65) of pulmonary cases (with or without extra pulmonary disease) were culture confirmed. This is higher than the 72% UK average reported by Public Health England as well as compared to other UK counterparts [1] and 3% above the European Centre for Disease Prevention and Control (ECDC) target of 80% for culture confirmation of pulmonary tuberculosis [2]. For 55% (36/65) of pulmonary cases in 2014 a sputum smear result was recorded, of which 56% (20/36) were positive (Table A11). Fifty-one percent (25/49) of cases which reported extra pulmonary disease only were culture confirmed. 5.2 Other mycobacterium species 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. More detailed analysis of all M.bovis cases reported between 2001 and 2010 in Wales can be found on Public Health Wales website ( Among 89 culture-confirmed cases reported through the Enhanced Tuberculosis Surveillance scheme in 2014, all cases were due to infection by Mycobacterium tuberculosis (Table A12). 5.3 Antimicrobial Resistance Drug susceptibility results for first line drugs isoniazid and rifampicin were reported for 100% (79/79) of culture confirmed tuberculosis cases. As with previous years, surveillance data continues to show that resistance to first line antimicrobials is low, although there was an increase in isoniazid resistance in culture confirmed cases from 9% (8/87) in 2013 to 11% (9/79) in 2014 and also an increase in rifampicin resistance in culture confirmed cases from 2% (2/87) in 2013 to 4% (3/79) in These resistance levels are higher than those reported in England but, since the number of TB cases in Wales is much smaller, these proportions should be interpreted with caution [3]. In 2014, there was a single case 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) [2]. There were a further two cases of multidrug resistant (MDR) TB reported in 2014, TB strains that are resistant to both 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 90.9% (110/121) of cases in this cohort notified in 2013 (Table A13). Seventy-nine percent (96/121) of cases completed treatment within 12 months within this cohort notified in 2013, compared to 73.3% (88/120) in 2012 (Table A13, Figure 8). From 2004 to 2012 the proportion of outcomes not evaluated had largely decreased but it increased again in Version: 1 Page: 15 of 32 Intended Audience: Health

16 Figure 8: TB outcome percentages at 12 months for drug sensitive cases with expected treatment duration <12 months 1, Wales, % 3.3% 5.0% 2.5% 0.8% 9.1% 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 and those with CNS, spinal, miliary or cryptic disseminated TB. 2 Not evaluated includes missing, unknown and transferred out. The proportion of cases who completed treatment within 12 months varied with age in 2013 (Table A14). Treatment completion was highest in 0-4 year olds (100%, 2/2) and lowest in those aged 65 years and older (66.7%, 10/15) and those aged 5-14 years (66.7%, 2/3). The proportion of cases that completed treatment was similar in males (80%, 59/74) and females (79%, 37/47, 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 (84.8%, 39/46) compared to those with pulmonary disease only (76.2%, 48/63, Table A16). In those with a known site of disease, completion was highest in those with lymph node TB (intra-thoracic lymph node 100.0%, 5/5 and extra-thoracic lymph node 95.7% 22/23). In 2013, treatment completion at 12 months varied by Health Board ranging from 55.0% (Abertawe Bro Morgannwg UHB) to 92.0% (Betsi Cadwaladr UHB) (Table A17). Table 2. Treatment completion at 12 months for drug sensitive TB cases with expected treatment duration <12 months by Health Board, Wales, 2013 Abertawe Bro Morgannwg UHB 55.0% Aneurin Bevan UHB 78.9% Betsi Cadwaladr UHB 92.0% Cardiff and Vale UHB 91.7% Cwm Taf UHB 62.5% Hywel Dda UHB 70.0% Powys THB % 1 Interpret with caution as number of cases in Powys is small Version: 1 Page: 16 of 32 Intended Audience: Health

17 TB outcomes at last reported outcome Information on the outcome of treatment based on the last reported outcome was reported for 91% (126/139) of cases in this cohort notified in 2013 (Table A18). The proportion of cases in this cohort notified in 2013 who completed treatment was 77.7% (108/139) (Table A18, Figure 9). Figure 9: Last recorded TB outcome percentages for the entire drug sensitive cohort 1, Wales % 5.0% 5.8% 0.7% 1.4% 9.4% 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 2013, treatment completion in the entire drug sensitive cohort varied by Health Board from 50.0% (Abertawe Bro Morgannwg UHB) to 92.5% (Cardiff and Vale UHB) (Table A19). Table 3. Treatment completion at last reported outcome for drug sensitive TB cases by Health Board, Wales, 2013 Abertawe Bro Morgannwg UHB 50.0% Aneurin Bevan UHB 83.3% Betsi Cadwaladr UHB 86.7% Cardiff and Vale UHB 92.5% Cwm Taf UHB 55.6% Hywel Dda UHB 63.6% Powys THB % 1 Interpret with caution as number of cases in Powys is small Version: 1 Page: 17 of 32 Intended Audience: Health

18 Deaths at last reported outcome In 2013, the proportion of cases who were reported to have died at the last reported outcome among all drug sensitive TB cases was 5.0% (7/139), less than half the proportion reported in 2012 (Table A20). Of the 7 deaths in 2013, tuberculosis caused or contributed to death in 14.3% (1), was incidental in 14.3% (1) and the relationship between tuberculosis and death was unknown for the remaining 71.4% (5). Among those reported to have died, 42.9% (3/7) were diagnosed post-mortem. Wales had the second lowest proportion of deaths in drug sensitive cases notified in 2013 (5%) compared to other countries in the UK (Scotland: 8.3%, Northern Ireland: 6.8%, and England: 4.6%) [1]. Loss to follow up at last reported outcome In 2013, 5.8% (8/139) of all drug sensitive TB cases were lost to follow up at the last reported outcome (Table A18). Of the six cases where reason for loss to follow up was recorded, all of the cases had left the UK. Version: 1 Page: 18 of 32 Intended Audience: Health

19 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. 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 [4]. Data presented in this report are correct as at March 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 is extracted for the report. References [1] Reports of cases of tuberculosis to enhanced tuberculosis surveillance systems: United Kingdom, 2000 to Public Health England [2] European Centre for Disease Control and Prevention (ECDC), Progress towards TB elimination, ds_tb_elimination.pdf [3] Public Health England. (2015) Tuberculosis in England: 2015 report version 1.1. Public Health England: London /TB_Annual_Report_v2.6_ pdf [4] Definitions and reporting framework for tuberculosis 2013 revision. WHO Version: 1 Page: 19 of 32 Intended Audience: Health

20 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 (2010 to 2014) Version: 1 Page: 20 of 32 Intended Audience: Health

21 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 Rate per 100,000 using ONS Mid-Year population estimates Version: 1 Page: 21 of 32 Intended Audience: Health

22 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 (2010 to 2014) 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: 22 of 32 Intended Audience: Health

23 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 Version: 1 Page: 23 of 32 Intended Audience: Health

24 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 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 A9. Number and Percentage of Cases in Wales with a History of BCG Vaccination by Age Group, 2014 Age Group Vaccinated Known Status Vaccinated % Known Status % Total Version: 1 Page: 24 of 32 Intended Audience: Health

25 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 Table A11. 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 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 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: 26 of 32 Intended Audience: Health

27 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: 27 of 32 Intended Audience: Health

28 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 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 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: 29 of 32 Intended Audience: Health

30 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: 30 of 32 Intended Audience: Health

31 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: 31 of 32 Intended Audience: Health

32 Table A20. 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