Tuberculosis in Wales Annual Report 2016

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

Acknowledgements Public Health Wales Communicable Disease Surveillance Centre would like to thank the microbiologists, clinicians, respiratory nurses and Health Protection Teams for their contributions to the running of the Enhanced Tuberculosis Surveillance Scheme in Wales. Public Health Wales greatly appreciates the support received from Public Health England in conducting tuberculosis surveillance and for coordinating the Enhanced Tuberculosis Surveillance scheme in England, Wales and Northern Ireland. Background The Enhanced Tuberculosis Surveillance Scheme commenced on the 1 st January 1999 with the aim of providing detailed and comparable information on the epidemiology of tuberculosis. The scheme is coordinated in England, Wales and Northern Ireland by Public Health England. In Wales, the scheme is administered by Public Health Wales in collaboration with Local Health Boards. This report summarises the latest annual trends in the epidemiology of tuberculosis in Wales, using data reported through the Enhanced Tuberculosis Surveillance Scheme. Wales data for the last ten years are summarised in a series of tables and graphs by demographic, geographical, clinical and microbiological characteristics. Suggested Citation: Tuberculosis in Wales Annual Report, October 2016. Public Health Wales Communicable Disease Surveillance Centre. Note: The data used in this report were derived from the Enhanced Tuberculosis Surveillance scheme. Figures for recent years should be considered provisional. Version: 1 Page: 2 of 33 Intended Audience: Health

Key Points The rate of tuberculosis in Wales has continued to decline steadily since 2009. In 2015, 116 cases of tuberculosis were reported in Wales (3.7 per 100,000 population), stable compared to last year. Notification rates vary geographically, with Newport and Cardiff having the highest rates. The notification rate was highest in those aged 35-44 years (6.7 per 100,000 population). Between 2014 and 2015 the notification rate remained stable in most age groups apart from those aged 15-24 years where the rate decreased by 1.7 per 100,000 population, and those aged 35-44 years where the rate increased by 1.7 per 100,000 population. Of the 116 cases reported in 2015, 54% were male and 46% female (rates of 4.1 and 3.4 per 100,000, respectively). In 2015, 46% of tuberculosis cases were reported in the White ethnic group, 52% were in the non-white population and 3% were of an unknown ethnic group. Forty-six percent of tuberculosis cases reported in Wales were born in the UK, 53% of cases were born abroad and 2% of cases had unknown place of birth. Completeness of recording of social risk factors varied from 88% to 96% in 2015. Of those reported, 7% of cases reported a history of, or current drug abuse; 5% reported a history of, or current alcohol misuse or abuse; 4% reported they had been, or are currently, homeless; and 5% reported they had been, or are currently, in prison. The rate of tuberculosis in those who reside in the most deprived areas of Wales was 6.7 (95% CI 4.8 9.1) per 100,000 population compared to 1.6 (95% CI 0.8 2.4) per 100,000 population in the least deprived areas. Over half of the cases in 2015 (56%, 65/116) had pulmonary tuberculosis (with or without extra-pulmonary disease); of these, 12 (18%) also had extra pulmonary disease. In 2015 there was one case of MDR-TB reported in culture confirmed tuberculosis in Wales. There was a decrease in both isoniazid and rifampicin resistance in culture confirmed cases of tuberculosis in 2015 compared to 2014, from 12% to 8% and 4% to 1% respectively. Version: 1 Page: 3 of 33 Intended Audience: Health

Outcome data are available for cases newly diagnosed in 2014. The proportion of drug sensitive cases with expected treatment duration of less than 12 months who had completed treatment by 12 months increased in 2014 to 84%, compared to 83% in 2013. Treatment completion was lowest in those aged 65 years and older (57%, 8/14). Treatment completion was over 80% in all other age groups. The proportion of deaths in drug sensitive cases has increased from 5% (7/139) in 2013 to 10% (11/111) in 2014, a similar proportion to 2012. Version: 1 Page: 4 of 33 Intended Audience: Health

Contents 1. Geographical Distribution................................ 6 2. Demographic Characteristics............................ 9 3. Social Determinants................................... 12 4. Deprivation............................................13 5. Clinical Characteristics................................. 14 6. Bacteriology, Speciation and Drug Susceptibility........... 15 7. Tuberculosis case outcomes............................ 16 8. Conclusions.......................................... 19 Notes on methods........................................ 20 References.............................................. 20 Appendix............................................... 21 Version: 1 Page: 5 of 33 Intended Audience: Health

1. Geographical Distribution TB Rates in Wales and the UK In Wales, 116 cases of tuberculosis were reported in 2015 to the Enhanced Tuberculosis Surveillance (ETS) scheme, equivalent to a rate of 3.7 per 100,000 population (95% confidence interval (CI) 3.1-4.5 per 100,000 population). There has been a sustained downward trend in TB since 2009, the 2015 rate remained stable compared to 2014 (Figure 1.1). Public Health England [1], reports the UK rate of tuberculosis as 9.6 (95% CI 9.3 9.8) per 100,000 population in 2015. England continues to have the highest rate of tuberculosis in the UK, with a rate of 10.5 (95% CI 10.2 10.8) per 100,000 population, followed by Scotland (5.7 (95% CI 5.1-6.4) per 100,000 population), Wales (3.7 per 100,000 population), and Northern Ireland (3.2 (95% CI 2.5-4.2) per 100,000 population). Between 2014 and 2015, the rate of tuberculosis per 100,000 population decreased in England, Northern Ireland and Scotland and remained the same in Wales. Area of Residence In 2015, the highest tuberculosis rate was observed in Cardiff and Vale University Health Board (5.8 per 100,000 population) and the lowest rate was in Cwm Taf University Health Board (1.3 per 100,000 population). Between 2014 and 2015, the rate of tuberculosis increased in Betsi Cadwaladr University (3.5 per 100,000 population compared to 2.0 per 100,000 population) and Powys Teaching Health Boards (5.3 per 100,000 population compared to 1.5 per 100,000 population), remained stable in Cardiff and Vale, Abertawe Bro Morgannwg and Hywel Dda University Health Boards and decreased in Aneurin Bevan (3.8 per 100,000 population compared to 5.3 per 100,000 population) and Cwm Taf University (1.3 per 100,000 population compared to 2.7 per 100,000 population) Health Boards (Table A1). Between 2014 and 2015 the rate of tuberculosis increased in seven of the 22 Local Authorities in Wales, remained stable in nine and decreased in six (Table A1). The rate of tuberculosis ranged from 0 per 100,000 in Monmouthshire and Blaenau Gwent to 12.2 per 100,000 population in Newport (Figure 1.3a). Figure 1.3b shows the five year average rate of tuberculosis per 100,000 population by Local Authority for the period 2011 to 2015. Tuberculosis rates continue to be highest in Cardiff and Newport. By comparing 2015 with the average in the five years 2011 to 2015, the rate in 2015 was higher in five Local Authorities, remained stable in seven Local Authorities and was lower in nine Local Authorities (Figure 1.3). Version: 1 Page: 6 of 33 Intended Audience: Health

Figure 1.1 Number of Cases and Rate of TB per 100,000 population in Wales, 2006-2015 6.8 7 6.1 183 204 5.6 169 213 5 152 4.3 4.4 131 136 4.6 142 3.7 3.7 114 116 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Number of cases Rate per 100 000 Figure 1.2 Rate of TB per 100,000 population in the UK, 2015 England Scotland Wales Northern Ireland 95% CI 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 Rate per 100,000 Version: 1 Page: 7 of 33 Intended Audience: Health

Figure 1.3 Rate of TB by Local Authority a. 2015 b. 2011-2015 Crown Copyright and database right 2014. Ordnance Survey 100044810 Version: 1 Page: 8 of 33 Intended Audience: Health

2. Demographic Characteristics Age and Sex In 2015, just over half of newly diagnosed tuberculosis cases were male (54%, 63/116), a rate of 4.1 (95% CI 3.2-5.3) per 100,000 male population, with a lower rate of 3.4 (95% CI 2.5-4.4) per 100,000 females (Table A2). The highest incidence was seen in people aged 35-44 (6.7 per 100,000; 21% of cases). The median age at diagnosis remained stable between 2014 and 2015 at 43 years of age. During 2015 there was only one reported case of tuberculosis in a child aged under 15 years, the same as in 2014 (Table A3). Changes in the rate of tuberculosis amongst different age groups from 2006-2015 are presented in Figure 2.1. Ethnicity Information on ethnic group was known for 97.4% (113/116) of cases notified in 2015. The largest proportions of cases were from White (45.7%, 53/116) and Pakistani (16.4%, 19/116) ethnic groups. The five year (2011 to 2015) average annual rate was highest in the Black-African ethnic group; 134.6 per 100,000 population (95% CI 76.9-218.6) and lowest in the White ethnic group, a rate of 1.7 per 100,000 population (95% CI 1.3-2.3) (Figure 2.2, Table A4). Using 2011 census population estimates, since 2006 the rate of TB has decreased or remained stable in all ethnic groups. The rate of TB has decreased by 54% in the Black African ethnic group (201.9 per 100,000 population in 2006 compared to 92.5 per 100,000 population in 2015), 35% in the Indian ethnic group (115.9 per 100,000 population in 2006 compared to 75.3 per 100,000 population in 2015) ethnic group, 35% in the White ethnic group (2.8 per 100,000 population in 2006 compared to 1.8 per 100,000 population in 2015) and 5% in the Pakistani ethnic group (163.5 per 100,000 population in 2006 compared to 155.4 per 100,000 population in 2015). Annual TB rates by ethnicity should be interpreted with caution as reliable annual denominator data are not available by ethnicity. Place of Birth Information on place of birth was known for 98.3% (114/116) of tuberculosis cases notified in Wales in 2015. Fifty-three percent of cases (61/116) were known to have been born outside of the UK whilst 45.7% of cases (53/1165) were known to have been born in the UK (Figure 2.3, Table A5). As in previous years, in 2015 the majority of cases known to be born outside the UK originated from South Asia (55.7%, 34/61) and Sub-Saharan Africa (16.4%, 10/61) (Table A6). Information on region of birth was known for all cases born outside of the UK. Version: 1 Page: 9 of 33 Intended Audience: Health

Rate per 100,000 population Public Health Wales Tuberculosis in Wales Annual Report 2016: Time between Entry into the UK and Diagnosis The time between entry to the UK and tuberculosis diagnosis was known for 75.4% (46/61) of non-uk born cases diagnosed in 2015 (Table A7). Where time since entry was known, the highest proportion of cases were diagnosed over ten years since UK entry (41.3%, 19/46) followed by less than two years since UK entry (23.9%, 11/46). Figure 2.1 Rate of TB per 100,000 population by Age Group and Year in Wales, 2006-2015 16 14 12 10 8 6 4 2 0-4 5-14 15-24 25-34 35-44 45-54 55-64 65+ 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Figure 2.2 Average Annual Number of TB Cases and Rate per 100,000 population in Wales by Ethnic Group, 2011-2015 134.6 122.9 117.8 51 31.0 35.6 19.1 19.3 1.7 0.0 16 1 21 14 4 3 12 Average Number of Cases Rate Version: 1 Page: 10 of 33 Intended Audience: Health

Number of TB cases Public Health Wales Tuberculosis in Wales Annual Report 2016: Figure 2.3 Number of non-uk born TB Cases in Wales, 2006-2015 1 250 Number of non-uk born TB cases Total number of TB cases 200 150 100 50 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 1 During 2006-2015 between 3-8% of cases were reported with an unknown origin for place of birth. Version: 1 Page: 11 of 33 Intended Audience: Health

3. Social Determinants The collection of information on social risk factors for tuberculosis was introduced to the Enhanced Tuberculosis Surveillance Scheme in 2009. In 2015, information on social risk factors was documented for between 91.4% and 95.7% of cases in Wales, depending on the risk factor investigated (Table 3.1). The completeness of recording social risk factors increased between 2014 and 2015 for all risk factors. The proportion of cases for which at least one social risk factor was recorded decreased between 2014 and 2015 from 17.2% to 11.8%. In 2015, 11.8% of cases reported at least one social risk factor. Seven percent of cases reported a history of, or current, drug use; 5.4% reported a history of, or current, alcohol misuse; 3.7% reported a history of, or current, homelessness; and 4.7% reported a history of, or current, imprisonment (Figure 3.1). Figure 3.1 History of or current social risk factors among TB patients in Wales, 2009-2015 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Drug use Alcohol misuse Homelessness Imprisonment Any risk factor 2009 2010 2011 2012 2013 2014 2015 Table 3.1 Completeness of social risk factors among TB patients in Wales, 2009-2015 2009 2010 2011 2012 2013 2014 2015 Drug use 77.0% 72.4% 86.3% 83.1% 84.5% 85.1% 92.2% Alcohol misuse 74.2% 79.6% 91.6% 90.4% 92.3% 87.7% 95.7% Homelessness 79.3% 82.9% 90.1% 89.7% 93.7% 90.4% 92.2% Imprisonment 62.9% 70.4% 85.5% 80.1% 85.9% 77.2% 91.4% Any risk factor 62.4% 69.7% 80.2% 73.5% 79.6% 76.3% 87.9% Version: 1 Page: 12 of 33 Intended Audience: Health

Rate per 100,000 population Public Health Wales Tuberculosis in Wales Annual Report 2016: 4. Deprivation The Welsh Index of Multiple Deprivation (WIMD) developed for Welsh Government assigns an estimated rank of deprivation to each Lower Super Output Area (LSOA) [2]. Cases have been assigned to LSOA using postcode of residence as reported on ETS, postcode was available for all cases in 2015. There were 40 cases that reported living in LSOAs comprising the most deprived fifth of Wales, 27 in the second most deprived fifth, 20 in the middle fifth, 19 in the forth fifth and 10 in the least deprived fifth. The highest rate of tuberculosis was in the most deprived quintile at 6.7 (95% CI 4.8 9.1) per 100,000 population compared to 1.6 (95% CI 0.8 2.4) per 100,000 population in the least deprived quintile (Figure 4.1). Figure 4.1 Rate of TB in Wales per 100,000 population by deprivation quintile, 2015 10 9 8 7 6 5 4 3 2 1 0 95% CI Most deprived Quintile 2 Quintile 3 Quintile 4 Least deprived Version: 1 Page: 13 of 33 Intended Audience: Health

5. Clinical Characteristics Site of Disease Information on site of disease was known for 98.3% (114/116) of cases notified in 2015. Over half of tuberculosis cases with a known site of disease had pulmonary disease (with or without extra-pulmonary disease) (56.1%, 65/114). Eighteen percent (12/65) of pulmonary cases were reported to also have extra pulmonary disease in at least one additional site. Many cases reported disease at multiple sites. For those where site of disease was known, the extra thoracic lymph nodes were the most common extra-pulmonary site of infection (19.3%, 22/114) (Table A8). Planned Course of Treatment In 2015, planned course of treatment was known for 95.7% (111/116) of cases. Of these 111 cases, 91.9% (102) were assigned to a standard six month course of treatment. It was known whether a patient was assigned to directly observed therapy (DOT) treatment in 94.0% of cases (109/116). Sixteen percent of these cases (17/109) were assigned DOT treatment. In 2015, 66.7% (8/12) of cases reporting at least one social risk factor were known to be assigned DOT. Vaccination Status The collection of data on Bacillus Calmette-Guérin (BCG) vaccination was introduced to the Enhanced Tuberculosis Surveillance Scheme in 2009. In 2015, BCG vaccination status was known for 58.6% (68/116) of tuberculosis cases, slightly higher completeness compared to 2014 (50.0%, 57/114). Of the 68 cases with known BCG vaccination status, 76.5% (52) were vaccinated, stable compared to 2014 (77.2%, 44/57). Coverage was highest in those aged 45-54 and 55-64, being 90.0% (9/10) in both age groups, and lowest in those aged 5-24 where coverage was 50.0% (5/10) (Table A9). Previous Diagnosis Information on previous tuberculosis diagnosis was known for 96.6% (112/116) of cases, of which two had a previous diagnosis of tuberculosis (Table A10). Version: 1 Page: 14 of 33 Intended Audience: Health

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

Table 6.1: Number and proportion of TB cases with first line drug resistance 1, Wales, 2006-2015 Any resistance to Isoniazid Rifampicin Ethambutol Pyrazinamide Year resistant resistant 2 one or more first resistant resistant line drug 1 Includes culture confirmed cases with drug susceptibility results for at least isoniazid and rifampicin 2 Excludes M. bovis cases n % n % n % n % n % 2006 6 4.7 1 0.8 0 0.0 0 0.0 6 4.7 2007 13 10.2 4 3.1 2 1.6 3 2.4 15 11.7 2008 5 4.9 3 2.9 2 2.0 0 0.0 6 5.9 2009 7 5.9 1 0.8 0 0.0 2 1.7 9 7.6 2010 6 5.6 0 0.0 1 0.9 2 1.9 8 7.5 2011 2 2.1 2 2.1 1 1.1 0 0.0 4 4.3 2012 10 9.5 1 1.0 1 1.0 0 0.0 10 9.5 2012 8 9.2 2 2.3 0 0.0 1 1.1 8 9.2 2014 10 12.3 3 3.7 1 1.2 0 0.0 10 12.3 2015 6 7.5 1 1.3 1 1.3 2 2.6 7 8.8 7. Tuberculosis case outcomes Drug sensitive cohort, 2005 2014 In accordance with the revised World Health Organization (WHO) TB outcome definitions, the drug sensitive cohort is defined as all TB cases excluding those with rifampicin resistant TB or MDR-TB (initial or amplified), or non-culture confirmed cases treated as MDR-TB [3]. In this report, treatment outcomes at 12 months for drug sensitive TB cases are reported for cases with an expected duration of treatment less than 12 months. This group excludes cases with central nervous system (CNS) disease who have an expected treatment duration of 12 months. Cases with spinal, cryptic disseminated or miliary disease are also excluded from this group, as CNS involvement cannot be reliably ruled out for the purposes of reporting. TB outcomes, loss to follow up and deaths in the entire drug sensitive cohort (including cases with CNS, spinal, cryptic disseminated or miliary TB disease) are presented by last recorded outcome. TB outcomes reported using these new cohort definitions will not be directly comparable with outcome data presented in previous reports. Treatment outcomes for all cases notified from 2005-2014 have been calculated using these new definitions, so that trends can be monitored. TB outcomes at 12 months for drug sensitive cohort with expected duration of treatment less than 12 months Information on the outcome of treatment, 12 months after treatment commenced, was reported for 98.9% (91/92) of cases in this cohort notified in 2014 (Table A13). Version: 1 Page: 16 of 33 Intended Audience: Health

Eighty-four percent (77/92) of cases completed treatment within 12 months within this cohort notified in 2014, compared to 82.6% (100/121) in 2013 (Table A13, Figure 7.1). The proportion of cases who completed treatment within 12 months varied with age (Table A14). Treatment completion was highest in 55-64 year olds (90.9%, 10/11) and 25-34 year olds (90.0%, 18/20), and lowest in those aged 65 years and older (57.1%, 8/14). The proportion of cases that completed treatment was higher in females (93.9%, 31/33) compared to males (78.0%, 46/59, Table A15). The proportion of cases with a known site of disease and who completed treatment within 12 months was higher in those with extra-pulmonary disease only (94.4%, 34/36) compared to those with pulmonary disease only (79.5%, 35/44, Table A16). In 2014, treatment completion at 12 months varied by Health Board ranging from 64.3% (Hywel Dda UHB) to 100.0% (Cwm Taf UHB and Powys THB) (Table A17). TB outcomes at last reported outcome Information on the outcome of treatment based on the last reported outcome was reported for 99.1% (110/111) of cases in this cohort notified in 2014 (Table A18). The proportion of cases in this cohort notified in 2014 who completed treatment was 82.0% (91/111) (Table A18, Figure 7.1). In 2014, treatment completion in the entire drug sensitive cohort varied by Health Board from 70.6% (Hywel Dda UHB) to 100.0% (Powys THB) (Table A19). Deaths at last reported outcome In 2014, the proportion of cases who were reported to have died at the last reported outcome among all drug sensitive TB cases was 9.9% (11/111), an increase from the proportion of deaths in cases reported in 2013 (5.0%, 7/139) (Table A20). Of the 11 deaths in 2014, tuberculosis caused or contributed to death in 27.3% (3), was incidental in 18.2% (2) and the relationship between tuberculosis and death was unknown for the remaining 54.4% (6). Among those reported to have died, 18.2% (2/11) were diagnosed post-mortem. For cases where TB caused or contributed to death, or the relationship between TB and death was unknown, 55.6% (5/9) were aged over 65 years and 44.4% (4/9) were aged 65 years or under. Wales had the highest proportion of deaths in drug sensitive cases notified in 2014 (9.9%) compared to other countries in the UK (Scotland: 5.9%, England: 5.5% and Northern Ireland: 5.3%) [1]. Loss to follow up at last reported outcome In 2014, 2.7% (3/111) of all drug sensitive TB cases were lost to follow up at the last reported outcome (Table A18). For all three cases the reason for loss to follow up was leaving the UK. Version: 1 Page: 17 of 33 Intended Audience: Health

Figure 7.1: TB outcome percentages at 12 months for drug sensitive cases with expected treatment duration <12 months 1, Wales, 2014 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 77 Completed Died Lost to follow up 8 3 3 0 1 Still on treatment Stopped Not evaluated 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB cases and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB. 2 Not evaluated includes missing, unknown and transferred out. Figure 7.2: Last recorded TB outcome percentages for the entire drug sensitive cohort 1, Wales 2014 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 91 11 Completed Died Lost to follow up 3 5 Still on treatment 0 1 Stopped Not evaluated 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB cases and MDR-TB treated cases. 2 Not evaluated includes missing, unknown and transferred out Version: 1 Page: 18 of 33 Intended Audience: Health

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

Notes on Methods All analysis was conducted using Stata 14.0. Rates were calculated using mid-year population estimates for Wales obtained from the Office of National Statistics (ONS). Rates for ethnic groups were calculated using ONS 2011 population estimates for ethnic groups resident in Wales. The 2014 Welsh Index of Multiple Deprivation (WIMD) was used to assign cases to deprivation fifth using postcode of residence and Lower Super Output Area (LSOA). Rates by deprivation fifth were calculated using ONS 2014 population estimates for LSOAs. Deprivation scores from the 2014 index are not comparable to previous indices. The WIMD is an ecological measure and not all deprived people live in deprived areas and not all people in deprived areas are deprived. This report only includes tuberculosis cases which have been notified to ETS. All Local Health Board and Local Authority figures are based on the area of residence of tuberculosis cases. Miliary tuberculosis is classified as pulmonary tuberculosis in accordance with the WHO s recommendation and international reporting definitions [5]. Data presented in this report are correct as at April 2016. As treatment outcomes are reported at 12 months, treatment outcomes are only available to be reported on for cases notified in the previous year, at the time data are extracted for the report. References [1] Reports of cases of tuberculosis to enhanced tuberculosis surveillance systems: United Kingdom, 2000 to 2015. Public Health England 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/555298/t B_Official_Statistics_2016_GTW2309.pdf [2] Welsh Index of Multiple Deprivation (WIMD). Welsh Government 2015. http://gov.wales/statistics-and-research/welsh-index-multiple-deprivation/?lang=en [3] European Centre for Disease Control and Prevention (ECDC), Progress towards TB elimination, 2010. http://ecdc.europa.eu/en/publications/publications/101111_spr_progressing_towards_ TB_elimination.pdf [4] Public Health England. (2016) Tuberculosis in England: 2016. Public Health England, London. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/555343/t B_Annual_Report_2016_GTW2309.pdf [5] Definitions and reporting framework for tuberculosis 2013 revision. WHO 2013. http://apps.who.int/iris/bitstream/10665/79199/1/9789241505345_eng.pdf [6] Royal College of Nursing, 2012. Tuberculosis case management and cohort review, guidance for health professionals. https://www2.rcn.org.uk/ data/assets/pdf_file/0010/439129/004204.pdf Version: 1 Page: 20 of 33 Intended Audience: Health

Appendix Table A1. Number of Cases and Rate 1 of Tuberculosis in Wales by LHB and LA, 2006-2015 HB and LA 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 5 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 28 5.6 41 8.1 33 6.5 36 7.0 23 4.5 19 3.7 17 3.3 23 4.4 14 2.7 15 2.9 18 3.4 Bridgend 8 6.0 11 8.1 8 5.8 3 2.2 3 2.2 5 3.6 1 0.7 3 2.1 0 0.0 5 3.5 3 2.0 Neath Port Talbot 10 7.2 6 4.3 2 1.4 7 5.0 5 3.6 5 3.6 4 2.9 9 6.4 2 1.4 4 2.8 5 3.4 Swansea 10 4.3 24 10.3 23 9.8 26 11.0 15 6.3 9 3.8 12 5.0 11 4.6 12 5.0 6 2.5 10 4.2 Aneurin Bevan University 24 4.3 32 5.6 20 3.5 37 6.5 24 4.2 24 4.2 25 4.3 25 4.3 31 5.3 22 3.8 25 4.4 Blaenau Gwent 2 2.9 3 4.3 0 0.0 3 4.3 4 5.7 1 1.4 1 1.4 2 2.9 2 2.9 0 0.0 1 1.7 Caerphilly 2 1.2 4 2.3 4 2.3 2 1.1 3 1.7 5 2.8 5 2.8 4 2.2 2 1.1 3 1.7 4 2.1 Monmouthshire 4 4.5 5 5.6 3 3.3 0 0.0 2 2.2 5 5.5 3 3.3 3 3.3 2 2.2 0 0.0 3 2.8 Newport 15 10.7 18 12.7 13 9.1 28 19.5 15 10.4 12 8.2 15 10.3 15 10.2 24 16.3 18 12.2 17 11.5 Torfaen 1 1.1 2 2.2 0 0.0 4 4.4 0 0.0 1 1.1 1 1.1 1 1.1 1 1.1 1 1.1 1 1.1 Betsi Cadwaladr University 49 7.2 35 5.2 28 4.1 36 5.3 28 4.1 19 2.8 19 2.8 30 4.3 14 2.0 24 3.5 21 3.1 Anglesey 13 18.7 0 0.0 4 5.7 7 10.0 4 5.7 0 0.0 2 2.9 6 8.6 3 4.3 5 7.1 3 4.6 Conwy 4 3.5 7 6.2 7 6.1 6 5.2 5 4.4 2 1.7 0 0.0 4 3.5 4 3.4 3 2.6 3 2.2 Denbighshire 5 5.3 3 3.2 4 4.2 2 2.1 2 2.1 3 3.2 3 3.2 4 4.2 1 1.1 6 6.3 3 3.6 Flintshire 4 2.7 3 2.0 5 3.3 6 3.9 2 1.3 5 3.3 3 2.0 4 2.6 1 0.7 4 2.6 3 2.2 Gwynedd 10 8.4 13 10.9 2 1.7 7 5.8 10 8.3 4 3.3 7 5.7 6 4.9 3 2.5 4 3.3 5 3.9 Wrexham 13 10.0 9 6.9 6 4.5 8 6.0 5 3.7 5 3.7 4 2.9 6 4.4 2 1.5 2 1.5 4 2.8 Cardiff and Vale University 49 11.0 70 15.5 54 11.8 65 14.0 45 9.6 43 9.1 36 7.6 40 8.4 28 5.8 28 5.8 35 7.3 Cardiff 42 13.0 57 17.4 49 14.7 59 17.5 41 12.0 35 10.1 32 9.2 38 10.8 27 7.6 27 7.6 32 9.0 Vale of Glamorgan 7 5.7 13 10.4 5 4.0 6 4.8 4 3.2 8 6.3 4 3.2 2 1.6 1 0.8 1 0.8 3 2.5 Cwm Taf University 9 3.1 13 4.5 23 7.9 22 7.5 16 5.5 6 2.0 16 5.4 10 3.4 8 2.7 4 1.3 9 3.0 Merthyr Tydfil 0 0.0 2 3.5 2 3.5 3 5.2 3 5.1 2 3.4 4 6.8 3 5.1 1 1.7 1 1.7 2 3.7 Rhondda Cynon Taff 9 3.8 11 4.7 21 8.9 19 8.1 13 5.5 4 1.7 12 5.1 7 3.0 7 3.0 3 1.3 7 2.8 Hywel Dda University 19 5.1 11 2.9 7 1.8 8 2.1 12 3.2 19 5.0 20 5.2 11 2.9 17 4.4 16 4.2 17 4.3 Carmarthenshire 9 5.0 9 5.0 0 0.0 5 2.7 9 4.9 9 4.9 7 3.8 7 3.8 10 5.4 7 3.8 8 4.3 Ceredigion 3 4.0 1 1.3 1 1.3 1 1.3 1 1.3 5 6.6 2 2.6 1 1.3 1 1.3 1 1.3 2 2.6 Pembrokeshire 7 5.9 1 0.8 6 5.0 2 1.6 2 1.6 5 4.1 11 8.9 3 2.4 6 4.9 8 6.5 7 5.4 Powys Teaching 5 3.8 2 1.5 4 3.0 9 6.8 4 3.0 1 0.8 3 2.3 3 2.3 2 1.5 7 5.3 3 2.4 Powys 5 3.8 2 1.5 4 3.0 9 6.8 4 3.0 1 0.8 3 2.3 3 2.3 2 1.5 7 5.3 3 2.4 Not known 0 0 0 0 0 0 0 0 0 0 0 Total 183 6.1 204 6.8 169 5.6 213 7.0 152 5.0 131 4.3 136 4.4 142 4.6 114 3.7 116 3.7 135 4.4 1 Rate per 100,000 using ONS Mid-Year population estimates 2 Average number of cases and rate calculated using the last 5 years data (2011 to 2015) Version: 1 Page: 21 of 33 Intended Audience: Health

Table A2. Number of Cases and Rate 1 of Tuberculosis in Wales by Sex, 2006-2015 Sex 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Male 111 7.6 114 7.8 94 6.4 122 8.2 92 6.2 71 4.7 91 6.0 90 5.9 73 4.8 63 4.1 Female 72 4.7 90 5.9 71 4.6 86 5.5 58 3.7 57 3.7 45 2.9 52 3.3 41 2.6 53 3.4 Unknown 0 0 4 5 2 3 0 0 0 0 Total 183 204 169 213 152 131 136 142 114 116 1 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, 2006-2015 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Age Group Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 0-4 5 3.1 11 6.7 8 4.7 11 6.4 2 1.1 2 1.1 0 0.0 2 1.1 1 0.6 0 0.0 5-14 4 1.1 3 0.8 9 2.6 3 0.9 4 1.2 6 1.8 3 0.9 3 0.9 0 0.0 1 0.3 15-24 21 5.3 25 6.2 17 4.2 29 7.1 17 4.2 21 5.1 14 3.4 26 6.3 18 4.4 11 2.7 25-34 43 12.5 53 15.4 32 9.2 44 12.5 32 9.0 29 8.0 40 11.0 37 10.0 23 6.1 24 6.4 35-44 35 8.2 36 8.4 29 6.9 33 8.0 25 6.2 27 6.9 17 4.5 16 4.3 18 4.9 24 6.7 45-54 21 5.4 28 7.1 18 4.5 32 7.8 19 4.6 11 2.6 24 5.6 19 4.4 19 4.4 17 3.9 55-64 20 5.2 9 2.3 18 4.6 17 4.3 18 4.6 9 2.3 9 2.3 20 5.3 14 3.7 17 4.4 65+ 34 6.5 39 7.4 38 7.1 44 8.0 35 6.3 26 4.6 29 4.9 19 3.2 21 3.4 22 3.5 Total 183 204 169 213 152 131 136 142 114 116 1 Rate per 100,000 using ONS Mid-Year population estimates Version: 1 Page: 22 of 33 Intended Audience: Health

Table A4. Number and Percentage of Tuberculosis Cases in Wales by Ethnic Group, 2006-2015 Ethnic Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 5 year Average 2 cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Cases Rate White 81 44.3 87 42.6 80 47.3 97 45.5 66 43.4 40 30.5 58 42.6 62 43.7 42 36.8 53 45.7 51 1.7 Black-Caribbean 1 0.5 0 0.0 1 0.6 0 0.0 1 0.7 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 Black-African 24 13.1 23 11.3 22 13.0 31 14.6 11 7.2 23 17.6 13 9.6 18 12.7 15 13.2 11 9.5 16 134.6 Black-Other 1 0.5 3 1.5 1 0.6 3 1.4 3 2.0 1 0.8 1 0.7 0 0.0 1 0.9 1 0.9 1 31.0 Indian 20 10.9 26 12.7 25 14.8 30 14.1 21 13.8 23 17.6 27 19.9 22 15.5 21 18.4 13 11.2 21 122.9 Pakistani 20 10.9 17 8.3 10 5.9 20 9.4 18 11.8 12 9.2 13 9.6 12 8.5 16 14.0 19 16.4 14 117.8 Bangladeshi 7 3.8 7 3.4 3 1.8 6 2.8 9 5.9 3 2.3 1 0.7 7 4.9 2 1.8 6 5.2 4 35.6 Chinese 2 1.1 5 2.5 6 3.6 6 2.8 3 2.0 3 2.3 1 0.7 4 2.8 3 2.6 2 1.7 3 19.1 Mixed/Other 20 10.9 20 9.8 12 7.1 5 2.3 8 5.3 15 11.5 15 11.0 13 9.2 10 8.8 8 6.9 12 19.3 Unknown 7 3.8 16 7.8 9 5.3 15 7.0 12 7.9 11 8.4 7 5.1 4 2.8 4 3.5 3 2.6 6 Total 183 204 169 213 152 131 136 142 114 116 128 4.2 1 Average number of cases and rates calculated using the last 5 years data (2011 to 2015) 2 Rate per 100,000 using ONS 2011 population estimates by ethnic group Table A5. Number and Percentage of Tuberculosis Cases in Wales by Place of Birth, 2006-2015 Place of Birth 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Born in UK 68 37.2 81 39.7 81 47.9 103 48.4 73 48.0 46 35.1 57 41.9 58 40.8 43 37.7 53 45.7 Born Abroad 90 49.2 97 47.5 75 44.4 89 41.8 68 44.7 80 61.1 74 54.4 82 57.7 65 57.0 61 52.6 Not Known 25 13.7 26 12.7 13 7.7 21 9.9 11 7.2 5 3.8 5 3.7 2 1.4 6 5.3 2 1.7 Total 183 204 169 213 152 131 136 142 114 116 Version: 1 Page: 23 of 33 Intended Audience: Health

Table A6. Number and Percentage of Tuberculosis Cases in Wales by World Region of Birth for Non-UK Born Cases, 2006-2015 Region of Birth 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % North Africa 2 2.2 1 1.0 1 1.3 4 4.5 1 1.5 0 0.0 1 1.4 3 3.7 3 4.6 3 4.9 Sub-Saharan Africa 23 25.6 27 27.8 20 26.7 27 30.3 12 17.6 25 31.3 15 20.3 19 23.2 11 16.9 10 16.4 East Asia 3 3.3 5 5.2 4 5.3 2 2.2 0 0.0 4 5.0 1 1.4 3 3.7 3 4.6 3 4.9 South Asia 38 42.2 36 37.1 32 42.7 42 47.2 35 51.5 37 46.3 40 54.1 41 50.0 36 55.4 34 55.7 South East Asia 4 4.4 13 13.4 9 12.0 3 3.4 8 11.8 8 10.0 7 9.5 8 9.8 3 4.6 3 4.9 Central Europe 3 3.3 2 2.1 0 0.0 0 0.0 2 2.9 1 1.3 1 1.4 3 3.7 0 0.0 4 6.6 East Europe 0 0.0 0 0.0 1 1.3 0 0.0 0 0.0 0 0.0 2 2.7 1 1.2 1 1.5 0 0.0 West Europe 11 12.2 12 12.4 7 9.3 9 10.1 9 13.2 2 2.5 3 4.1 2 2.4 3 4.6 2 3.3 East Mediterranean 4 4.4 1 1.0 1 1.3 2 2.2 0 0.0 2 2.5 2 2.7 1 1.2 2 3.1 2 3.3 North America 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 1.4 0 0.0 1 1.5 0 0.0 South & Central America 1 1.1 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 1.4 1 1.2 1 1.5 0 0.0 Not Known 1 1.1 0 0.0 0 0.0 0 0.0 1 1.5 1 1.3 0 0.0 0 0.0 1 1.5 0 0.0 Total 90 97 75 89 68 80 74 82 65 61 Table A7. Time between UK Entry and Tuberculosis Diagnosis for Non-UK Born Cases, 2006-2015 Time between UK Entry and Diagnosis 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % < 2 years 19 21.1 29 29.9 19 25.3 20 22.5 9 13.2 19 23.8 19 25.7 22 26.8 15 23.1 11 18.0 2-5 years 32 35.6 20 20.6 15 20.0 32 36.0 20 29.4 20 25.0 25 33.8 17 20.7 15 23.1 10 16.4 6-10 years 7 7.8 4 4.1 11 14.7 10 11.2 8 11.8 20 25.0 11 14.9 15 18.3 5 7.7 6 9.8 >10 years 9 10.0 13 13.4 15 20.0 6 6.7 13 19.1 11 13.8 11 14.9 13 15.9 16 24.6 19 31.1 Not Recorded 23 25.6 31 32.0 15 20.0 21 23.6 18 26.5 10 12.5 8 10.8 15 18.3 14 21.5 15 24.6 Total 90 97 75 89 68 80 74 82 65 61 Version: 1 Page: 24 of 33 Intended Audience: Health

Table A8. Number and Percentage of Tuberculosis Cases in Wales by Site of Disease, 2006-2015 2008 2009 2010 2013 2014 2015 Site of Disease 1 2006 2007 2011 2012 Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Pulmonary 2 112 61.2 135 66.2 102 60.4 126 59.2 93 61.2 71 54.2 78 57.4 84 59.2 64 56.1 65 56.0 Extra thoracic lymph nodes 41 22.4 39 19.1 26 15.4 39 18.3 28 18.4 33 25.2 33 24.3 25 17.6 19 16.7 22 19.0 Intra thoracic lymph nodes 9 4.9 21 10.3 16 9.5 11 5.2 9 5.9 1 0.8 5 3.7 6 4.2 8 7.0 10 8.6 Pleural 12 6.6 17 8.3 10 5.9 14 6.6 6 3.9 12 9.2 10 7.4 8 5.6 8 7.0 8 6.9 Gastrointestinal 11 6.0 7 3.4 10 5.9 6 2.8 6 3.9 8 6.1 5 3.7 5 3.5 3 2.6 3 2.6 CNS-meningitis 3 1.6 4 2.0 4 2.4 4 1.9 5 3.3 3 2.3 2 1.5 3 2.1 7 6.1 3 2.6 CNS-other 2 1.1 4 2.0 3 1.8 4 1.9 4 2.6 2 1.5 4 2.9 4 2.8 4 3.5 3 2.6 Bone-Spine 4 2.2 4 2.0 4 2.4 8 3.8 2 1.3 4 3.1 3 2.2 8 5.6 8 7.0 4 3.4 Bone-other 3 1.6 3 1.5 3 1.8 4 1.9 1 0.7 5 3.8 4 2.9 2 1.4 1 0.9 3 2.6 Genitourinary 2 1.1 6 2.9 2 1.2 6 2.8 3 2.0 2 1.5 5 3.7 4 2.8 5 4.4 5 4.3 Laryngeal 1 0.5 1 0.5 1 0.6 0 0.0 2 1.3 1 0.8 0 0.0 1 0.7 0 0.0 2 1.7 Cryptic 1 0.5 0 0.0 1 0.6 1 0.5 0 0.0 2 1.5 1 0.7 1 0.7 3 2.6 3 2.6 Other extra pulmonary 10 5.5 5 2.5 13 7.7 22 10.3 14 9.2 21 16.0 8 5.9 8 5.6 7 6.1 10 8.6 Unknown extra pulmonary 44 24.0 36 17.6 33 19.5 40 18.8 37 24.3 40 30.5 45 33.1 30 21.1 29 25.4 20 17.2 Total cases 183 204 169 213 152 131 136 142 114 116 1 Patients may have disease at more than one site 2 Pulmonary TB includes miliary TB in accordance with the WHO s recommendation and international reporting definitions [5]. Revised trends in site of disease are presented for previous years using the revised WHO definitions. Table A9. Number and Percentage of Cases in Wales with a History of BCG Vaccination by Age Group, 2015 Age Group Vaccinated Known Status Vaccinated % Known Status % 0-4 - - - - 5-14 0 1 0.0 100.0 15-24 5 9 55.6 81.8 25-34 13 17 76.5 70.8 35-44 12 14 85.7 58.3 45-54 9 10 90.0 58.8 55-64 9 10 90.0 58.8 65+ 4 7 57.1 31.8 Total 52 68 76.5 58.6 Version: 1 Page: 25 of 33 Intended Audience: Health

Table A10. Number and Percentage of Tuberculosis Cases in Wales with Previous Tuberculosis Diagnosis, 2006-2015 Previous Diagnosis 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Yes 8 4.4 17 8.3 15 8.9 23 10.8 6 3.9 10 7.6 6 4.4 8 5.6 9 7.9 2 1.7 No 140 76.5 147 72.1 127 75.1 152 71.4 122 80.3 108 82.4 121 89.0 125 88.0 91 79.8 110 94.8 Not Reported 35 19.1 40 19.6 27 16.0 38 17.8 24 15.8 13 9.9 9 6.6 9 6.3 14 12.3 4 3.4 Total 183 204 169 213 152 131 136 142 114 116 Table A11. Number and Percentage of Tuberculosis Cases in Wales with Bacteriological Confirmation, 2006-2015 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Bacteriological Results cases % cases % cases % cases % cases % cases % cases % cases % cases % cases % Culture Confirmed 1 128 69.9 128 62.7 102 60.4 119 55.9 107 70.4 94 71.8 105 77.2 87 61.3 81 71.1 80 69.0 Culture Confirmed Pulmonary Cases 2 89 79.5 93 68.9 73 71.6 80 63.5 72 77.4 56 78.9 63 80.8 62 73.8 55 85.9 59 90.8 Pulmonary Cases with Sputum Smear Taken 2 89 79.5 94 69.6 55 53.9 39 31.0 41 44.1 39 54.9 39 50.0 43 51.2 35 54.7 40 61.5 Positive Sputum Smear Pulmonary Cases 3 45 50.6 42 44.7 27 49.1 19 48.7 23 56.1 29 74.4 32 82.1 36 83.7 20 57.1 26 65.0 1 Denominator for percentage is total number of TB cases 2 Denominator for percentage is total number of pulmonary TB cases 3 Denominator for percentage is number of pulmonary cases with sputum smear taken Version: 1 Page: 26 of 33 Intended Audience: Health

Table A12. Species Identification in Culture Confirmed Tuberculosis Case, Wales, 2006-15 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Species Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % Cases % M. africanum 0 0.0 0 0.0 0 0.0 1 0.8 0 0.0 4 4.3 1 1.0 0 0.0 0 0.0 1 1.3 M. bovis 0 0.0 1 0.8 2 2.0 4 3.4 1 0.9 0 0.0 3 2.9 0 0.0 1 1.2 3 3.8 M. tuberculosis 128 100.0 127 99.2 100 98.0 114 95.8 105 98.1 90 95.7 101 96.2 87 100.0 80 98.8 76 95.0 M. tuberculosis complex 0 0.0 0 0.0 0 0.0 0 0.0 1 0.9 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 Total 128 128 102 119 107 94 105 87 81 80 Table A13. TB outcome at 12 months after treatment start for drug sensitive cases with expected treatment duration <12 months 1, Wales, 2005-2014 Completed Died Lost to follow-up Still on treatment Stopped Not evaluated 2 Total Year n % n % n % n % n % n % n 2005 116 67.4 17 9.9 8 4.7 13 7.6 2 1.2 16 9.3 172 2006 115 66.9 14 8.1 5 2.9 6 3.5 4 2.3 28 16.3 172 2007 113 60.8 13 7.0 11 5.9 21 11.3 3 1.6 25 13.4 186 2008 115 76.2 12 7.9 3 2.0 14 9.3 0 0.0 7 4.6 151 2009 145 75.9 17 8.9 6 3.1 11 5.8 5 2.6 7 3.7 191 2010 107 77.5 17 12.3 5 3.6 7 5.1 1 0.7 1 0.7 138 2011 90 76.3 8 6.8 8 6.8 5 4.2 6 5.1 1 0.8 118 2012 91 75.8 11 9.2 6 5.0 9 7.5 1 0.8 2 1.7 120 2013 100 82.6 4 3.3 6 5.0 3 2.5 2 1.7 6 5.0 121 2014 77 83.7 8 8.7 3 3.3 3 3.3 0 0.0 1 1.1 92 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB 2 Not evaluated includes missing, unknown and transferred out. Version: 1 Page: 27 of 33 Intended Audience: Health

Table A14. Treatment completion at 12 months by age group for drug sensitive cases with expected treatment duration <12 months 1, Wales, 2005-2014 0-4 5-14 15-24 25-34 35-44 45-54 55-64 65+ Year n % n % n % n % n % n % n % n % 2005 2 50.0 4 100.0 12 66.7 28 82.4 23 85.2 14 66.7 7 58.3 26 50.0 2006 4 100.0 2 50.0 15 71.4 33 80.5 19 61.3 14 73.7 14 77.8 14 41.2 2007 6 54.5 0-15 68.2 29 67.4 22 64.7 18 72.0 4 44.4 19 48.7 2008 7 100.0 7 87.5 13 81.3 23 79.3 20 80.0 15 93.8 13 76.5 17 51.5 2009 11 100.0 3 100.0 19 73.1 31 75.6 21 80.8 26 86.7 13 76.5 21 56.8 2010 1 100.0 4 100.0 13 86.7 23 82.1 20 83.3 14 82.4 11 68.8 21 63.6 2011 1 100.0 6 100.0 13 72.2 21 80.8 18 78.3 10 100.0 7 87.5 14 53.8 2012 0-2 100.0 11 84.6 30 83.3 11 68.8 16 84.2 5 62.5 16 61.5 2013 2 100.0 2 66.7 18 90.0 25 83.3 13 86.7 13 76.5 16 84.2 11 73.3 2014 0-0 - 15 93.8 18 90.0 13 86.7 13 81.3 10 90.9 8 57.1 1 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, 2005-2014 Male Female Year n % n % 2005 67 69.8 49 64.5 2006 70 66.7 45 67.2 2007 61 58.1 52 64.2 2008 65 77.4 48 76.2 2009 83 76.1 58 75.3 2010 60 71.4 46 88.5 2011 46 74.2 42 79.2 2012 58 71.6 33 84.6 2013 62 83.8 38 80.9 2014 46 78.0 31 93.9 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB Version: 1 Page: 28 of 33 Intended Audience: Health

Table A16. TB outcome at 12 months by site of disease for drug sensitive cases with expected treatment duration < 12 months, 2014 1 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 35 79.5 5 11.4 0 0.0 3 6.8 0 0.0 1 2.3 44 Pulmonary, with or without EP 43 76.8 7 12.5 2 3.6 3 5.4 0 0.0 1 1.8 56 Extrapulmonary only 34 94.4 1 2.8 1 2.8 0 0.0 0 0.0 0 0.0 36 Extra-thoracic lymph nodes 17 94.4 0 0.0 1 5.6 0 0.0 0 0.0 0 0.0 18 Intra-thoracic lymph nodes 6 100.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 6 Pleural 6 75.0 1 12.5 1 12.5 0 0.0 0 0.0 0 0.0 8 Bone Other 1 100.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 All other EP sites 4 31 86.1 2 5.6 3 8.3 0 0.0 0 0.0 0 0.0 36 Total 77 83.7 8 8.7 3 3.3 3 3.3 0 0.0 1 1.1 92 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB 2 Not evaluated includes missing, unknown and transferred out 3 Multiple sites of disease can be reported so the total does not add up to the total number of cases 4 All other extra-pulmonary sites includes gastrointestinal, genitourinary, laryngeal, other and unknown extra-pulmonary disease Version: 1 Page: 29 of 33 Intended Audience: Health

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, 2013 2014 1 LHB and LA 2013 2014 Total Treatment completed Total Treatment completed n n % n n % Abertawe Bro Morgannwg University 20 12 60.0 10 8 80.0 Bridgend 3 2 66.7 0 0 - Neath Port Talbot 9 3 33.3 2 1 50.0 Swansea 8 7 87.5 8 7 87.5 Aneurin Bevan 19 16 84.2 24 21 87.5 Blaenau Gwent 2 2 100.0 1 1 100.0 Caerphilly 3 3 100.0 2 2 100.0 Monmouthshire 3 3 100.0 2 2 100.0 Newport 10 7 70.0 18 15 83.3 Torfaen 1 1 100.0 1 1 100.0 Betsi Cadwaladr University 25 23 92.0 13 10 76.9 Anglesey 6 5 83.3 3 3 100.0 Conwy 3 3 100.0 4 2 50.0 Denbighshire 4 4 100.0 1 1 100.0 Flintshire 3 3 100.0 1 1 100.0 Gwynedd 4 4 100.0 2 1 50.0 Wrexham 5 4 80.0 2 2 100.0 Cardiff and Vale University 36 33 91.7 24 22 91.7 Cardiff 34 32 94.1 23 21 91.3 Vale of Glamorgan 2 1 50.0 1 1 100.0 Cwm Taf 8 5 62.5 6 6 100.0 Merthyr Tydfil 3 1 33.3 0 0 - Rhondda Cynon Taf 5 4 80.0 6 6 100.0 Hywel Dda 10 9 90.0 14 9 64.3 Carmarthenshire 7 7 100.0 10 6 60.0 Ceredigion 1 1 100.0 0 0 - Pembrokeshire 2 1 50.0 4 3 75.0 Powys Teaching 3 2 66.7 1 1 100.0 Powys 3 2 66.7 1 1 100.0 Total 121 100 82.6 92 77 83.7 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases and those with CNS, spinal, miliary or cryptic disseminated TB Version: 1 Page: 30 of 33 Intended Audience: Health

Table A18. Last recorded TB outcome for entire drug sensitive cohort, Wales, 2005-2014 1 Completed Died Lost to follow-up Still on treatment Stopped Not evaluated 2 Total Year n % n % n % n % n % n % n 2005 123 67.2 19 10.4 8 4.4 13 7.1 3 1.6 17 9.3 183 2006 127 70.2 14 7.7 6 3.3 1 0.6 4 2.2 29 16.0 181 2007 138 69.0 17 8.5 15 7.5 1 0.5 3 1.5 26 13.0 200 2008 139 83.7 14 8.4 4 2.4 0 0.0 1 0.6 8 4.8 166 2009 169 79.7 20 9.4 8 3.8 3 1.4 5 2.4 7 3.3 212 2010 122 80.3 22 14.5 6 3.9 0 0.0 1 0.7 1 0.7 152 2011 105 81.4 8 6.2 9 7.0 0 0.0 6 4.7 1 0.8 129 2012 106 78.5 15 11.1 6 4.4 3 2.2 3 2.2 2 1.5 135 2013 113 81.3 7 5.0 8 5.8 1 0.7 3 2.2 7 5.0 139 2014 91 82.0 11 9.9 3 2.7 5 4.5 0 0.0 1 0.9 111 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases 2 Not evaluated includes missing, unknown and transferred out Version: 1 Page: 31 of 33 Intended Audience: Health

Table A19. Last recorded TB outcome for entire drug sensitive cohort by LHB and LA, Wales, 2013-2014 1 LHB and LA 2013 2014 Total Treatment completed Total Treatment completed n n % n n % Abertawe Bro Morgannwg University 22 13 59.1 11 9 81.8 Bridgend 3 2 66.7 0 0 - Neath Port Talbot 9 4 44.4 2 1 50.0 Swansea 10 7 70.0 9 8 88.9 Aneurin Bevan 24 21 87.5 31 25 80.6 Blaenau Gwent 2 2 100.0 2 2 100.0 Caerphilly 4 3 75.0 2 2 100.0 Monmouthshire 3 3 100.0 2 2 100.0 Newport 14 12 85.7 24 18 75.0 Torfaen 1 1 100.0 1 1 100.0 Betsi Cadwaladr University 30 26 86.7 14 10 71.4 Anglesey 6 5 83.3 3 3 100.0 Conwy 4 3 75.0 4 2 50.0 Denbighshire 4 4 100.0 1 1 100.0 Flintshire 4 3 75.0 1 1 100.0 Gwynedd 6 6 100.0 3 1 33.3 Wrexham 6 5 83.3 2 2 100.0 Cardiff and Vale University 40 37 92.5 28 26 92.9 Cardiff 38 36 94.7 27 25 92.6 Vale of Glamorgan 2 1 50.0 1 1 100.0 Cwm Taf 9 5 55.6 8 7 87.5 Merthyr Tydfil 3 1 33.3 1 0 - Rhondda Cynon Taf 6 4 66.7 7 7 100.0 Hywel Dda 11 9 81.8 17 12 70.6 Carmarthenshire 7 7 100.0 10 7 70.0 Ceredigion 1 1 100.0 1 1 100.0 Pembrokeshire 3 1 33.3 6 4 66.7 Powys Teaching 3 2 66.7 2 2 100.0 Powys 3 2 66.7 2 2 100.0 Total 139 113 81.3 111 91 82.0 1 Excludes initial and amplified to rifampicin resistant TB and MDR-TB treated cases Version: 1 Page: 32 of 33 Intended Audience: Health