Communicable Disease Surveillance Centre, London Country presentation United Kingdom Metropolitan and regional situation Delphine Antoine Communicable Disease Surveillance Centre, London November 2003

United Kingdom 58 789 194 population in 2001 52 084 500 in England and Wales International migration: 172 000 net inflows in 2001 (480 000 inflows and 308 000 outflows) 4 states 12 regions

Map of the United Kingdom SCOTLAND N IRELAND WALES ENGLAND

Tuberculosis (all forms) TB notification and death rate, England and Wales, 1913 - 2000

Tuberculosis: notifications, Mycobnet reports Tuberculosis: notifications, Mycobnet reports* and deaths, England & Wales 1981-2000 *Initial isolates of M. tuberculosis complex. Note: Notification data for 2000 are preliminary.

Tuberculosis notifications, England and Wales, 1982-2001 Sources: Tuberculosis notifications (PHLS/CDSC-NOIDS), population figures (ONS estimates)

Possible explanations for the increase of TB rate Change in reporting system ? Change in diagnosis practice ? International migration form high TB incidence countries HIV deterioration of socio-economic status in some population groups lack of vigilance and resources to combat a disease often considered to be almost eradicated Failure of control

Methods of tuberculosis surveillance in England & Wales, 2001 Notifications Intermittent survey (until 1998) Enhanced tuberculosis surveillance reporting system implemented in 1999 Treatment outcome monitoring implemented in 2002 on TB cases reported in 2001 Reference laboratory reports (MycobNet since 1993) Mortality

Main elements of tuberculosis surveillance in England & Wales, 2002 CDSC Colindale Patient with TB Clinician CCDC specimen result identification + drug sensitivity result (Mycobnet) Mycobacterial isolate Local hospital laboratory Mycobacterial reference laboratory Identification + drug sensitivity result

Methods of tuberculosis surveillance in England & Wales, 2001 Some examples of specific studies Strain typing studies on TB cases reported in 1998 HIV infection among TB cases 1993 and 1998, 1998-2000 London TB nurses caseload profile (2003) TB in children (2004)

Enhanced surveillance of tuberculosis in England, Wales and Northern Ireland case definition Culture confirmed cases: Culture confirmed disease, due to Mycobacterium tuberculosis complex (M. tuberculosis, M. bovis or M. africanum).   Other than culture confirmed cases: in the absence of culture confirmation, a case that meets the following criteria: a clinician’s judgment that the patient’s clinical and/or radiological signs and/or symptoms are compatible with tuberculosis and a clinician’s decision to treat the patient with a full course of anti tuberculosis treatment

Tuberculosis cases reported in the UK, 2001 No. Cases Rate United Kingdom 7004 11.9 England & Wales * 6597 12.7 Northern Ireland* 55 3.3 Scotland 352 6.9 * Source : Enhanced TB surveillance

Tuberculosis cases reported in England and Wales and Northern Ireland, 2001 Total number of cases: 6652 Of which : males / females 55% / 45% cases in persons born abroad 63% Pulmonary / extra pulm. cases 60% / 40% pulmonary SS+ cases 21% culture positive cases 57% Reported in London 41% Number of cases with DST results 3389 MDR 2.6%

TB rates by age group, sex, and geographic origin 1998-2000, England and Wales Male foreigners Female foreigners Male nationals Female nationals

Tuberculosis case report rate (/100 000) by geographic origin and ethnic group, England and Wales, 1998 - 2000 White Indian, Pakistani, Bangladeshi Black African Other Total Born in UK 3.4 41.0 35.8 13.9 4.4 Born abroad 9.2 175.3 280.5 58.9 73.4 England and Wales = 11.2

Metropolitan and sub-regional information Availability in surveillance data on national level Region of reporting Local authority of residence of patient Town/city Primary care trust (from 2003) Post code

Tuberculosis case report rates, by region, England and Wales, 2001

Tuberculosis case report rates, by region, England and Wales, 2001

Tuberculosis rate in cities, England and Wales, 2001 (preliminary results)

Tuberculosis case report rate by local authority in London, 2001

Spatial analysis of tuberculosis rates by postal district – 2001 Defined by Triangulated Network Analysis (TIN) cell size 0.1km Legend Source: London Hostels Directory 2003; RIS Source: Notifying centre Enhanced TB Surveillance CDSC GIS mapping by Chris Lane CDSC 2003

London in 2001 Population 7.1 million (14% total England) 300 different spoken languages 27% born outside UK 17% households overcrowded 13 of the 20 most deprived areas in England HIV/AIDS infected population (41,200) > 100,000 homeless people Est. 70,000 ‘problem’ drug users 3.5% IDU’s HIV+ (0.3% outside London) > 6,000 prisoners

Tuberculosis case reports, England & Wales London England & Wales (without London) TB cases reported in 2001 No. of TB cases 2717 3880 TB rate/100 000 37.8 8.4 Median age 34 43 cases born abroad 80% 51% MDR at start of tt 5.2% 0.7% TB cases reported 1998-2000 HIV infection 5.3% 2.4%

Metropolitan and sub-regional information Limitations Completeness of information on geographical area Definition of area Availability of denominator (overall and for higher TB risk population groups) Completeness of information on TB cases vary Change of administrative health organisation Interpretation of trends ?

Questions How to monitor TB in higher TB risk subgroups or areas in a low incidence countries ? Specific surveys ?