4.1 Introduction

The Regional Surveillance Unit of the Health Protection Agency (West Midlands) processes data from health protection units and NHS Trust laboratories from across the region.  In this chapter, data from the enhanced surveillance schemes for tuberculosis, HIV, and meningococcal disease are used to explore links between ethnicity and health.

4.2 Tuberculosis in the West Midlands

The Enhanced Tuberculosis Surveillance system was introduced in England and Wales in 1999.  It replaced the five-yearly national tuberculosis surveys with a continuous monitoring system, designed to enable more rapid detection of the changes in the epidemiology of tuberculosis.  The Enhanced system collects a wide range of information on patient risk factors (e.g. ethnicity, place of birth, previous TB diagnoses) unlike the notifications system (NOIDS), which only collects basic patient information.

There has been a steady increase in the number of tuberculosis diagnoses in the West Midlands over the last five years (Figure 4.01).  The total number of diagnoses in 2004 was 921 which was 48% higher than in 1999 (624).

Figure 4.01: Tuberculosis in the West Midlands by year, 1999-2004

Tuberculosis in the West Midlands by year, 1999-2004

Rates of Tuberculosis were highest within the Birmingham and Solihull Health Protection Unit (34 per 100, 000 in 2004) and the Black Country Health Protection Unit (25 per 100, 000 in 2004).  Rates of Tuberculosis by Primary Care Trust are available on the HPA-West Midlands Extranet site, (see extranet section at the end of this chapter for further details).

Over 50% of cases of tuberculosis occur in people of Indian Sub-Continent origin (Indian, Pakistani and Bangladeshi ethnic groups).  The next highest proportion is in the White ethnic group, accounting for 22% of all cases.

Figure 4.02: Notifications of tuberculosis by ethnic group in the West Midlands, 1999-2004

Notifications of tuberculosis by ethnic group in the West Midlands, 1999-2004.

Rates of tuberculosis are, however, highest in the Black African ethnic group.  Rates of disease have been increasing rapidly in this ethnic group and have made a substantial contribution to the overall increase in tuberculosis in the West Midlands (Figure 4.03).  Measured rates may, however, be distorted by a rapid short term increase in this sector of the population and therefore the numbers of cases, as rates are measured against a constant (mid-2001) denominator.

Figure 4.03: Rates of tuberculosis in the West Midlands by ethnic group

Rates of tuberculosis in the West Midlands by ethnic group

In 2004 64% of patients diagnosed with tuberculosis were born abroad, and of these nearly 50% had entered the UK within the last 5 years.  The number of tuberculosis patients born abroad has increased by 15% since 2000 with the percentage being diagnosed within 5 years of entry to the UK almost tripling (Figure 4.04).

Figure 4.04: Proportion of tuberculosis patients born abroad by time of entry into the UK.

Proportion of tuberculosis patients born abroad by time of entry into the UK

4.3 HIV in the West Midlands

The Regional HIV Surveillance Project was set up in the West Midlands in 1991.  Its aim was to allow local monitoring, including timely and detailed analysis of trends and changes in the epidemiology of HIV in the region.  It also acts as a valuable resource for local colleagues involved in the treatment, management and care of HIV-infected individuals, as well as those involved in health promotion and service planning.  Reporting to the project is voluntary, yet we are pleased to have all 21 GUM clinics in the region involved, ensuring the system is as complete as possible.  The surveillance system collects a wide range of patient demographic and treatment data while still ensuring patient confidentiality. 

Please note that all HIV data are provisional and subject to change as further reports are received.

The number of HIV cases rose rapidly between 1999 and 2003 (Figure 4.05). Between 2003 and 2004 there was a slight drop in the number of cases. Despite this decrease the number of cases reported in 2004 was still the second highest ever (518 cases).

Figure 4.05: Number of HIV diagnoses in West Midlands residents, 1999-2004

Number of HIV diagnoses in West Midlands residents, 1999-2004 .

Following a slight drop in HIV diagnoses between 1999 and 2000 the trend amongst the white ethnic group has shown a steady increase, rising from 88 cases in 2000 to 139 in 2004, an increase of 58% (Figure 4.6). There was a much bigger increase seen in the Black African population, with new diagnoses in 2003 nearly nine times greater than in 1999 (Figure 4.6). There was a decrease of 17% in new diagnoses in this group between 2003 and 2004.

Figure 4.06: New HIV diagnoses by year of first positive test in Black African and White ethnic groups 1999-2004

New HIV diagnoses by year of first positive test in Black African and White ethnic groups 1999-2004

There has also been a generally increasing trend in new HIV diagnoses for the other ethnic groups (Figure 4.7).

Figure 4.07: New HIV diagnoses by year of first positive test in Black Caribbean, Black Other, Indian sub-continent and Other Ethnic Groups, 1999-2004

New HIV diagnoses by year of first positive test in Black Caribbean, Black Other, Indian sub-continent and Other Ethnic Groups, 1999-2004

There are marked differences in the rates between ethnic groups, with Black minority ethnic groups exhibiting a disproportionately large burden of disease (Table 4.01).

Table 4.01 Number of HIV diagnoses and rates per 100,000 population, 1999-2004

4.4 Meningococcal Disease

Between 2000 and 2005 there were 1727 notifications of meningococcal disease in the West Midlands, which equates to an incidence of 5.5 notifications per 100,000 population per year (Table 4.02).

Table 4.02 Meningococcal notifications by ethnicity and year of report: West Midlands, 2000-2005

Unfortunately our knowledge of the ethnic profile of these cases is poor because the ethnic origin field is incomplete in 44% of cases. The calculated incidence rates of meningococcal disease for each ethnic group shown in the table are therefore underestimates of the true incidence of disease. There have only been a handful of notifications in those classified as being of ‘Black’ or ‘Other’ ethnic origin. The quoted incidence rates for these groups are therefore subject to large chance variation due to the small numbers involved. The incidence rate was slightly higher in Whites compared to Asians with rates of 3.2 and 2.7 notifications per 100,000 population per year respectively. A similar finding based on a different methodology has been reported previously (Robinson et al, 2000).

In the period examined, 52% of notifications were of White origin and 4% were of Asian origin, with the rest of the notifications being nearly all of unknown ethnic origin (Figure 4.08).

Figure 4.08: Meningococcal disease notifications by ethnic group: West Midlands, 2000 to 2005.

Meningococcal disease notifications by ethnic group: West Midlands, 2000 to 2005

A brief analysis of the epidemiology of disease in Asian as compared to White cases in 2000 to 2004 is presented in Table 4.03. The results should be treated with caution given that the ethnic origin of 44% of notifications is unknown. The main findings are:

1. Notifications are commoner in men than women in both Whites and Asians although the this is more pronounced in Asians with around two-thirds of notifications being male in this group.

2. Meningococcal disease is concentrated in the youngest age group with those aged under five making up around half of notifications in Asians and 57% of notifications in whites.

3. Figure 4.09 shows a fuller breakdown of incidence by age. A higher proportion of notifications are from those aged 0 to 14 in Whites compared to Asians.  It is difficult to comment on relative incidence in the older age groups as there are only small numbers of cases of Asian notifications in these age bands and so the results are susceptible to significant chance variation.

4. The commonest serogroup in both ethnic groups is serogroup B which is identified in around 4 in 10 notifications. Around 40% of notifications in Asians and 50% of those in Whites have an unknown serogroup.

5. Serogroup W135 accounts for almost 10% of notifications in Asians but only around 1% of notifications in Whites. Serogroup A is rare in both ethnic groups with one White case and two Asian cases reported between 2000 and 2005.

6. Case fatality appears to be around a quarter lower in Asians than Whites although this may partly reflect problems of lack of ascertainment in Asians where the fatality result is almost three times more likely to be classified as ‘unknown’  compared to Whites.

Table 4.03 Comparative epidemiology of meningococcal disease notifications in those of Asian and White ethnic origin: West Midlands 2000 to 2004 (incidence results based on 2000 to 2005.

Figure 4.09: Meningococcal disease notification by ethnic origin and age band: West Midlands, 2000 to 2004.

Meningococcal disease notification by ethnic origin and age band: West Midlands, 2000 to 2004.

Reference:

ADDITIONAL INFORMATION

Health Protection Agency (HPA) - West Midlands Extranet

The HPA-West Midlands extranet site is a secure website allowing public health professionals in the West Midlands to gain access to the latest reports and data produced by HPA – West Midlands (www.hpa-wm.co.uk) (Figure 4.10).  Access to the site requires a username and password which can be obtained by contacting yasmin.rehman@hpa.org.uk.

Figure 4.10: HPA West Midlands Extranet Site

Figure 04.10 HPA West Midlands Extranet Site

The Regional Surveillance Unit section of the extranet site includes the latest reports on the epidemiology of communicable disease in the West Midlands.  The extranet site now also plays host to an interactive mapping tool called InstantAtlasTM.   The software allows geographical data on communicable disease in the West Midlands to be viewed online.  Data can be viewed as a map, an interactive list, a timeline and a ranked bar chart (Figure 4.11).  Data currently available on the site includes TB, Meningococcal and HIV data by Primary Care Trust, Vaccine uptake (COVER) data by Primary Care Trust and statutory notifications (NOIDS) data by Health Authority. 

Figure 4.11: InstantAtlas ^TM

Figure 04.11 Instant AtlasTM