One person a week dies with undiagnosed and therefore untreated tuberculosis in England, a study has found.
British-born, older men were among those most likely to have TB diagnosed only after death, researchers said, suggesting healthcare workers could be overlooking the possibility of the disease in these patients.
Being diagnosed with TB postmortem should be considered a “never event” that prompts urgent investigations, they said, describing it as “the ultimate diagnostic delay”.
Tuberculosis rates in England are at a 10-year high, with 9.4 cases per 100,000 people in 2024. The rate is only just below the World Health Organization’s “low incidence country” threshold of 10 cases per 100,000 – a level expected to be breached when 2025 figures are published.
Most TB cases are diagnosed in people born outside the UK, with an average age of 36. But research published in the journal Thorax found that was not the case in those diagnosed after death, who tended to be older and British-born.
“As TB rates continue to rise, we need to keep asking: ‘Could this be TB?’, even in people who do not fit the usual risk profiles,” said Dr Eleanor Morgan, the study’s co-author and a resident doctor at Liverpool University hospitals NHS foundation trust.
“If England is to eliminate TB, reducing delays in diagnosis will be essential so that fewer people miss the opportunity to receive effective treatment.”
The likelihood of postmortem diagnoses was greater in people who lived outside London and had a history of misuse of drugs or alcohol.
The researchers also found children aged under four were at higher risk, which they said could be linked to underdeveloped immune systems, non-specific symptoms, and challenges in getting samples from very young children for testing.
Tuberculosis is the biggest infectious disease killer globally, with 1.23 million people dying from the disease and an estimated 10.7 million falling ill in 2024.
It is preventable, and treatable using special antibiotics, and recent advances have dramatically reduced the time patients need to be on medication, even if they have drug-resistant forms of the disease.
Dr Tom Wingfield, of the Liverpool School of Tropical Medicine and the paper’s senior author, said deaths related to superbugs such as MRSA or clostridioides difficile were routinely investigated in the NHS. Treating TB the same way “as a never event that triggers root cause analysis” could help prevent future deaths, he suggested.
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He said the increase in rates of TB in England was concerning, especially because delayed diagnosis meant worse health, social and economic outcomes for people with the disease and longer periods during which it could be transmitted, but should not be “a cause for panic”.
“TB is preventable, treatable and curable,” Wingfield said. TB deaths “should trigger learning, not blame, so that services can identify where opportunities were missed and prevent the next avoidable death”.
The researchers noted that limitations in the data they used meant it was not possible to say whether the people died with TB but from other causes, or if TB caused their death.
Dr Paul Cleary, a consultant epidemiologist at the UK Health Security Agency and another author of the study, said either case might “represent missed opportunities to identify and treat the disease earlier, as well as to prevent possible transmission to others”.
Disruption to TB detection and treatment programmes globally during the Covid-19 pandemic led to a resurgence of the disease, and experts fear that aid cuts by the US and other donors may have a similar impact.
