One Person a Week Dies with Undiagnosed TB in England, Study Finds
Key Insights
A study published in Thorax found 574 people in England were diagnosed with TB only after death between 2010 and 2022, averaging nearly one person per week.
British-born older men, children under four, and those with substance misuse history were disproportionately affected by postmortem TB diagnosis.
England's TB rate reached 9.4 per 100,000 in 2024, approaching the WHO low-incidence threshold of 10 cases per 100,000.
A national study has revealed that nearly one person per week in England dies with undiagnosed and untreated tuberculosis (search), with postmortem diagnoses disproportionately affecting British-born older men — a demographic often overlooked by healthcare professionals who may associate TB primarily with younger, foreign-born populations.
The research, published in the journal Thorax, identified 574 people in England who were diagnosed with TB only after death between 2010 and 2022. These cases represented 0.8% of all TB diagnoses but accounted for nearly one in five deaths recorded among people with the disease. The data could not establish whether TB caused or contributed to each death.
"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."
Rising TB Rates Threaten Low-Incidence Status
Tuberculosis (search) rates in England have reached a 10-year high, with 9.4 cases per 100,000 people recorded in 2024. This figure sits 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. The increase follows the largest annual rise since 1971.
Globally, TB remains the leading cause of death from a single infectious organism. An estimated 10.7 million people developed TB and 1.23 million died from the disease in 2024. While most TB cases in England are diagnosed in people born outside the UK, with an average age of 36, the postmortem diagnosis pattern tells a different story.
Older, British-Born Men at Heightened Risk
The likelihood of diagnosis after death rose sharply with age and was higher among men, UK-born individuals, and people with recorded harmful drug or alcohol use. Researchers suggest that older UK-born people may have encountered TB during childhood, when infection was more common, and the immune system can contain the bacteria for decades as latent TB infection — which can later become active when immunity weakens due to age, illness, or medicines.
Smoking, which damages the lungs' defenses and increases TB risk, may further complicate diagnosis. An older man presenting with cough and weight loss may be investigated for cancer or chronic lung disease before TB is considered. Previous BCG vaccination does not rule out TB, as the vaccine protects young children against severe disease but does not reliably prevent TB in adults.
Children under four were also found to be at higher risk of postmortem diagnosis, potentially linked to underdeveloped immune systems, non-specific symptoms, and challenges in obtaining samples from very young children for testing.
Geographic and Systemic Disparities
People living outside London were more likely to receive a TB diagnosis only after death. Doctors in London may encounter TB more frequently and have better access to specialist services, though differences in reporting may also contribute. The researchers noted that their findings probably underestimate the problem, as some people may die without ever being tested.
The median interval between symptom onset and diagnosis of lung TB in England was 72 days in 2024. During that delay, an infectious person may continue transmitting TB while their illness worsens, and delays can create avoidable, sometimes catastrophic costs for patients, their households, and health services.
A Call for "Never Event" Classification
Dr Tom Wingfield, of the Liverpool School of Tropical Medicine and the paper's senior author, drew parallels with how the NHS handles other infection-related deaths. Deaths related to superbugs such as MRSA or clostridioides difficile are routinely investigated. He suggested treating TB the same way — "as a never event that triggers root cause analysis" — could help prevent future deaths.
"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."
Dr Paul Cleary, a consultant epidemiologist at the UK Health Security Agency (search) and another author of the study, noted that whether individuals died with TB but from other causes, or whether TB caused their death, either scenario might "represent missed opportunities to identify and treat the disease earlier, as well as to prevent possible transmission to others."
The researchers emphasized that public awareness is also critical. A persistent cough, fever, drenching night sweats, or unexplained weight loss deserves medical attention regardless of age or birthplace. Healthcare professionals must consider TB even when cancer, pneumonia, or chronic lung disease initially appears more likely.
TB bacteria grow slowly, meaning traditional laboratory cultures can take several weeks. While rapid molecular tests can sometimes provide results much sooner, doctors must first suspect TB to order them. The study's authors recommend that each postmortem TB diagnosis should prompt a review of symptoms, tests, and referral decisions to identify where opportunities were missed.