Tuberculosis remains a disease of profound diagnostic inequity, and the most extreme form of that inequity is when the diagnosis arrives only after death. Understanding who falls through these gaps is critical not merely for surveillance but for redesigning screening protocols that could prevent fatal delays — a concern particularly relevant as TB resurfaces in post-pandemic public health priorities.
Drawing on England's National TB Surveillance System over a 13-year period spanning 72,039 notified TB cases, this national retrospective cohort study identified 574 postmortem diagnoses — roughly one missed diagnosis per week throughout the study window. Advanced age emerged as the dominant risk amplifier: adjusted odds of postmortem diagnosis escalated from roughly threefold higher at ages 35–39 compared to a younger reference group, to an extraordinary 85-fold elevation in those aged 90 and older. Male sex, UK-born status, alcohol misuse, and drug misuse each independently increased the likelihood of missed antemortem diagnosis. Geographic disparities were also stark — every NHS region outside London showed elevated odds of postmortem diagnosis, suggesting that London's higher TB burden may paradoxically sharpen clinical vigilance. BCG vaccination and pulmonary TB presentation were both associated with reduced odds of postmortem diagnosis.
These findings carry important implications for TB's characteristic masquerade as other respiratory or systemic conditions, particularly in older adults where symptoms are easily attributed to chronic comorbidities. The near-absence of TB suspicion in elderly UK-born patients — a demographic not typically profiled as high-risk — represents a structural blind spot. The protective association with BCG vaccination, even in this diagnostically delayed cohort, adds to accumulating evidence that early immunization may modestly sharpen immune signaling sufficient to produce clinical symptoms earlier. The study's observational design precludes causal inference, and postmortem diagnostic practices may vary regionally, potentially confounding geographic patterns. Still, this is one of the largest national analyses of postmortem TB ascertainment, making its core message — that age and social vulnerability compound diagnostic invisibility — both robust and actionable at a public health level.