Social and health factors associated with postmortem diagnosis of tuberculosis in England: a national, retrospective cohort study
Eleanor Morgan, Paul Cleary, Tom WingfieldIntroduction
People diagnosed with tuberculosis (TB) after death (postmortem) experience the ultimate diagnostic delay. We aimed to identify social and health factors associated with postmortem TB diagnosis in England.
Methods
We conducted a national retrospective cohort study using routinely collected surveillance data from the UK Health Security Agency’s National TB Surveillance System (NTBS) between 1 January 2010 and 31 December 2022. Of 72 058 people notified with TB, 19 without a recorded diagnostic outcome were excluded, leaving 72 039 for analysis. The primary outcome was postmortem versus antemortem TB diagnosis. Associations were assessed using univariate and multivariable logistic regression.
Results
Of 72 039 participants, 574 were diagnosed postmortem, averaging 0.84 cases per week. With the exception of age 0-4 years (adjusted odds ratio, aOR, 5.36 (95%CI 1.62-17.67), the likelihood of postmortem diagnosis increased markedly with age, from aOR 2.96 (95% CI 1.14 to 7.64) at age 35–39 years to 85.67 (95% CI 32.34 to 226.97) at age ≥90 years. Male sex (aOR 1.62; 95% CI 1.31 to 2.00), UK birth (aOR 1.53; 95% CI 1.10 to 2.14), alcohol misuse (aOR 3.08; 95% CI 1.30 to 7.30) and drug misuse (aOR 2.48; 95% CI 1.21 to 5.12) were associated with increased odds of postmortem diagnosis. Compared with London, all other National Health Service regions had increased odds of postmortem diagnosis. BCG vaccination (aOR 0.49; 95% CI 0.29 to 0.84) and pulmonary TB (aOR 0.60; 95% CI 0.48 to 0.75) were associated with lower odds.
Discussion
Postmortem TB diagnosis in England is frequent and associated with being in early childhood (0-4 years), older age, male sex, UK birth, substance misuse and notification outside London. Recognising postmortem TB diagnosis as a ‘never event’ and developing targeted interventions to reduce diagnostic delays are essential to achieve England’s TB elimination goals.