Background: Tuberculosis (TB) natural history remains poorly characterised and new investigations are impossible as it would be unethical to follow up TB patients without treating them. Estimates of TB burden and mortality rely heavily on TB self-recovery and mortality rates, as around 40% of individuals with TB are never detected, making their prognosis entirely dependent on the disease natural history. Methods: We considered the reports identified in a previous systematic review of studies from the prechemotherapy era, and extracted detailed data on mortality over time. We used a continuous-time Markov model in a Bayesian framework to estimate the rates of TB-induced mortality and self-cure. A hierarchical model was employed to allow estimates to vary by cohort. Inference was performed separately for smear-positive TB (SP-TB) and smear-negative TB (SN-TB). Results: We included 41 cohorts of SP-TB patients and 19 cohorts of pulmonary SN-TB patients in the analysis. No data were available on extrapulmonary TB. The posterior median estimates of the TB-specific mortality rates were 0.390 year-1 (0.329-0.452, 95% credible interval) and 0.025 year-1 (0.016-0.036) for SP-TB and SN-TB patients, respectively. The estimates for self-recovery rates were 0.233 year-1 (0.179-0.293) and 0.147 year-1 (0.087-0.248) for SP-TB and SN-TB patients, respectively. These rates correspond to average durations of untreated TB of 1.57 years (1.37-1.81) and 5.35 years (3.42-8.23) for SP-TB and SN-TB, respectively, when assuming a natural mortality rate of 0.014 year-1 (i.e. a 70-year life expectancy). Conclusions: TB-specific mortality rates are around 15 times higher for SP-TB than for SN-TB patients. This difference was underestimated dramatically in previous TB modelling studies that parameterised models based on the ratio of 3.3 between the 10-year case fatality of SP-TB and SN-TB. Our findings raise important concerns about the accuracy of past and current estimates of TB mortality and predicted impact of control interventions on TB mortality.

Revisiting the Natural History of Pulmonary Tuberculosis: a Bayesian Estimation of Natural Recovery and Mortality rates