Mortality After Tuberculosis Treatment Completion: A Systematic Review of Incidence, Timing, and Predictors

Madinah Nalubega; Esther Buregyeya; Phyllis Awor

Authors

Nalubega Madinah School of Public Health, College of Health Sciences, Makerere University Author
Buregyeya Esther School of Public Health, College of Health Sciences, Makerere University, Uganda Author
Awor Phyllis School of Public Health, College of Health Sciences, Makerere University Author

Keywords:

Tuberculosis, post-treatment mortality, TB survivors, HIV, predictors, systematic review

Abstract

Background: Tuberculosis (TB) survivors experience elevated mortality risk even after successful treatment completion. Understanding the magnitude, timing, and predictors of post-treatment mortality is essential for designing effective survivorship care and reducing long-term TB-related deaths.

Objectives: To systematically review the incidence, timing, and predictors of mortality after TB treatment completion.

Methods: We conducted a systematic review following PRISMA guidelines. We searched SciSpace, PubMed, and Google Scholar through March 2026 for peer-reviewed English-language studies reporting mortality, survival, or predictors of death after TB treatment completion. We included cohort, case-control, and analytical observational studies. Two reviewers independently screened titles, abstracts, and full texts. Data on study characteristics, mortality incidence, timing of deaths, and predictors were extracted and synthesized narratively.

Results: Thirty studies met inclusion criteria, representing diverse settings including Uganda, Georgia, Israel, China, India, Haiti, Vietnam, Brazil, and systematic reviews. Pooled standardized mortality ratio (SMR) was 2.91 (95% CI 2.21–3.84), indicating nearly three-fold higher mortality compared to general populations. Mortality incidence ranged from 6.9% to 34.7% across cohorts, with rates of 15.4–28.5 per 1,000 person-years. Most deaths occurred within the first 1–3 years post-treatment, though elevated risk persisted for years. Consistent predictors included HIV co-infection (adjusted hazard ratio [aHR] 1.81–3.74), low CD4 count (<200 cells/µL), prior TB or retreatment (aHR 2.12), older age, comorbidities (diabetes, chronic kidney disease, malignancy), drug-resistant TB, malnutrition, and socioeconomic vulnerability (unemployment aHR 7.04). High heterogeneity (I²=99%) reflected diverse study designs, populations, and follow-up durations. Major gaps included limited cause-specific mortality data, scarce intervention studies, and underrepresentation of general TB populations in high-burden settings.

Conclusions: TB survivors face substantially elevated long-term mortality, concentrated in the early post-treatment period and driven by HIV, comorbidities, socioeconomic factors, and treatment history. Findings support the need for structured post-TB follow-up, integrated chronic disease management, and social protection interventions, particularly in the first three years after treatment completion.

Author Biography

Nalubega Madinah, School of Public Health, College of Health Sciences, Makerere University

Background: Tuberculosis (TB) survivors experience elevated mortality risk even after successful treatment completion. Understanding the magnitude, timing, and predictors of post-treatment mortality is essential for designing effective survivorship care and reducing long-term TB-related deaths.

Objectives: To systematically review the incidence, timing, and predictors of mortality after TB treatment completion.

Methods: We conducted a systematic review following PRISMA guidelines. We searched SciSpace, PubMed, and Google Scholar through March 2026 for peer-reviewed English-language studies reporting mortality, survival, or predictors of death after TB treatment completion. We included cohort, case-control, and analytical observational studies. Two reviewers independently screened titles, abstracts, and full texts. Data on study characteristics, mortality incidence, timing of deaths, and predictors were extracted and synthesized narratively.

Results: Thirty studies met inclusion criteria, representing diverse settings including Uganda, Georgia, Israel, China, India, Haiti, Vietnam, Brazil, and systematic reviews. Pooled standardized mortality ratio (SMR) was 2.91 (95% CI 2.21–3.84), indicating nearly three-fold higher mortality compared to general populations. Mortality incidence ranged from 6.9% to 34.7% across cohorts, with rates of 15.4–28.5 per 1,000 person-years. Most deaths occurred within the first 1–3 years post-treatment, though elevated risk persisted for years. Consistent predictors included HIV co-infection (adjusted hazard ratio [aHR] 1.81–3.74), low CD4 count (<200 cells/µL), prior TB or retreatment (aHR 2.12), older age, comorbidities (diabetes, chronic kidney disease, malignancy), drug-resistant TB, malnutrition, and socioeconomic vulnerability (unemployment aHR 7.04). High heterogeneity (I²=99%) reflected diverse study designs, populations, and follow-up durations. Major gaps included limited cause-specific mortality data, scarce intervention studies, and underrepresentation of general TB populations in high-burden settings.

Conclusions: TB survivors face substantially elevated long-term mortality, concentrated in the early post-treatment period and driven by HIV, comorbidities, socioeconomic factors, and treatment history. Findings support the need for structured post-TB follow-up, integrated chronic disease management, and social protection interventions, particularly in the first three years after treatment completion.