While under treatment for TB, a proportion of individuals die from the disease. In India, 6% of 676 patients age 14 to 87 years old died in a directly observed therapy program. Death rates were independently associated with weight <35 kg and history of previous treatment. A study in Mexico found that the risk of death from pulmonary TB was associated with delays in treatment after the onset of disease and to poor adherence by patients to the treatment regimen. In Ghana, patients who died were likely to be human immunodeficiency virus (HIV)-positive, to be older, live in a rural area, have sputum smear-negative disease, and prolonged duration of symptoms before diagnosis. A United Kingdom study indicated that delay in diagnosis was the main contributing factor leading to death from TB. Delayed diagnosis of active pulmonary TB among hospitalized patients (which leads to greater morbidity, mortality, and transmission of infection) in Canada was associated with atypical clinical and demographic characteristics. An investigation conducted among inner city residents in a large United States city identified predictors of death to be underlying illnesses such as diabetes mellitus, renal failure, chronic obstructive pulmonary disease, and HIV infection. Cases of TB can go undetected until discovered after death. Among 3,102 TB cases in San Francisco, California, 4% were identified at death. Factors associated with these cases were age >=43 years, male sex, white race, birth in the United States, and injecting drug use. Death from TB may sometimes have a rapid onset and progression. TB-related sudden death has been related to bronchopneumonia in 64 percent (n = 30) of reported patients, of which 30% had hemoptysis (n = 14).  
In New York State, exclusive of New York City, deaths from TB appear to be relatively rare events. In 2001, of the 415 TB cases reported, 9 were identified at death. There are a number of reasons why TB cases are "missed" and are identified and reported at death. Individuals may have had a concurrent condition masking TB disease; they may have been treated for TB disease or infection in the past and suffered an unidentified reactivation; or they may have encountered economic or sociocultural barriers to accessing health care.
A TB-related sudden death, where TB disease was not suspected or detected until autopsy, led to a large contact investigation and prompted the New York State Department of Health to look into other TB deaths in an effort to identify patterns where TB disease may have gone undetected and to identify opportunities for intervention to prevent transmission of infection and subsequent development of disease. Some of the results of this investigation were previously reported as an abstract.  
At a large resort hotel (550 employees providing service to 600 guest rooms and a food service capacity of 1,000 guests/sitting), the security officer was on routine patrol when she was notified by radio of an individual lying on the hallway floor of one of the buildings where resort employees reside. On arrival, the officer found a man lying on his back, not breathing and without a pulse. One officer observed blood on the walls and floor of the hallway. There were no obvious signs of violence. The local rescue unit and the state police were summoned. The officer started cardiopulmonary resuscitation (CPR), and the others cordoned off the area. The patient was transported by ambulance to the hospital, and the officers secured the area as a crime scene until notified by the hospital, 3 hours later, that the man had died from natural causes. The officers cleaned the area with bleach and a biohazard clean-up kit, and the man's room was padlocked.
Because the death was unattended, the hospital conducted an autopsy. The cause of death was determined to be cardiorespiratory failure caused by or as a consequence of TB, and the County Health Department was immediately notified. The case had never received medical attention for TB and was unknown to the county staff. The postmortem examination of lung tissue identified Mycobacterium tbcomplex, which was susceptible to all first-line drugs, e.g., rifampin, isoniazid, pyrazinamide, ethambutol, and streptomycin. A contact investigation was launched immediately.
County staff contacted the manager of the resort to report a TB death in one of the resort staff and explained both the need to conduct, and the logistics of, a contact investigation. The resort management worked closely with the county nurses to be sure that complete and accurate information was available for the investigation. The resort is located in a sparsely populated area north of New York City. Service worker staff for resorts of this type frequently have ties to New York City and travel to area resorts for seasonal jobs. These employees often live in housing available right on the resort grounds and include a high proportion of foreign-born individuals who often are not fluent in English. Foreign-born staff in this investigation came from 17 countries outside the United States, many of which were Central or South America; however, other countries of origin included China, former Soviet Union, and Indonesia. Language barriers were addressed through existing staff at the local health unit and the use of commercially available telephone-based translating services.
Management of the resort recognized the importance of the contact investigation and provided all necessary work schedules and assignments to facilitate identification of staff who may have been exposed to the patient. Transportation to the county clinic proved to be a barrier to attendance despite the provision of shuttles by the resort, so additional clinic sessions were held on the grounds of the resort at a location not accessible to the guests.