Forensic Post-Mortem Examination as Sentinel Evidence of Rifampicin-Resistant TB Outside Routine Clinical Reporting

ABSTRACT Background Drug-resistant tuberculosis (TB) is under-ascertained when deaths occur outside health facilities. We evaluated whether forensic post-mortem molecular testing identifies rifampicin-resistant TB among community deaths not represented in routine clinical reporting. Methods We conducted a prospective observational study of community deaths undergoing medico-legal post-mortem examination in Lusaka, Zambia (September 2022-April 2024). Cases with macroscopic features suggestive of tuberculosis underwent histological evaluation, and histology-compatible cases were tested using GeneXpert MTB/RIF Ultra. Results Among 2,988 post-mortem examinations, 73 decedents had histological features consistent with tuberculosis. Mycobacterium tuberculosis DNA was detected in 56/73 cases, with rifampicin resistance identified in 8/56. Conclusions Forensic post-mortem molecular testing identified rifampicin-resistant TB among community deaths not represented in routine clinical drug-resistance reporting. While not informative of prevalence, these findings demonstrate that post-mortem examination can provide sentinel evidence of drug-resistant TB beyond conventional diagnostic pathways.