Clinical outcomes and recurrence after treatment of asymptomatic pulmonary tuberculosis: A nationwide cohort study

Abstract

Objectives: Asymptomatic tuberculosis (TB) has gained programmatic recognition in WHO's 2025 framework, but large-scale real-world evidence on its prognosis remains limited. We compared clinical characteristics, treatment outcomes, and post-treatment recurrence between asymptomatic and symptomatic pulmonary TB in South Korea. Methods: We conducted a nationwide retrospective cohort study linking the Korean National Tuberculosis Surveillance System, National Health Information Database, and cause-of-death registry. From Jan 1, 2016, to Dec 31, 2019, 88,929 patients with pulmonary TB were included. End-of-treatment outcomes were assessed using multivariable logistic regression. Recurrence among those with treatment success was evaluated through Dec 31, 2022 using competing-risks regression. Results: At diagnosis, 37.9% (33,753/88,929) were asymptomatic, of whom 69.3% were bacteriologically confirmed. Compared with symptomatic patients, asymptomatic patients had higher treatment success and lower TB-related mortality during treatment (adjusted odds ratio 0.70; 95% CI, 0.64-0.75). Asymptomatic status was also associated with a reduced risk of post-treatment recurrence (adjusted subdistribution hazard ratio 0.84; 95% CI, 0.76-0.94). Conclusions: Over one-third of pulmonary TB cases were asymptomatic at diagnosis, most with bacteriological confirmation. Asymptomatic TB showed more favorable short- and long-term outcomes, yet a non-trivial proportion remained potentially infectious. These findings support expanding active case finding beyond symptom-based approaches and highlight the need for risk-stratified treatment strategies. (c) 2026 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )