Diagnostic work-up and loss of tuberculosis suspects in Jogjakarta, Indonesia

Abstract

Background: Early and accurate diagnosis of pulmonary tuberculosis (TB) is critical for successful TB control. To assist in the diagnosis of smear-negative pulmonary TB, the World Health Organisation (WHO) recommends the use of a diagnostic algorithm. Our study evaluated the implementation of the national tuberculosis programme's diagnostic algorithm in routine health care settings in Jogjakarta, Indonesia. The diagnostic algorithm is based on the WHO TB diagnostic algorithm, which had already been implemented in the health facilities.

Methods: We prospectively documented the diagnostic work-up of all new tuberculosis suspects until a diagnosis was reached. We used clinical audit forms to record each step chronologically. Data on the patient's gender, age, symptoms, examinations (types, dates, and results), and final diagnosis were collected.

Results: Information was recorded for 754 TB suspects; 43.5% of whom were lost during the diagnostic work-up in health centres, 0% in lung clinics. Among the TB suspects who completed diagnostic work-ups, 51.1% and 100.0% were diagnosed without following the national TB diagnostic algorithm in health centres and lung clinics, respectively. However, the work-up in the health centres and lung clinics generally conformed to international standards for tuberculosis care (ISTC). Diagnostic delays were significantly longer in health centres compared to lung clinics.

Conclusions: The high rate of patients lost in health centres needs to be addressed through the implementation of TB suspect tracing and better programme supervision. The national TB algorithm needs to be revised and differentiated according to the level of care.

Figure 1

Pathway of diagnostic work-up of patients suspected of having TB in lung clinics and health centres. Green boxes represent the standardised national TB diagnostic algorithm and the number of patients whose diagnostic work-ups followed the standardised algorithm. Red arrows and boxes represent diagnostic work-ups that did not follow the standardised algorithm. Black boxes represent patients who were lost during diagnostic work-up. Broken arrows represent subsequent diagnostic examinations not shown in the graph. All patients who completed diagnostic work-up underwent sputum smear examinations at a certain point during their diagnostic work-up. After each sputum examination, or series of sputum examinations, the possible outcomes are indicated by '+' (positive) or '-'(negative). TB: tuberculosis; EP TB: extra-pulmonary TB; TB sm+: smear-positive tuberculosis; TB sm-: smear-negative tuberculosis. * Pathway that occurred in health centres only. ** Pathway that occurred in lung clinics only

Figure 2

Adherence to the national TB diagnostic algorithm and outcomes of diagnostic work-ups in lung clinics and health centres.