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

Abstract

BackgroundEarly 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.MethodsWe 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.ResultsInformation 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.ConclusionsThe 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.

Sensitivity and specificity of routine diagnostic work-up for tuberculosis in lung clinics in Yogyakarta, Indonesia: a cohort study

“…In addition, the lung clinics conducted both microscopy and CXR examinations in the first visit, while primary health centers followed the national diagnostic algorithm that recommends CXR examination only when sputum smears are negative. Therefore, the duration of diagnostic delay for TB diagnosis in primary health centers was significantly longer than in lung clinics [23], and the primary health centers may not have sufficient tools to establish the correct diagnosis. However, there have been no studies that investigated the sensitivity and specificity of TB diagnosis in the primary health centers in Indonesia, thus we could not compare the results with the lung clinics.…”

“…However, there have been no studies that investigated the sensitivity and specificity of TB diagnosis in the primary health centers in Indonesia, thus we could not compare the results with the lung clinics. Furthermore, the proportion of patients lost in primary health centers was higher than in lung clinics, due to this longer duration of the diagnostic process [23], although generally the distances between patients’ houses and primary health centers were closer than distances between their houses and lung clinics. Often patients needed to come more frequently to the primary health centers than to lung clinics to get diagnosed, which means more costs and time spent, thus causing patients’ reluctance to finish the diagnostic procedures [23].…”

“…Furthermore, the proportion of patients lost in primary health centers was higher than in lung clinics, due to this longer duration of the diagnostic process [23], although generally the distances between patients’ houses and primary health centers were closer than distances between their houses and lung clinics. Often patients needed to come more frequently to the primary health centers than to lung clinics to get diagnosed, which means more costs and time spent, thus causing patients’ reluctance to finish the diagnostic procedures [23]. Indeed, there is a high gap (estimated around 47%) between notification and the estimation of incident TB cases due to undetected and underreported cases in Indonesia, including Yogyakarta [1].…”

“…According to the TB national guidelines in Indonesia, patients with negative smear should return or be followed-up to investigate their responses to the antibiotics given [2]. However, in reality, patients often do not return to the health centers, and the patients who are lost are not tracked [23]. Many negative-sputum-smeared patients in our study did not visit the lung clinics or other health centers after their initial diagnosis.…”

“…While waiting for an implementation of a rapid, reliable, and point-of-care TB diagnostic tool, optimizing the current routine TB diagnostic work is a reasonable option. The current national diagnostic algorithm that recommends CXR examination when sputum smear results are negative, was proven to delay the TB diagnosis, and one of the factors causing patient’s loss, although it was originally developed to improve the sensitivity and specificity of TB diagnosis [23]. Our study showed that the diagnostic process in the lung clinics which employs clinical evaluation, sputum smear microscopy, and chest radiography all together had high sensitivity and specificity, and in the same time reduced the delay time of TB diagnosis, as indicated by a previous study [23].…”