Ahmad et al. BMC Public Health 2012, 12:132 http://www.biomedcentral.com/1471-2458/12/132 R E S E A R C H A R T I C L E Open Access Diagnostic work-up and loss of tuberculosis suspects in Jogjakarta, Indonesia Riris Andono Ahmad1,2*†, Francine Matthys3†, Bintari Dwihardiani1, Ning Rintiswati4, Sake J de Vlas2, Yodi Mahendradhata1,3 and Patrick van der Stuyft3 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. Keywords: Diagnostic work-up, Tuberculosis, TB DOTS facilities, Indonesia Background Early and accurate diagnosis of pulmonary tuberculosis (TB) is critical for better treatment outcomes and reduced transmission [1,2]. The gold standard for TB diagnosis is bacilli culture in Löwenstein-Jensen (LJ) media, but this is difficult in many resource-poor set- tings. In addition, LJ culture takes 6-8 weeks, which lim- its its usefulness as a first-line diagnostic test. Rapid cultures in liquid media provide faster results but are more expensive and prone to contamination [3]. There- fore, the World Health Organisation (WHO) and the * Correspondence: risandono.ahmad@gmail.com † Contributed equally 1Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Jogjakarta, Indonesia Full list of author information is available at the end of the article International Union Against Tuberculosis and Lung Dis- ease (IUATLD) endorse sputum smear microscopy with at least one positive sputum smear for a diagnosis of smear-positive TB [4,5]. For patients with suspected TB and negative sputum results, the diagnostic criteria for smear-negative pulmonary TB encompasses at least two negative smears, radiographic abnormalities consistent with active pulmonary TB, no response to a course of broad-spectrum antibiotics, HIV-positive status, and a decision by a clinician to treat with a full course of anti- TB chemotherapy [4]. The WHO recommends the use of diagnostic algo- rithms to diagnose smear-negative pulmonary TB [6], and many TB-endemic countries have adopted an algo- rithm approach [7]. However, the effectiveness of diag- nostic algorithms is influenced by local factors, such as © 2012 Ahmad et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.