Pre-treatment lost to follow up among presumptive tuberculosis patients in a tertiary care centre, South India

Revathi Ulaganeethi, Divya Nair, Gomathi Ramaswamy, Shivangi Choubey, Saka Vinod Kumar, Gautam Roy


Background: At tertiary care centres, presumptive tuberculosis (TB) patients who come from far off places and are more likely to drop out during diagnosis or before treatment initiation. We aimed to describe the proportion lost during diagnosis or before treatment and also assessed the reasons for the loss to follow up.

Methods: We did a hospital based descriptive study, reviewing laboratory register and referral register to assess the status of submission of second sputum and referral letter, respectively, for patients visiting a designated microscopy centre at a teaching hospital. Reasons for lost to follow up were assessed through telephonic interviews.

Results: Out of a total 2025 presumptive TB patients, 315 (15.6%, 95% CI 14.0-17.2) did not provide a second sputum sample. ‘Symptoms had reduced or subsided’ (30%), ‘not aware that second sample needs to be given’ (23%) and ‘visited other hospital’ (14%) were the common reasons reported for the same. A total of 270 (13.3%) patients were sputum smear positive; of them 92 (34.1% CI 28.4-40.1) did not collect referral letter. Among those who were referred, 66% were referred within a week. Deaths, ‘busy in routine work’ and treatment at other government hospitals were the common reasons reported for not collecting referral letter.

Conclusions:One out of seven patients did not submit a second sputum sample and one third of sputum smear positive TB patients did not collect the referral letter. Follow up mechanisms needs to be strengthened in the national program to reduce this pre-treatment lost to follow up. 



Diagnostic drop out, Diagnostic default, Spot-spot sample, Designated microscopy centre

Full Text:



World Health Organisation. Global Health TB Report. World Health Organisation; 2018: 277.

World Health Organisation. End TB Strategy. World Health Organisation; 2015.

Mase SR, Ramsay A, Ng V, Henry M, Hopewell PC, Cunningham J, et al. Yield of serial sputum specimen examinations in the diagnosis of pulmonary tuberculosis: a systematic review. Int J Tuberc Lung Dis. 2007;11(5):485-95.

Central TB Division. Technical and operational guidelines for tuberculosis control in India. Directorate of Health Services, Ministry of Health and Family Welfare; 2016: 276.

Subbaraman R, Nathavitharana RR, Satyanarayana S, Pai M, Thomas BE, Chadha VK, et al. The Tuberculosis Cascade of Care in India’s Public Sector: A Systematic Review and Meta-analysis. PLoS Med. 2016;13(10):1002149.

Rawat J, Biswas D, Sindhwani G, Kesharwani V, Masih V, Chauhan BS. Diagnostic defaulters: an overlooked aspect in the Indian Revised National Tuberculosis Control Program. J Infect Dev Ctries. 2012;6(1):20-2.

Ramachandran D, Purty AJ, Singh Z, Soundappan G, Anandan V. Initial default among tuberculosis patients diagnosed in selected medical colleges of Puducherry: issues and possible interventions. Int J Med Sci Public Heal. 2015;4(7):957-60.

Mehra D, Kaushik RM, Kaushik R, Rawat J, Kakkar R. Initial default among sputum-positive pulmonary TB patients at a referral hospital in Uttarakhand, India. Trans R Soc Trop Med Hyg. 2013;107(9):558-65.

Nayak P, Kumar AMV, Claassens M, Enarson DA, Satyanarayana S, Kundu D, et al. Comparing same day sputum microscopy with conventional sputum microscopy for the diagnosis of tuberculosis Chhattisgarh, India. PLoS One. 2013;8(9):74964.

Chauhan R, Purty A, Samuel A, Singh Z. Incremental yield of second sputum smear examination for diagnosis of tuberculosis patients at a tertiary care teaching hospital in Puducherry, India. J Med Soc. 2016;30(2):89-93.

Thomas B, Subbaraman R, Sellappan S, Suresh C, Lavanya J, Lincy S, et al. Pretreatment loss to follow-up of tuberculosis patients in Chennai, India: A cohort study with implications for health systems strengthening. BMC Infect Dis. 2018;18(1):142.

Rao NA, Anwer T, Saleem M. Magnitude of initial default in pulmonary tuberculosis. J Pak Med Assoc. 2009;59(4):223-5.

Buu TN, Lonnroth K, Quy HT. Initial defaulting in the National Tuberculosis Programme in Ho Chi Minh City, Vietnam: a survey of extent, reasons and alternative actions taken following default. Int J Tuberc Lung Dis. 2003;7(8):735-41.

Rao N, Anwer T, Arain I, Ara I. To evaluate primary default among smear positive pulmonary tuberculosis patients at three chest clinics of Ojha Institute of Chest Diseases, Karachi, Pakistan. Eur Respir J. 2011;38(55):4372.

Htwe KK, Kyaw NTT, Kumar AMV, Kyaw KWY, Oo MM, Thwin T, et al. Pre-treatment loss to follow-up and treatment delay among bacteriologically-confirmed tuberculosis patients diagnosed in Mandalay Region, Myanmar. Trop Med Health. 2019;47(1):30.