Pre-Diagnosis and Pre-Treatment Loss to Follow-Up Among Individuals with Presumptive Tuberculosis and Diabetes Mellitus: A Retrospective Study Using Routine Surveillance Data in Minahasa, North Sulawesi
DOI:
https://doi.org/10.52434/jifb.v17i2.43716Keywords:
pre-diagnosis LTFU, pre-treatment LTFU, SITB, tuberculosisAbstract
Tuberculosis (TB) remains a foremost infectious cause of death worldwide and stands as a major public health concern, particularly in high-burden countries such as Indonesia. Loss to follow-up (LTFU) during the early stages of the TB care cascade, including diagnostic evaluation and treatment initiation, contributes to under-detection and ongoing transmission. Patients with diabetes mellitus (DM) are at increased risk of TB and poor outcomes, with evidence on early-stage LTFU in this population remaining limited in specific settings such as district-level health systems. The objective of this study is to assess the proportion of pre-diagnosis and pre-treatment LTFU and to explore associated factors among presumptive TB individuals with DM. A retrospective cross-sectional study was performed using secondary data from Sistem Informasi Tuberkulosis (SITB). The study population comprised presumptive TB individuals with DM aged ≥18 years recorded between January 1 and November 30, 2025. Total sampling was applied. The chi-square or Fisher’s exact test was employed for bivariate statistical analysis. A p-value <0.05 was considered statistically significant. A total of 289 presumptive TB individuals with DM were included. Pre-diagnosis LTFU was 4.8 %, while pre-treatment LTFU was 6.4 %. Pre-diagnosis LTFU was significantly associated with area of residence (p=0.021), mode of entry into the TB program (p<0.001), and HIV status (p=0.037), suggesting that disparities in healthcare access and clinical characteristics may influence completion of the diagnostic process. No significant associations were observed for pre-treatment LTFU, likely due to the very limited number of events. Early-stage attrition in the TB-DM care cascade remains low but critical (4.8% pre-diagnosis and 6.4% pre-treatment LTFU). Geographical factors, entry points, and HIV comorbidity significantly influence diagnostic continuity. Minimizing patient loss requires strengthening localized tracking, enhancing referral coordination, and optimizing TB-HIV integration within routine health systems.
References
1. World Health Organization. Global tuberculosis report 2025 [Internet]. 2025. Available from: https://www.who.int/publications/i/item/9789240116924
2. Xie S, Xiao H, Xu L, Zhang F, Luo M. Decadal trends and regional disparities in tuberculosis burden: a comprehensive analysis of global, African, and Southeast Asian data from the GBD 1990–2021. Front Public Health. 2025 Aug 4;13.
3. Rahmati S, Nasehi M, Bahrampour A, Mirzazadeh A, Shahesmaeili A. Barriers and gaps in tuberculosis care and treatment in Iran: A multi-center qualitative study. J Clin Tuberc Other Mycobact Dis. 2023 May;31:100353.
4. Asemahagn MA, Alene GD, Yimer SA. A qualitative insight into barriers to tuberculosis case detection in East Gojjam Zone, Ethiopia. Am J Trop Med Hyg. 2020 Oct 7;103(4):1455–65.
5. MacPherson P, Houben RM, Glynn JR, Corbett EL, Kranzer K. Pre-treatment loss to follow-up in tuberculosis patients in low- and lower-middle-income countries and high-burden countries: a systematic review and meta-analysis. Bull World Health Organ. 2014 Feb 1;92(2):126–38.
6. Thomas BE, 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 Dec 27;18(1):142.
7. Nuwematsiko R, Kiwanuka N, Wafula ST, Nakafeero M, Nakanjako L, Luzze H, et al. Pre-diagnosis and pre-treatment loss to follow-up and associated factors among patients with presumed tuberculosis and those diagnosed in Uganda. BMC Health Serv Res. 2024 Dec 23;24(1):1638.
8. Abbas U, Masood KI, Khan A, Irfan M, Saifullah N, Jamil B, et al. Tuberculosis and diabetes mellitus: Relating immune impact of co-morbidity with challenges in disease management in high burden countries. J Clin Tuberc Other Mycobact Dis. 2022 Dec;29:100343.
9. Zhang Y, Lei J, Li W, Li Y, Liang L, Tian X, et al. Under the bidirectional screening policy, impact of diabetes mellitus on patient and diagnosis delays of pulmonary tuberculosis patients in Ningxia, China: a propensity score analysis. J Heal Popul Nutr. 2025 Dec 24;45(1):28.
10. Kementerian Kesehatan RI. Laporan program penanggulangan tuberkulosis 2023. Jakarta; 2024.
11. Jiang Y, Chen J, Ying M, Liu L, Li M, Lu S, et al. Factors associated with loss to follow-up before and after treatment initiation among patients with tuberculosis: A 5-year observation in China. Front Med. 2023 Apr 25;10.
12. Ahmad RA, Matthys F, Dwihardiani B, Rintiswati N, de Vlas SJ, Mahendradhata Y, et al. Diagnostic work-up and loss of tuberculosis suspects in Jogjakarta, Indonesia. BMC Public Health. 2012 Dec 15;12(1):132.
13. Soeroto AY, Lestari BW, Santoso P, Chaidir L, Andriyoko B, Alisjahbana B, et al. Evaluation of Xpert MTB-RIF guided diagnosis and treatment of rifampicin-resistant tuberculosis in Indonesia: A retrospective cohort study. Cox H, editor. PLoS One. 2019 Feb 28;14(2):e0213017.
14. Mugauri H, Shewade HD, Dlodlo RA, Hove S, Sibanda E. Bacteriologically confirmed pulmonary tuberculosis patients: Loss to follow-up, death and delay before treatment initiation in Bulawayo, Zimbabwe from 2012–2016. Int J Infect Dis. 2018 Nov;76:6–13.
15. Mohan R, Ganapathy K, Vinayagamoorthy V. Lost to Follow - Up during diagnosis (LTFU) of tuberculosis patients: a mixed method study on determinant’s and potential solutions. Online J Heal Allied Sci. 2020;19(2).
16. Dinas Kesehatan Kabupaten Minahasa. Profil kesehatan tahun 2025 [Internet]. Minahasa; 2025. Available from: https://files.minahasa.go.id/satudata/DINKES/Profil-Kesehatan-Dinas-Kesehatan-Kab-Minahasa-2025.pdf
17. Pratiwi RD, Alisjahbana B, Subronto YW, Priyanta S, Suharna S. Implementation of an information system for tuberculosis in healthcare facilities in Indonesia: evaluation of its effectiveness and challenges. Arch Public Heal. 2025 Jan 24;83(1):22.
18. Kementerian Kesehatan RI. Petunjuk teknis penggunaan sistem informasi tuberkulosis (SITB). Kementerian Kesehatan Republik Indonesia. Jakarta: Kementerian Kesehatan RI; 2023.
19. Kim J, Keshavjee S, Atun R. Health systems performance in managing tuberculosis: analysis of tuberculosis care cascades among high-burden and non-high-burden countries. J Glob Health. 2019 Jun;9(1).
20. Kementerian Kesehatan RI. Pedoman nasional pelayanan kedokteran tata laksan tuberkulosis. Jakarta; 2020.
21. Perhimpunan Dokter Paru Indonesia. Pedoman diagnosis dan penatalaksanaan tuberkulosis di Indonesia. Jakarta: Perhimpunan Dokter Paru Indonesia; 2021. 81 p.
22. Barton B, Peat J. Medical statistic: a guide to SPSS, data analysis and critical appraisal. BMJ Publishing Group Limited, used under licence by John Wiley & Sons. 2014.
23. Kementerian Kesehatan RI. Petunjuk teknis skrining tuberkulosis secara sistemik. Jakarta: Kementerian Kesehatan RI; 2024. 136 p.
24. Samal J, Preetha GS, Singh H. Delays in tuberculosis care among the top-ten-tuberculosis-high burden countries in the world: a scoping review. J Egypt Public Health Assoc. 2026 Jan 29;101(1):1.
25. Osman M, Meehan S-A, von Delft A, Du Preez K, Dunbar R, Marx FM, et al. Early mortality in tuberculosis patients initially lost to follow up following diagnosis in provincial hospitals and primary health care facilities in Western Cape, South Africa. Lessells RJ, editor. PLoS One. 2021 Jun 14;16(6):e0252084.
26. Zawedde-Muyanja S, Musaazi J, Manabe YC, Katamba A, Nankabirwa JI, Castelnuovo B, et al. Estimating the effect of pretreatment loss to follow up on TB associated mortality at public health facilities in Uganda. Peters RP, editor. PLoS One. 2020 Nov 18;15(11):e0241611.
27. BPS Kabupaten Minahasa. Kabupaten Minahasa dalam angka 2025. Minahasa: Badan Pusat Statistik Kabupaten Minahasa; 2025. 393 p.
28. Kementerian Kesehatan RI. Peraturan menteri kesehatan Republik Indonesia nomor 43 tahun 2019 tentang pusat kesehatan masyarakat. Indonesia; 2019.
29. Hilmi IL, Alfian SD, Abdulah R, Puspitasari IM. Factors Associated with Health-Seeking Behavior in Indonesia: Evidence from the Indonesian Family Life Survey 2014. Medicina (B Aires). 2024 Oct 1;60(10):1607.
30. Saunders MJ, Tovar MA, Collier D, Baldwin MR, Montoya R, Valencia TR, et al. Active and passive case-finding in tuberculosis-affected households in Peru: a 10-year prospective cohort study. Lancet Infect Dis. 2019;19(5).
31. Murongazvombo AS, Dlodlo RA, Shewade HD, Robertson V, Hirao S, Pikira E, et al. Where, when, and how many tuberculosis patients are lost from presumption until treatment initiation? A step by step assessment in a rural district in Zimbabwe. Int J Infect Dis. 2019 Jan;78:113–20.
32. Sharma AK, Gupta N, Verma S, Chandran A, Dixit R. A study on procedural delay in diagnosis and start of treatment in drug resistant tuberculosis under RNTCP. Indian J Tuberc. 2019 Jul;66(3):394–401.
33. Shewade HD, Nair D, Klinton JS, Parmar M, Lavanya J, Murali L, et al. Low pre-diagnosis attrition but high pre-treatment attrition among patients with MDR-TB: An operational research from Chennai, India. J Epidemiol Glob Health. 2017;7(4):227.
34. Dlatu N, Longo-Mbenza B, Apalata T. Models of integration of TB and HIV services and factors associated with perceived quality of TB-HIV integrated service delivery in O. R Tambo District, South Africa. BMC Health Serv Res. 2023 Jul 27;23(1):804.
35. Lima LV de, Pavinati G, Palmieri IGS, Vieira JP, Blasque JC, Higarashi IH, et al. Factors associated with loss to follow-up in tuberculosis treatment in Brazil: a retrospective cohort study. Rev Gaúcha Enferm. 2023;44.
36. Ngari MM, Mberia JK, Kanana E, Sanga D, Ngari MK, Nyagah DN, et al. Mortality and loss to follow-up among Tuberculosis patients on treatment in Meru County, Kenya: a retrospective cohort study. Shah NS, editor. PLOS Glob Public Heal. 2025 Mar 10;5(3):e0003896.
37. Lydersen S, Pradhan V, Senchaudhuri P, Laake P. Choice of test for association in small sample unordered r × c tables. Stat Med. 2007 Oct 15;26(23):4328–43.
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