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.

OBJECTIVES: To describe the pre-diagnosis and pre-treatment loss to follow-up (LTFU) in the tuberculosis (TB) care cascade in Guruve (2015-16), a rural district in Zimbabwe. DESIGN: Guruve has 19 rural health centres (RHCs) and one district hospital. In this cohort study, persons ≥15 years of age with presumptive pulmonary TB were tracked from the facility presumptive TB registers to the laboratory registers; if laboratory diagnosed, they were tracked to the district TB register (contains details of all TB patients registered for treatment). Each patient was tracked for 90days after registration as presumptive TB and for 90days after laboratory diagnosis. Environmental health technicians transported sputum specimens from the health facilities to the laboratories (n=3). RESULTS: Of 2974 persons with presumptive TB, pre-diagnosis LTFU occurred in 575 (19%, 95% confidence interval 18-21%). Associated factors included registration at a RHC, at a facility more than 2km from the laboratory, and absence of an environmental health technician. Of 162 laboratory diagnosed pulmonary TB patients, pre-treatment LTFU occurred in 19 (12%, 95% confidence interval 8-18%). CONCLUSIONS: The presumptive TB register was helpful to assess the pre-diagnosis gaps beginning from presumption. Pre-diagnosis LTFU can be reduced by placement of an environmental health technician at all facilities.