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Objective The WHO estimates that almost 40% of patients diagnosed with tuberculosis (TB) are not reported. We implemented this study to assess TB under-reporting and delayed treatment registration in nine counties in China. Design A retrospective inventory study (record review). Setting Counties were selected using purposive sampling from nine provinces distributed across eastern, central and western regions of China in 2015. Primary and secondary outcome measures Underreporting was calculated as the percentage of patients with TB not reported to TB Information Management System (TBIMS) within 6 months of diagnosis. Delayed registration was estimated as the percentage of reported cases initiating treatment 7 or more days after diagnosis. Multivariable logistic regression and an alpha level of 0.05 were used to examine factors associated with these outcomes. Results Of the 5606 patients with TB identified from project health facilities and social insurance systems, 1082 (19.3%) were not reported to TBIMS. Of the 4524 patients successfully reported, 1416 (31.3%) were not registered for treatment within 7 days of diagnosis. Children, TB pleurisy, patients diagnosed in the eastern and central regions and patients with a TB diagnosis recorded in either health facilities or social insurance system--but not both--were statistically more likely to be unreported. Delayed treatment registration was more likely for previously treated patients with TB, patients with negative or unknown sputum results and for patients diagnosed in the eastern region. Conclusion Almost one in every five patients diagnosed with TB in this study was unknown to local or national TB control programmes. We recommend strengthening TB data management practices, particularly in the eastern and central regions, and developing specific guidelines for reporting paediatric TB and TB pleurisy. Patient education and follow-up by diagnosing facilities could improve timely treatment registration. Additional studies are needed to assess under-reporting elsewhere in China. [ABSTRACT FROM AUTHOR]