Time to first consultation, diagnosis and treatment of TB among patients attending a referral hospital in Northwest, Ethiopia

Patient delay of patients with pulmonary tuberculosis in Yantai, China, 2013 to 2022: Analysis of a case series

Patient delay increases the morbidity and mortality due to tuberculosis (TB). This study aimed to assess patient delay among patients with pulmonary tuberculosis in Yantai from 2013 to 2022, and to analyze factors related to patient delay. Data of patients with pulmonary tuberculosis in Yantai City from 2013 to 2022 were obtained from the Tuberculosis Management Information System of the Chinese Disease Prevention and Control System. Statistical analyses were performed using the SPSS.26.0 software. The trend in patient delay rate was tested using the chi-square trend test. Univariate analyses were performed using the chi-square test, and factors with statistically significant differences in the univariate analysis were included in the binary logistic regression analysis to identify the factors affecting patient delay. Patient delay was defined as an interval of more than 14 days between the onset of clinical symptoms and the patient first visit to a healthcare facility. From 2013 to 2022, the median delay time for patients with pulmonary tuberculosis in Yantai was 28 ± 52 days and the patient delay rate was 69.5%. There was an overall increasing trend in the rate of patient delay as the number of years increased. Univariate analyses revealed statistically significant differences in patient delay in terms of age, occupation, patient source, domicile, pathogenetic results, and the presence of comorbidities (all P < .05). The results of logistic regression analysis showed that the age was 20 to 39, 40 to 59, and ≥ 60 years (OR = 1.365, 95%CI: 1.156-1.612; OR = 1.978, 95%CI: 1.660-2.356; OR = 1.767, 95%CI: 1.480-2.110), occupation was domestic and un-employed (OR = 1.188, 95%CI: 1.071-1.317), domicile as mobile population (OR = 1.212, 95%CI: 1.099-1.337), and positive pathogenic results (OR = 1.242, 95%CI: 1.015-1.520) were risk factors for patient delay. Patient delays were serious among pulmonary tuberculosis patients in Yantai City, 2013 to 2022, and patient delay was related to factors such as age, occupation, domicile, patient source, and pathogenetic results.

Delay in seeking treatment and associated factors among pulmonary tuberculosis patients attending public health facilities in the Metekel zone, Benishangul Gumuz region, Western Ethiopia

Background

Tuberculosis is a major global public health problem and a leading cause of morbidity and mortality in Ethiopia. TB prevention and control in low-income countries, such as Ethiopia, face significant challenges, including late detection and treatment initiation. A delay in the initiation of tuberculosis treatment increases the morbidity and mortality of patients and community transmission. Therefore, this study aimed to assess patient delay and associated factors among pulmonary tuberculosis patients attending public health facilities in the Metekel Zone, Benishangul Gumuz Region, Western Ethiopia.

Methods

An institution-based cross-sectional study was conducted from March to August 2020 among newly diagnosed pulmonary tuberculosis patients. All pulmonary tuberculosis patients (416) who came to all public health facilities of the Metekel zone for treatment during the period were included. Data were collected through face-to-face interviews using a structured and pretested questionnaire. A multivariable logistic regression was fitted to identify independent factors for delay in seeking treatment among PTB patients. Adjusted odds ratios with 95% CIs were determined, and variables with p values <0.05 were considered statistically significant.

Results

Nearly three-fourths 302 (72.6, 95% CI: 68.5, 76.7) of the patients were delayed in seeking medical advice, with a median patient delay of 27 days (IQR: 21-31). Age of the patients [above 54 years (AOR = 2.65, 95% CI: 1.30, 5.40), 36-54 years (AOR = 1.86, 95% CI: 1.14,3.02)], family size of 5 members and above (AOR = 1.62, 95% CI: 1.10-3.14), travel time above 60 min (AOR = 3.65, 95% CI: 1.55, 8.60), history of visits to informal care providers (AOR = 1.74, 95% CI: 1.11, 3.14), and poor knowledge about PTB (AOR = 1.64, 95% CI: 1.04-2.44) were statistically significant factors associated with delays in seeking treatment among PTB patients.

Conclusion

Most pulmonary tuberculosis patients delay seeking medical advice for their illnesses. Delays in seeking treatment were associated with older age, large household size, longer travel time to reach the nearby health facility, visiting informal care providers, and poor knowledge about pulmonary tuberculosis. Hence, it is crucial to consider community screening programs, enhance public awareness, and ensure the accessibility of TB diagnostic and treatment services.

Self-reported delays in care-seeking in West Africa during the first wave of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic caused delays in care-seeking due to fears of infection and decreased healthcare access globally. These delays have been linked in some countries to COVID-19 perceptions, decreased income, and food insecurity, but little is known about patient-level factors for decreased care-seeking specifically at the beginning of COVID-19 in West Africa. Understanding these factors is important to identify those at highest risk and address healthcare-related barriers.

METHODS

This study used self-reported data from telephone surveys in a population-based sample in Burkina Faso (n = 1352), Ghana (n = 1621), and Sierra Leone (n = 1301) in May-June 2020. Questions assessed delays in care-seeking, sociodemographic variables, COVID-19 beliefs, and food insecurity. Bivariate analyses using chi-square and multivariate analyses using logistic regression were used to explore associations between factors and delays in care-seeking by country. Independent variables were chosen based on prior research suggesting that financial insecurity, older age, female sex, rural location, and COVID-related concerns are associated with delays.

RESULTS

Between March-June 2020, 9.9%, 10.6%, and 5.7% of participants in Burkina Faso, Ghana, and Sierra Leone, respectively, delayed care-seeking. Food insecurity was prevalent (21.8-46.1%) and in bivariate analyses was associated with delays in care-seeking in Burkina Faso and Ghana. Concern about risk of household contraction of COVID-19 was common (18.1-36.0%) and in Ghana and Sierra Leone was associated with delays in care-seeking in both bivariate and multivariate analyses. In bivariate analyses, females showed more delays in Burkina Faso, while age above 30 and urban location were associated with delays in Ghana. In multivariate analyses, food insecurity was associated with increased delayed care-seeking in Burkina Faso.

CONCLUSIONS

Multiple factors were associated with delays in care-seeking early in the COVID-19 pandemic, with food insecurity and concerns about infection showing significant associations in multiple countries. These findings highlight the need to invest in clinic accessibility, community education, and financial assistance to address barriers in healthcare. While many delays have subsided since the initial phase of the COVID-19 pandemic, understanding factors associated with early disruptions of care-seeking at the patient and household level will inform strategies for maintaining healthcare access during future pandemics in West Africa.

Tuberculosis notifications in regional Victoria, Australia: Implications for public health care in a low incidence setting

BACKGROUND

Regionality is often a significant factor in tuberculosis (TB) management and outcomes worldwide. A wide range of context-specific factors may influence these differences and change over time. We compared TB treatment in regional and metropolitan areas, considering demographic and temporal trends affecting TB diagnosis and outcomes.

METHODS

Retrospective analyses of data for patients notified with TB in Victoria, Australia, were conducted. The study outcomes were treatment delays and treatment outcomes. Multivariable Cox proportional hazard model analyses were performed to investigate the effect of regionality in the management of TB. Six hundred and eleven (7%) TB patients were notified in regional and 8,163 (93%) in metropolitan areas between 1995 and 2019. Of the 611 cases in the regional cohort, 401 (66%) were overseas-born. Fifty-one percent of the overseas-born patients in regional Victoria developed TB disease within five years of arrival in Australia. Four cases of multidrug-resistant tuberculosis were reported in regional areas, compared to 97 cases in metropolitan areas. A total of 3,238 patients notified from 2012 to 2019 were included in the survival analysis. The time follow-up for patient delay started at symptom onset date, and the event was the presentation to the healthcare centre. For healthcare system delay, follow-up time began at the presentation to the healthcare centre, and the event was commenced on TB treatment. Cases with extrapulmonary TB in regional areas have a non-significantly longer healthcare system delay than patients in metropolitan (median 64 days versus 54 days, AHR = 0.8, 95% CI 0.6-1.0, P = 0.094).

CONCLUSION

Tuberculosis in regional Victoria is common among the overseas-born population, and patients with extrapulmonary TB in regional areas experienced a non-significant minor delay in treatment commencement with no apparent detriment to treatment outcomes. Improving access to LTBI management in regional areas may reduce the burden of TB.

Usefulness and effectiveness of community pharmacists-led mobile phone communication in identification and referral of presumptive tuberculosis cases in a selected district of Tamil Nadu

BACKGROUND

Community pharmacists' usually are not able to be actively involved in the identification and referral of presumptive TB cases approaching their pharmacy for over-the-counter (OTC) drugs. The main barriers from their perspective were increased patient volume and work burden. Therefore, a new methodology was adopted by appointing an auxiliary pharmacist who will be actively involved in the identification and referral of presumptive TB cases. The present study aimed to assess the usefulness and effectiveness of community pharmacists-led mobile phone communication in identification and referral of presumptive tuberculosis cases in a selected district of Tamil Nadu.

METHODS

A community intervention trial with pre and post-test comparison study was conducted among the community pharmacists in Tiruvallur district of Tamil Nadu. Knowledge about TB and referral practice of community pharmacists were captured and the same were taught to them. Details of the cases with the complaints of TB who came to the enrolled pharmacists for OTC drugs during the intervention period were collected by the community pharmacists and given to auxiliary pharmacist through WhatsApp. Auxiliary pharmacist called each patient and educated about TB and followed the patients.

RESULTS

A total of 191 pharmacists were included in the study. 389 patients who approached pharmacy for OTC medications were suspected as TB by the community pharmacists based on their symptoms. 32 patients were not willing to give their details, while the details of others were collected by the community pharmacists and forwarded to auxiliary pharmacist through WhatsApp. 217 patients responded to phone calls made by the auxiliary pharmacist. Of them, 189 patients' health conditions were improved, while 28 patients suffered with symptoms and they had visited PHC and 2 patients were diagnosed as TB by clinician.

CONCLUSION

Use of auxiliary pharmacist in collaboration with community pharmacists through phone communication is a useful and comfortable mode of collection of presumptive TB cases from the community pharmacies. Similarly, health education and follow-up of the presumptive cases via phone call is an effective way in the identification and referral of presumptive tuberculosis cases.

Association between diagnostic delay and prognosis of pulmonary tuberculosis in Shandong, China: a retrospective study

BACKGROUND

Tuberculosis (TB) is one of the main infectious diseases that seriously threatens global health, while diagnostic delay (DD) and treatment dramatically threaten TB control.

METHODS

Between 2005 and 2017 in Shandong, China, we enrolled pulmonary tuberculosis (PTB) patients with DD. DD trends were evaluated by Joinpoint regression, and associations between PTB patient characteristics and DD were estimated by univariate and multivariate logistic regression. The influence of DD duration on prognosis and sputum smear results were assessed by Spearman correlation coefficients.

RESULTS

We identified 208,822 PTB cases with a median DD of 33 days (interquartile range (IQR) 18-63). The trend of PTB with DD declined significantly between 2009 and 2017 (annual percent change (APC): - 4.0%, P = 0.047, 2009-2013; APC: - 6.6%, P = 0.001, 2013-2017). Patients aged > 45 years old (adjusted odds ratio (aOR): 1.223, 95% confidence interval (CI) 1.189-1.257, 46-65 years; aOR: 1.306, 95% CI 1.267-1.346, > 65 years), farmers (aOR: 1.520, 95% CI 1.447-1.596), and those with a previous treatment history (aOR: 1.759, 95% CI 1.699-1.821) were prone to developing long DD (> 30 days, P < 0.05). An unfavorable outcome was negatively associated with a short DD (OR: 0.876, 95% CI 0.843-0.910, P < 0.001). Sputum smear positive rate and unfavorable outcomes were positively correlated with DD duration (Spearman correlation coefficients (rs) = 1, P < 0.001).

CONCLUSIONS

The DD situation remains serious; more efficient and comprehensive strategies are urgently required to minimize DD, especially for high-risk patients.

Health system delay and its associated factors among tuberculosis patients in Gamo Zone public health facilities, Southern Ethiopia: An institution-based cross-sectional study

Background

Delayed tuberculosis (TB) diagnosis and treatment increase morbidity, mortality, expenditure, and transmission in the community. Early diagnosis and initiation of treatment are essential for effective TB control.

Objective

The main objective of this study was to assess the magnitude and factors associated with health system delay among tuberculosis patients in Gamo Zone, Southern Ethiopia.

Methods

A cross-sectional study was conducted in Gamo Zone, Southern Ethiopia from February to April 2019. Fifteen health facilities in the study area were selected randomly and 255 TB patients who were ≥ 18 years of age were included. Data were collected using a questionnaire through face-to-face interviews and analyzed using SPSS version 20.0. Health system delay was analyzed using the median as a cut-off. Logistic regression analysis was performed to investigate factors of delays. A p-value of ≤ 0.05 at multivariable analysis was considered statistically significant.

Results

The median (inter-quartile range) of health system delays was 14(6-30) days. About 54.5% of patients had prolonged health system delays. Patients who had multiple healthcare contacts (AOR: 5.74; 95% CI: 2.47, 13.34) and aged between 25 and 44 years old (AOR: 1.98; 95% CI: 1.02, 3.86) and aged ≥ 45 years (AOR: 3.54; 95% CI: 2.17, 14.27) were significantly associated with longer health system's delay. However, female gender (AOR: 0.46; 95% CI: 0.25, 0.87) and patients presenting symptoms [Hemoptysis (AOR: 0.27; 95%CI: 0.11, 0.65) and Chest pain (AOR: 0.28; 95%CI; 0.14, 0.56)] were significantly associated with reduced health system's delay.

Conclusion

In this study, it was observed that a significant proportion of patients experienced more than the acceptable level for health system delay. The number of health care contact, presenting symptoms, age and sex were factors associated with health system delay. Hence, increasing clinician awareness of TB clinical presentation, implementing systems enabling early case detection, and ensuring rapid diagnosis of TB are required to achieve further TB control. Finally, maintenance of a high index of suspicion for tuberculosis in the vulnerable population could reduce long health system delays in the management of TB.

Magnitude and determinants of delay in diagnosis of tuberculosis patients in Ethiopia: a systematic review and meta-analysis: 2020

Background

Tuberculosis (TB) remains a main public health concern in the world resulting in significant morbidity and mortality as well as in Ethiopia. In Ethiopia, there are various primary studies with inconsistent findings. Delay in the diagnosis of TB is determined by different factors like the type of TB, marital status, TB-HIV co-infection, employment status, place of residence, educational status, type of first visited a health facility, and gender of the patient. This review will produce pooled evidence on delay in diagnosis and associated factors among TB that might have huge public health impacts, like unfavorable treatment outcomes, increase transmission of the disease in the community for better intervention.

Methods

The presence of systematic reviews and meta-analysis on similar topics was checked and the topic was registered on PROSPERO to prevent duplication with the registration number of (CRD42020158963). Both published and unpublished studies conducted in Ethiopia from 2002 to April 1 2020 were searched thoroughly using electronic databases. Data were analyzed using STATA version 14. Heterogeneity was checked by using I² and Cochrane Q test. In the presence of heterogeneity, a random effect model was employed to estimate the pooled magnitude and determinants of diagnosis delay of TB. Publication bias was checked by using the graphical funnel plot and Egger’s statistical test.

Result

The Pooled magnitude of tuberculosis diagnosis delay in Ethiopia was 45.42% [95%CI 34.44, 56.40]. Residing in urban, having educational status and patients with positive serostatus were protective against TB diagnostic delay while having extra-pulmonary TB and not being married were risk factors for delaying TB diagnosis.

Conclusion

TB diagnosis delays in Ethiopia are significantly high. Sociodemographic and institutional factors were significantly contributing to the delay. Therefore, national TB control programs need to identify and address gaps, barriers, and weaknesses along the entire patient care cascade, to improve appropriately.

Total, Patient and System Diagnostic Delays for Pulmonary Bacilliferous Tuberculosis in the Six Diagnostic and Treatment Centers in the Five Health Districts of the Central Region, Burkina Faso, 2018

Introduction

Long diagnosis delay contributes significantly to the failure to eradicate tuberculosis. The objective of this study was to evaluate the total, patient and system delays in diagnosis of pulmonary bacilliferous in the six tuberculosis Diagnostic and Treatment Centers in the five health districts of the central region in Burkina Faso.

Methods

A descriptive cross-sectional study was conducted among 384 microscopy-positive pulmonary tuberculosis patients in 2018 to address this objective. It concerned the socio-demographic, clinical, microbiological characteristics, and referral location/pathway characteristics of the patients. We then calculated the different delays. The “patient” (time from first symptoms to first consultation), “system” (time from first consultation to first diagnosis) and total (time from first symptoms to diagnosis) median diagnostic delay were estimated.

Results

The median “total”, “patient” and “system” diagnostic times were 37, 21 and 7 days, respectively. Of the 384 patients surveyed, 158 patients or 41.25% of patients had a long total diagnostic delay (> 45 days). The number of patients with a long system diagnostic delay was 125 patients (32.55%; p < 0.001) and those with a long patient diagnostic delay were 105 patients (27.34%; p < 0.001).

Conclusion

The total diagnosis delay of pulmonary tuberculosis was long for almost half of the patients. Awareness of the signs of tuberculosis among patients and caregivers, and consultation in a health center must be intensified to help considerably reduce these delays.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44197-021-00027-z.

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis

BACKGROUND

Thirty countries with the highest tuberculosis (TB) burden bear 87% of the world's TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the duration and determinants of delayed diagnosis and treatment of pulmonary TB in high TB-burden countries.

METHODS

We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. We performed a narrative synthesis of the covariates significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis.

RESULTS

This review included 124 articles from 14 low- and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC). The pooled median duration of delays (in days) were-patient delay (LIC/LMIC: 28 (95% CI 20-30); UMIC: 10 (95% CI 10-20), health system delay (LIC/LMIC: 14 (95% CI 2-28); UMIC: 4 (95% CI 2-4), and treatment delay (LIC/LMIC: 14 (95% CI 3-84); UMIC: 0 (95% CI 0-1). There was consistent evidence that being female and rural residence was associated with longer patient delay. Patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Organizational and policy factors mediated health system and treatment delays. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high-burden countries.

CONCLUSIONS

This review presented the duration of delays and detailed the determinants of delayed TB diagnosis and treatment in high-burden countries. The gaps identified could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care. PROSPERO registration: CRD42018107237.

Reducing the risk of tuberculosis transmission for HCWs in high incidence settings

Globally, tuberculosis (TB) is a leading cause of death from a single infectious agent. Healthcare workers (HCWs) are at increased risk of hospital-acquired TB infection due to persistent exposure to Mycobacterium tuberculosis (Mtb) in healthcare settings. The World Health Organization (WHO) has developed an international system of infection prevention and control (IPC) interventions to interrupt the cycle of nosocomial TB transmission. The guidelines on TB IPC have proposed a comprehensive hierarchy of three core practices, comprising: administrative controls, environmental controls, and personal respiratory protection. However, the implementation of most recommendations goes beyond minimal physical and organisational requirements and thus cannot be appropriately introduced in resource-constrained settings and areas of high TB incidence. In many low- and middle-income countries (LMICs) the lack of knowledge, expertise and practice on TB IPC is a major barrier to the implementation of essential interventions. HCWs often underestimate the risk of airborne Mtb dissemination during tidal breathing. The lack of required expertise and funding to design, install and maintain the environmental control systems can lead to inadequate dilution of infectious particles in the air, and in turn, increase the risk of TB dissemination. Insufficient supply of particulate respirators and lack of direction on the re-use of respiratory protection is associated with unsafe working practices and increased risk of TB transmission between patients and HCWs. Delayed diagnosis and initiation of treatment are commonly influenced by the effectiveness of healthcare systems to identify TB patients, and the availability of rapid molecular diagnostic tools. Failure to recognise resistance to first-line drugs contributes to the emergence of drug-resistant Mtb strains, including multidrug-resistant and extensively drug-resistant Mtb. Future guideline development must consider the social, economic, cultural and climatic conditions to ensure that recommended control measures can be implemented in not only high-income countries, but more importantly low-income, high TB burden settings. Urgent action and more ambitious investments are needed at both regional and national levels to get back on track to reach the global TB targets, especially in the context of the COVID-19 pandemic.

Prevalence of delay in seeking tuberculosis care and the health care seeking behaviour profile of tuberculous patients in a rural district of KwaZulu Natal, South Africa

Introduction

patient delay in seeking TB (tuberculosis) care is reported as one of the major hurdles undermining the efforts of controlling TB by many TB control programmes of the world. The main aim of this study was to determine the prevalence of this phenomenon and to profile the TB patients that delayed seeking TB care in a rural area of KwaZulu Natal province of South Africa.

Methods

this was a cross-sectional study, conducted among 200 TB patients attending primary health care facilities in Ugu District. Patient data were collected by a self-administered questionnaire, entered into an Excel file and imported into the EpiInfo 7 statistical software for analysis. Frequency tables were used to display the data and the p value was used for statistical significance.

Results

about 40% of the participants delayed seeking TB care in this study, and these were mostly individuals who were married, the employed and those who walked to the clinic. Delay was also prevalent among those that self-medicated, bought medication from the pharmacy and sought TB care from a private doctor. The reasons included the great distances, long queues waiting at the facilities, and not feeling ill.

Conclusion

the 4 weeks cut-off in seeking TB care in this study far exceeds the recommended 2 weeks. This study recommends periodic active TB case finding and active engagement between the public and the private health sectors.

Evaluation of timeliness of treatment initiation among smear positive pulmonary tuberculosis patients in Brong Ahafo Region, Ghana, 2015

Background

We evaluated timeliness and factors influencing treatment initiation (TI) among smear positive pulmonary tuberculosis (PTB+) patients in Brong Ahafo Region (BAR), Ghana.

Design and Setting

We conducted a cross-sectional study in health facilities (HF) in six districts in BAR, from November 2014 to May 2015. Newly diagnosed smear positive PTB patients were selected randomly proportionate to size of facility cases. Timeliness of symptoms, diagnosis, TI and factors for delay were assessed using structured questionnaire. Patient delay was defined as presentation to a health care provider after 21 days of the onset of TBrelated symptoms and TI delay as therapy initiated after 30-days of onset of TB-related symptoms. We determined median patient timeliness, HF, and TI timeliness. We identified factors associated with TI delay using logistic regression.

Results

There were a total of 237 PTB+ patients; median patient timeliness of 30 days (IQR:14, 60). The median health facility timeliness was 8 days (IQR:4, 10); and the median TI timeliness was 36 days (IQR:25, 69). Majority (58.7%) of patients delayed in seeking treatment. TI delay was associated with: unemployment [aOR=7.4, 95%CI(1.9-28.8)], fear of losing job [aOR=3.4, 95%CI(1.3-8.5)], traditional healer as first port of call [aOR=10.6, 95%CI(13.0-66.8)], and initially being treated for HIV [aOR=4.9, 95%CI(1.6-14.8)].

Conclusion

There were delays in treatment initiation and patient treatment seeking timeliness. One-third of patients would prefer traditional healers/self-treatment/drug store as an option. A concerted effort by stakeholders is needed to improve behaviour change communication on good health seeking behaviour for persons living with TB to reduce delays in seeking treatment.

Funding

The study was funded by the authors.

Patient delay in the diagnosis of tuberculosis in Ethiopia: a systematic review and meta-analysis

Background

Delay in the diagnosis of Tuberculosis (TB) remains a major challenge against achieving effective TB prevention and control. Though a number of studies with inconsistent findings were conducted in Ethiopia; unavailability of a nationwide study determining the median time of patient delays to TB diagnosis is an important research gap. Therefore, this study aimed to determine the pooled median time of the patient delay to TB diagnosis and its determinants in Ethiopia.

Methods

We followed PRISMA checklist to present this study. We searched from Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library databases for studies. The comprehensive search for relevant studies was done by two of the authors (MA and LY) up to the 10th of October 2019. Risk of bias was assessed using the Newcastle-Ottawa scale adapted for observational studies. Data were pooled and a random effect meta-analysis model was fitted to provide the overall median time of patient delay and its determinants in Ethiopia. Furthermore, subgroup analyses were conducted to investigate how the median time of patient delay varies across different groups of studies.

Results

Twenty-four studies that satisfied the eligibility criteria were included. Our meta-analysis showed that the median time of the patient delay was 24.6 (95%CI: 20.8–28.4) days. Living in rural area (OR: 2.19, 95%CI: 1.51–3.18), and poor knowledge about TB (OR: 2.85, 95%CI: 1.49–5.47) were more likely to lead to prolonged delay. Patients who consult non-formal health providers (OR: 5.08, 95%CI: 1.56–16.59) had a prolonged delay in the diagnosis of TB. Moreover, the narrative review of this study showed that age, educational level, financial burden and distance travel to reach the nearest health facility were significantly associated with a patient delay in the diagnosis of TB.

Conclusions

In conclusion, patients are delayed more-than three weeks in the diagnosis of TB. Lack of awareness about TB, consulting non-formal health provider, and being in the rural area had increased patient delay to TB diagnosis. Increasing public awareness about TB, particularly in rural and disadvantaged areas could help to early diagnosis of TB.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12879-020-05524-3.

Factors associated with treatment initiation delay among new adult pulmonary tuberculosis patients in Tigray, Northern Ethiopia

Background

Delayed treatment initiation of Tuberculosis patients results in increased infectivity, poor treatment outcome, and increased mortality. However, there is a paucity of evidence on the delay in new adult pulmonary Tuberculosis patients to initiate treatment in Tigray, Northern Ethiopia.

Objective

To assess the factors associated with treatment initiation delay among new adult pulmonary tuberculosis patients in Tigray, Northern Ethiopia.

Methods

The study design was cross-sectional. A total of 875 new adult pulmonary tuberculosis patients were recruited from 21 health facilities from October 2018 to October 2019. Health facilities were selected by simple random sampling technique and tuberculosis cases from the health facilities were consecutively enrolled. Data were collected using structured questionnaire within the first 2 weeks of treatment initiation. Delay was categorized as patient, health system and total delays. Data were analyzed using SPSS version 21 and logistic regression was used to identify factors associated with the odds of delays to initiate treatment. A p-value of less than 0.05 was reported as statistically significant.

Results

The median patient, health system and total delays were 30, 18 and 62 days, respectively. Rural residence, being poor, visiting non-formal medication sources, being primary health care and the private clinic had higher odds of patient delay whereas being HIV positive had lower odds of patient delay. Illiteracy, first visit to primary health care and private clinic had higher odds of health system delay whereas a visit to health facility one time and have no patient delay had lower odds of health system delay.

Conclusion

The median patient delay was higher than the median health system delay before initiating treatment. Hence, improved awareness of the community and involving the informal medication sources in the tuberculosis pathways would reduce patient delay. Similarly, improved cough screening and diagnostic efficiency of the lower health facilities would shorten health system delay.

Barriers and facilitators to bidirectional screening of TB-DM in Ghana: Healthcare workers' perspectives

Background

The tuberculosis (TB) and diabetes mellitus (DM) co-epidemic continues to increase globally. Low-and middle-income countries bear the highest burden of co-epidemic, and Ghana is no exception. In 2011, the World Health Organisation (WHO) responded to this global challenge by launching a collaborative framework with a view to guide countries in implementing their DM and TB care, prevention and control plans. Subsequently, several countries, including Ghana, adopted this framework and began implementing bidirectional screening of TB and DM patients. Almost a decade later since the launch of the framework, the implementation of bidirectional screening in Ghana has not been subjected to empirical research. This study explored the barriers and facilitators to bidirectional screening through the lenses of the implementing healthcare workers.

Methods

This was an exploratory qualitative study conducted in three public health facilities offering both TB and DM services in Northern Ghana. In-depth interviews, document review and observations, were used to generate data. In total twenty-three healthcare workers (doctors, nurses, prescriber, health managers and TB task- shifting officers delivering care in TB and DM clinics) were interviewed, using semi-structured interview guides. The interview questions solicited information on the screening process, including knowledge of the collaborative framework, comorbidity, collaboration and workload.

Results

Six themes emerged from the analysis, of which two (Increase in staff capacity, and Institutionalisation of bidirectional screening) were facilitators, and four (Delays in screening, Fear and stigmatization of TB, Poor collaboration between TB and DM units, and Skewed funding for screening) were barriers.

Conclusions

The implementation of bidirectional screening at public health facilities in Ghana was evident in this study and increased staff capacity, funding and institutionalisation enhanced the policy implementation process. However, the screening of TB patients for DM is yet to be prioritised, and emphasis should be put on the design for cost-effective screening approaches for low- and middle-income countries.

Delays in care seeking, diagnosis and treatment of patients with pulmonary tuberculosis in Hubei, China

BACKGROUND

Early diagnosis and treatment are essential for effective tuberculosis (TB) control. However, delays in the diagnosis and treatment of TB in central China have not been sufficiently investigated. This cross-sectional study was conducted between October 2013 and March 2014 in Hubei, China to identify risk factors of delays in care seeking, diagnosis and treatment among patients with TB.

METHODS

A total of 1342 patients with TB seen in the designated institutions were included. Multivariate logistic regression was used to analyse factors associated with delays in TB diagnosis and treatment.

RESULTS

Overall, 21.54%, 23.62% and 42.25% of patients with TB experienced delays in care seeking, diagnosis and treatment, respectively. Multivariate logistic regression showed that medical insurance and monthly household income were significantly associated with delays in care seeking. The time to reach a township hospital or the facility of a patient's first consultation was significantly associated with delays in diagnosis. Sex, education, time to reach a township hospital and the facility where the diagnosis was made were significantly associated with delays in treatment.

CONCLUSIONS

Delays in TB diagnosis and treatment in Hubei remain a serious issue. Improvements in the capability and accessibility of health care services are imperative to reduce delays and expedite TB diagnosis and treatment.

Improving sputum collection processes to increase tuberculosis case finding among HIV-positive persons in Botswana

SETTING

Twenty-two human immunodeficiency virus (HIV) clinics in Botswana.

OBJECTIVE

To compare sputum collection rates, sputum quality and volume, and tuberculosis (TB) diagnosis rates before and after field efforts to improve sputum collection among individuals newly diagnosed with HIV with TB symptoms.

DESIGN

Newly diagnosed individuals living with HIV attending 22 HIV clinics in Botswana were screened for TB from August 2012 to March 2014. Starting in May 2013, a field intervention composed of the introduction of a tracking log for presumed TB patients, and patient instructions and sputum induction to improve sputum collection rates was implemented.

RESULTS

Prior to the intervention, sputum collection rates were 44.1% (384/870). Subsequently, sputum collection increased to 58.3% (579/993) (P < 0.001). Sputum quality and volume also improved. Although rates of TB diagnosis increased from 9.7% (84/870) to 12.5% (120/993), this difference was not significant (P = 0.143).

CONCLUSION

Sputum collection rates among presumptive TB cases, as well as sputum quality and volume improved after implementation of the field intervention. To improve sputum collection rates, efforts at the program level should be ongoing.

Rural Residence and Diagnostic Delay for Amyotrophic Lateral Sclerosis in Saskatchewan

BACKGROUND

Diagnostic delay in amyotrophic lateral sclerosis (ALS) is common. In a recent Canadian study evaluating provincial differences in care, Saskatchewan had the longest delay at 27 months. Since Saskatchewan has a large rural population, this study sought to determine whether geographically determined access to a neurologist at tertiary centers could be contributing to this lengthy delay.

METHODS

A retrospective chart review of 171 patients seen in the ALS clinic in Saskatoon, Saskatchewan was performed. Urban or rural location, distance from nearest tertiary center, and clinically relevant data were collected.

RESULTS

There was no difference between urban and rural populations for delay in symptom onset to diagnosis. For rural patients, linear regression modeling did not uncover a significant relationship between distance from tertiary center and time to diagnosis. Additionally, there were no differences between urban and rural dwellers either for referral or utilization of feeding tube, noninvasive ventilation, riluzole, or communication devices. Contrary to the previous data showing a 27-month diagnostic delay in Saskatchewan, our study which included a larger provincial population found the mean diagnostic delay was 16.6 months.

CONCLUSIONS

This study did not uncover differences in diagnostic delay or ALS care between urban and rural dwellers. Further study is required to determine reproducibility of results.

Time Interval for Diagnosis of Tuberculosis and Related Expenditure in Selected Health Centers in Addis Ababa, Ethiopia

Background. Tuberculosis (TB) has continued to be a major health problem globally, in spite of the efforts to improve the diagnosis, treatment, and prevention. It affects millions of people each year and stands as the second cause of death due to infectious disease in the world. Early case finding and timely initiation of treatment is essential to ensure effective control of the disease as late diagnosis and treatment can aggravate the disease and result in poor outcomes and increase chances of transmission. Although TB services are supposed to be provided free of charge, TB affected families incur different types of costs in the process of seeking care, which might include health and nonhealth related costs. TB programs need to identify the underlying factors for delay and related expenditure for TB related services, in order to devise an effective strategy to reduce them. Therefore, the study aimed to assess the time interval between developing TB symptom until patients start anti-TB treatment and associated cost incurred by patients and families. Methods. This cross-sectional study was conducted among pulmonary TB patients who are bacteriologically confirmed, whose age is above 15 years and diagnosed at health centres in Addis Ababa. Results. The median time interval between onset of symptom and commencement of treatment was 4 weeks (IQR: 3, 6). Most patients with TB symptoms visited several health facilities before the final diagnosis was confirmed, the median number of visits being two, and only 48.8% were diagnosed on their first visit. Hence, they spent a lot of their limited resource in search of getting the right diagnosis. The total combined expenditure for all the visits was estimated to be median (IQR) 172.65 birrs (12, 671). Two variables were found to show statistically significant association with higher expenditure. Respondents who have good level of knowledge about TB are less likely to spend more than the median expenditure almost by a fifth compared to those with limited knowledge on TB, (adjusted odds ratio (AOR) = 0.2, with 95% confidence interval (CI): 0.06, 0.84). Patients who visited public hospitals were almost three times and those who visited private health facilities almost four times more likely to pay more than the median total expenditure, compared to those who visited health centre, AOR (95% CI) = 2.8 (1.53, 5.19) and AOR (CI) of 3.86 (1.06, 14.03), respectively. Conclusion. Patients with TB symptoms visit several health facilities till they are diagnosed, the median duration from onset of symptom till commencement of TB treatment being 4 weeks. It was noted that they face major expenses in the process of navigation to the right care. Two variables had statistically significant association with high pre-diagnosis expenditure, where patients with good level of knowledge about TB are less likely to spend more than the median, while patients who visited public hospitals or private health facilities had very high expenses. Improved public awareness about TB, minimizing service charges and other related fees, and further improvement in increasing access to services could reduce the length of time and expense for TB patients and their families. It is recommended to build capacity of health service providers to update them on programmatic approaches and latest diagnostic algorithm. It is important to strengthen public private partnership for TB services.

TB treatment delay associated with drug resistance and admission at Daru General Hospital in Papua New Guinea

SETTING

Daru General Hospital, Daru Island, Papua New Guinea, where high rates of tuberculosis (TB) have been reported. Prompt diagnosis and effective treatment are needed for improving TB outcomes and to prevent nosocomial transmission.

OBJECTIVE

To assess the time to treatment initiation and the risk factors associated with delayed treatment for patients started on TB treatment at Daru General Hospital from January to September 2017.

DESIGN

This was a retrospective cohort study that entailed reviewing the records from treatment, admission, discharge and presumptive TB registers.

RESULTS

The study included 360 patients on TB treatment. The median time from presentation to treatment initiation was 7 days [IQR 3-11]. Treatment was started <7 days for 215 patients (60%); however, only 16.2% commenced treatment <2 days. Risk factors for delayed treatment were diagnosis of TB as an inpatient (OR 2.67, 95% CI 1.35-5.28, P = 0.005) and having drug-resistant TB (OR 2.65, 95% CI 1.5-4.68. P = 0.001).

CONCLUSION

A high proportion of TB patients commenced treatment <7 days. Inpatient status, DR-TB and lack of microbiological confirmation were associated with delays in treatment initiation. We recommend that programmes monitor the time from presentation to treatment initiation, and propose that a period of >3 days from presentation to treatment initiation be considered as delayed treatment initiation.

Health seeking behavior among individuals presenting with chronic cough at referral hospitals in Uganda; Missed opportunity for early tuberculosis diagnosis

Background

Tuberculosis (TB) is the 9^th leading cause of death from a single infectious agent. Patients live in a complex health care system with both formal and informal providers, and it is important that a TB diagnosis is not missed at the first interaction with the health care system. In this study, we highlight the health seeking behavior of patients and missed opportunities for early TB diagnosis for which interventions could be instituted to ensure early TB diagnosis and prompt TB treatment initiation.

Methods

This study was nested in a cross-sectional study that assessed the accuracy of different Xpert MTB/Rif implementation strategies in programmatic settings at the referral hospitals in Uganda. We documented the symptom profile of presumptive TB patients and assessed the health seeking behavior of those with chronic cough by calculating proportion of patients that visited each type of health facility and further calculated the odds of being TB positive given the type of health facility initially visited for consultation.

Results

A total of 1,863 presumptive TB patients were enrolled of which 979 (54.5%) were male, and 1795 (99.9%) had chronic cough. A total of 1352 (75.4%) had previously sought care for chronic cough, with 805 (59.6%) seeking care from a public health facility followed by private health facility (289; 21.4%). Up to 182 (13.5%) patients visited a drug store for chronic cough. Patients whose first contact was a private health facility were more likely to have a positive GeneXpert test (adjOR 1.4, 95% CI: 1.0–1.9; p = 0.047).

Conclusions

Chronic cough is a main symptom for many of the presumptive TB patients presenting at referral hospitals, with several patients having to visit the health system more than once before a TB diagnosis is made. This suggests the need for patients to be thoroughly evaluated at first interface with the health care system to ensure prompt diagnosis and treatment initiation. Improved TB diagnosis possibly with the GeneXpert test, at first contact with the health care system has potential to increase TB case finding and break the transmission cycle in the community.

Total Delay in Treatment of Tuberculosis and Associated Factors among New Pulmonary TB Patients in Selected Health Facilities of Gedeo Zone, Southern Ethiopia, 2017/18

BACKGROUND

TB is an infectious disease caused by the bacillus Mycobacterium TB complex. It is a major public health concern causing devastating illness in millions of people each year and one of the top 10 causes of death worldwide following HIV pandemic. It demands huge costs each year for prevention, diagnosis, and treatment of TB. Global TB control progress depends on major advances in early diagnosis and treatment. Despite progress in providing diagnosis and preventive treatment of TB, big detection and treatment gaps remained with delayed diagnosis and treatment of TB especially in resource-limited countries. This is mainly because of factors related to the patient and health care system including sociodemographic, economic, and cultural barriers to accessing TB care.

OBJECTIVE

The study conducted in Gedeo Zone, Southern Ethiopia, had the primary purpose of identifying the median delay in starting a correct TB treatment and the associated factors for such a delay in patients newly diagnosed with PTB in selected health facilities of Gedeo Zone, Southern Ethiopia, 2017/18.

METHODS

Institutional based cross-sectional study was conducted among new pulmonary TB patients in selected health institution of Gedeo Zone, Southern Ethiopia, 2017, from October, 2017, to May, 2018. All new pulmonary TB patients who fulfill the inclusion criteria during the study period were included in the study after informed consent was obtained from the participants. Data was cleaned, coded, and entered into SPSS version 20 for analysis. A frequency for variables was calculated. Chi-square was used to screen the possible potential associated factors and multivariate analysis was used to ascertain the association between variables. All statistical tests values of p<0.05 were considered as statistically significant.

RESULT

The median total in treatment of TB was 60 days. Among the total study participants, 50.9% of the participants have unacceptable/longer total delay in TB treatment. Being of female gender, not attending formal education, having rural residency, having poor knowledge of TB, having home distance >10Km from the nearest health facility, visiting nonformal health care provider, and taking antibiotic treatment before TB diagnosis empirically were identified as significant independently associated factors for unacceptable total treatment in TB.

CONCLUSIONS

There was higher median total delay in treatment of TB (60 days) and an overall prevalence of 50.9% unacceptable/longer total delay in treatment of TB. Female gender, rural residence, not attending formal education, visiting nonformal health facility as first health care seeking, having poor knowledge of TB, and having antibiotic treatment before TB diagnosis were identified as independent significant associated factors.

Delays to anti-tuberculosis treatment intiation among cases on directly observed treatment short course in districts of southwestern Ethiopia: a cross sectional study

BACKGROUND

Delayed tuberculosis (TB) diagnosis and treatment increase morbidity, mortality, expenditure, and transmission in the community. This study assessed patient and provider related delays to diagnosis and treatment of TB.

METHODS

A cross-sectional study was conducted among 735 new adult TB cases registered between January to December 2015 in 10 woredas equivalent to districts of southwestern Ethiopia. Data were collected through face-to-face interview of patients within the first 2 months of treatment initiation. Delay in days was tracked at three intervals: between onset of symptoms and self-presentation (Patient delay), Self-presentation to treatment initiation (Provider delay) and total delay. Days elapsed beyond median were used to define the delays. Bivariate and multiple logistic regression models were fit to identify predictors of delays and statistical significance was judged at p < 0.05.

RESULT

The median (inter-quartile range) of patient, provider and total delays were 25 (IQR;15-36), 22 (IQR:9-48) and 55 (IQR:32-100) days, respectively. More than half (54.6%) of the total delay was attributed to health system. Prior self-treatment [adjusted Odds Ratio (aOR)]: 1.72, 95% confidence interval [CI]:1.07-2.75), HIV co-infection (aOR:1.8, 95% CI: 1.05-3.10) and extra-pulmonary TB (aOR: 1.54,95% CI:1.03-2.29) were independently associated with increased odds of patient delay. On the other hand initial presentation to health posts or private clinics (aOR: 1.42, 95% CI: 1.01, 2.0) and patient delay (aOR: 1.81, 95% CI: 1.33-2.50) significantly predicted longer provider delay. Finally, having extra pulmonary TB (aOR: 1.6, 95% CI: 1.07-2.38), prior consultation of traditional healer (aOR: 3.72, 95% CI: 1.01-13.77) and use of holy water (aOR: 2.73, 95% CI: 1.11, 6.70) independently predicted longer total delay.

CONCLUSION

Tuberculosis patients waited too long time to initiate anti-TB treatment reflecting longer periods of morbidity and disease transmission. The delays are attributed to the patient, disease and health system related factors. Hence, improving community awareness, involving informal providers, health extension workers and TB treatment supporters can reduce the patient delay. Similarly, cough screening and improving diagnostic efficiencies of healthcare facilities should be in place to reduce the provider delays.

Patient Health Seeking and Diagnostic Delay in Extrapulmonary Tuberculosis: A Hospital Based Study from Central India

Objective

We aimed to investigate the awareness, health care seeking behavior, and diagnostic delay in extrapulmonary tuberculosis (EPTB) in a resource-constrained setting from Central India.

Setting and Method

Questionnaire based interview of 1220 EPTB patients ≥14 years of age was conducted between July 2004 and August 2012 at Ujjain charitable Hospital, Ujjain, India.

Results

Only 15% of patients had ever heard about EPTB and 2-4% knew about its prevention or treatment. Only 12% patients first sought medical advice while 49% patients practiced self-medication, 28% consulted traditional healers and 11% drug store/pharmacy. The median patient delay was 8 weeks (4.6-21.4 weeks). Majority (78%) of patients visited ≥3 health centers. Thirty-eight percent patients first visited any government health facility. Majority (97%) who first visited district and primary public health center were referred to private sector for investigations and 82% patients changed the consultation to private doctor after initial visit to public hospital. The median health system delay was 7 weeks (0.6-16.4 weeks).

Conclusion

Patients had very poor awareness of EPTB. Patients were referred from public to private sector in search of diagnostic facilities. Improvement of public awareness about EPTB and better public-private partnership may contribute towards reduction in diagnostic delay.

Determinants of Health Care-Seeking Delay among Tuberculosis Patients in Rural Area of Central China

Background The prevalence of tuberculosis (TB) in low and middle-income countries is a significant public health and social concern. TB is a common infectious disease caused by the Mycobacterium tuberculosis infection, which has a widespread infection rate. Health care-seeking delay maybe one of the most important neglected risk factors for the spread of TB. Objectives The aim of this study was to understand the situation of health care-seeking delay among rural tuberculosis patients in Hubei Province, and explore its risk factors. Methods A total of 1408 rural tuberculosis patients were surveyed using a standard structured questionnaire in three cities of Hubei Province during the past two years. Results For the 1408cases of pulmonary tuberculosis, 39.70% of them were health care-seeking delayed. Logistic regressions indicate that the Han nationality, farming careers, the over 45 min walk to the township’s hospital, and awareness of the national TB free treatment policy, were significantly associated with higher odds of a delay in care seeking. Conclusions The prevalence of health care-seeking delay among tuberculosis patients was high in rural areas. It is essential to take comprehensive targeted interventions to reduce care-seeking delay.

Diagnostic delay in extrapulmonary tuberculosis and impact on patient morbidity: A study from Zanzibar

Background

Early and proper treatment of tuberculosis could have an important impact on the morbidity, mortality and the economic situation of patients. There is insufficient knowledge on the extent of diagnostic delay and the associated factors in extrapulmonary tuberculosis (EPTB). The aims of this study were to assess the health care seeking behaviour, EPTB knowledge and diagnostic delay in presumptive EPTB patients at the main referral hospital in Zanzibar, factors associated with longer delay, and the impact of untreated EPTB on self-rated health.

Materials and methods

Prospective data collection using a semi-structured questionnaire in patients presenting with symptoms suggestive of EPTB. The time between the onset of symptoms and first visit to a health care provider (patient delay), and then to the initiation of treatment (health system delay) and total delay were analysed according to sociodemographic and clinical factors and health care seeking trajectories. The EQ-5D-3L was used among the adult EPTB patients to assess the impact of treatment on self-rated health.

Results

Of the 132 patients with median age of 27 years (interquartile range 8–41), 69 were categorized as TB cases and 63 as non-TB cases. The median patient, health system and total delays were 14, 34 and 62 days respectively, among the EPTB patients. A longer health system delay with repeated visits to the same health care level was reported. Significantly better self-rated health status was described after treatment. The knowledge regarding extrapulmonary disease was low.

Conclusion

Many EPTB patients, presenting to the main referral hospital in Zanzibar, experience a long delay in the initiation of treatment, specially patients with TB lymphadenitis. The health system delay is the major contributor to the total delay. The improvement of self-rated health after treatment implies that timely treatment has the potential to reduce morbidity and the economic loss for the patient.

Factors associated with treatment delay among newly diagnosed tuberculosis patients in Dessie city and surroundings, Northern Central Ethiopia: a cross-sectional study

BACKGROUND

Delayed treatment of tuberculosis (TB) cases increases the risk of death and rate of infection in the community. Early diagnosis and initiation of treatment is essential for effective TB control. The aim of this study was to assess length of delays and analyze predictors of treatment delay of newly diagnosed TB patients.

METHODS

A cross-sectional study was conducted in Dessie city and surroundings from April1, 2016 to January 30, 2017. Fifteen health facilities of study area were selected randomly and 382 adult TB patients were included consecutively. Data were collected using a questionnaire and analyzed using SPSS version 20.0. Delay was analyzed at three levels (patient, health system and total) using median as cut-off. Logistic regression analysis was performed to investigate predictors of delays. A p-value of ≤0.05 at multivariate analysis was considered statistically significant.

RESULTS

The median total, patients' and health system's delay was 36 [interquartile range (IQR): 24, 64], 30 (IQR: 15, 60) and 6 (IQR: 4, 8) days, respectively. About 41 and 47% of patients had prolonged patients' and total delay, respectively. Practicing self-medication [adjusted odds ratio (AOR): 3.0; 95% CI: 1.3-5.6], having more than three family member in the household (AOR: 1.6; 95% CI: 1.02-2.50), older age (≥55 years) (AOR: 2.7; 95% CI: 1.27-5.83), being smear negative pulmonary tuberculosis (AOR: 2.3; 95% CI: 1.25-4.21) and extrapulmonary tuberculosis (AOR: 2.3; 95% CI: 1.28-4.07) were independent predictors of patients' delay. Initial visit of general practitioners (AOR: 2.57; 95% CI: 1.43-4.63) and more than one health care visit (AOR: 2.12; 95% CI: 1.30-3.46) were independent predictors of health system's delay. However, patients' delay was shorter among widowed/divorced patients (AOR: 0.3; 95% CI: 0.1-0.8). Lower level of education [illiterate (AOR: 0.42; 95% CI: 0.20-0.92), grade 1-8 (AOR: 0.38; 95% CI: 0.18-0.81)] and diagnosis of TB using a chest X-ray (AOR, 0.32; 95% CI, 0.16-0.68) significantly reduce health system's delay.

CONCLUSION

About half of TB patients delayed beyond 36 days before starting treatment, and the late patient health seeking behavior was the major contributor of total delay. Development and implementation of strategies aimed at addressing identified factors should be recognized in order to reduce TB treatment delay. Further well designed research is needed to explore additional risk factors of delayed treatment.

Delay in diagnosis of pulmonary tuberculosis in low-and middle-income settings: systematic review and meta-analysis

Background

Assessment of delays in seeking care and diagnosis of tuberculosis is essential to evaluate effectiveness of tuberculosis control programs, and identify programmatic impediments. Thus, this review of studies aimed to examine the extent of patient, health system, and total delays in diagnosis of pulmonary tuberculosis in low- and middle- income countries.

Methods

It was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Electronic databases were searched to retrieve studies published from 2007 to 2015 including Pubmed central, Springer link, Hinari and Google scholar. Searching terms were pulmonary tuberculosis, health care seeking, health care seeking behavior, patient delay, diagnostic delay, health system delay, provider delay, and doctor delay. Retrieved studies were systematically reviewed and summarized using Comprehensive Meta-analysis software.

Results

Forty studies involving 18,975 patients qualified for systematic review, and 14 of them qualified for meta-analysis. The median diagnostic delay ranged from 30 to 366.5 days [IQR = 44–77.8], with a 4–199 days [IQR = 15–50] and 2–128.5 days [IQR = 12–34] due to patient and health system delays, respectively. The meta-analysis showed 42% of pulmonary tuberculosis patients delayed seeking care by a month or more; uneducated patients [pooled OR = 1.5, 95%CI = 1.1–1.9] and those who sought initial care from informal providers [pooled OR = 3, 95%CI = 2.3–3.9] had higher odds of patient delay.

Conclusion

Delay in diagnosis is still a major challenge of tuberculosis control and prevention programs in low- and middle- income settings. Efforts to develop new strategies for better case-finding using the existing systems and improving patients’ care seeking behavior need to be intensified.

Tuberculosis treatment success among rural and urban Ugandans living with HIV: a retrospective study

Setting: Government health centres and hospitals (six urban and 20 rural) providing tuberculosis (TB) treatment for people living with the human immunodeficiency virus (PLHIV) in central and western Uganda. Objective: To identify and quantify modifiable factors that limit TB treatment success among PLHIV in rural Uganda. Design: A retrospective cross-sectional review of routine Uganda National Tuberculosis and Leprosy Programme clinic registers and patient files of HIV-positive patients who received anti-tuberculosis treatment in 2014. Results: Of 191 rural patients, 66.7% achieved treatment success compared to 81.1% of 213 urban patients. Adjusted analysis revealed higher average treatment success in urban patients than in rural patients (OR 3.95, 95%CI 2.70-5.78, P < 0.01, generalised estimating equation model). Loss to follow-up was higher and follow-up sputum smear results were less frequently recorded in TB clinic registers among rural patients. Patients receiving treatment at higher-level facilities in rural settings had greater odds of treatment success, while patients receiving treatment at facilities where drug stock-outs had occurred had lower odds of treatment success. Conclusion: Lower reported treatment success in rural settings is mainly attributed to clinic-centred factors such as treatment monitoring procedures. We recommend strengthening treatment monitoring and delivery.

Diagnostic delay and associated factors among patients with pulmonary tuberculosis in Dar es Salaam, Tanzania

Background

Tanzania is among the 30 countries with the highest tuberculosis (TB) burdens. Because TB has a long infectious period, early diagnosis is not only important for reducing transmission, but also for improving treatment outcomes. We assessed diagnostic delay and associated factors among infectious TB patients.

Methods

We interviewed new smear-positive adult pulmonary TB patients enrolled in an ongoing TB cohort study in Dar es Salaam, Tanzania, between November 2013 and June 2015. TB patients were interviewed to collect information on socio-demographics, socio-economic status, health-seeking behaviour, and residential geocodes. We categorized diagnostic delay into ≤ 3 or > 3 weeks. We used logistic regression models to identify risk factors for diagnostic delay, presented as crude (OR) and adjusted Odds Ratios (aOR). We also assessed association between geographical distance (incremental increase of 500 meters between household and the nearest pharmacy) with binary outcomes.

Results

We analysed 513 patients with a median age of 34 years (interquartile range 27–41); 353 (69%) were men. Overall, 444 (87%) reported seeking care from health care providers prior to TB diagnosis, of whom 211 (48%) sought care > 2 times. Only six (1%) visited traditional healers before TB diagnosis. Diagnostic delay was positively associated with absence of chest pain (aOR = 7.97, 95% confidence intervals [CI]: 3.15–20.19; P < 0.001), and presence of hemoptysis (aOR = 25.37, 95% CI: 11.15–57.74; P < 0.001) and negatively associated with use of medication prior to TB diagnosis (aOR = 0.31, 95% CI: 0.14–0.71; P = 0.01). Age, sex, HIV status, education level, household income, and visiting health care facilities (HCFs) were not associated with diagnostic delay. Patients living far from pharmacies were less likely to visit a HCF (incremental increase of distance versus visit to any facility: OR = 0.51, 95% CI: 0.28–0.96; P = 0.037).

Conclusions

TB diagnostic delay was common in Dar es Salaam, and was more likely among patients without prior use of medication and presenting with hemoptysis. Geographical distance to HCFs may have an impact on health-seeking behaviour. Increasing community awareness of TB signs and symptoms could further reduce diagnostic delays and interrupt TB transmission.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0276-4) contains supplementary material, which is available to authorized users.

Factors associated with the length of delay with tuberculosis diagnosis and treatment among adult tuberculosis patients attending at public health facilities in Gondar town, Northwest, Ethiopia

Background

Early diagnosis and prompt treatment is essential for an effective tuberculosis (TB) control program. However, significant proportion of cases remains undiagnosed and untreated. Delay in diagnosis and treatment increases transmission. Hence, the study assessed the length of delay and associated factors with tuberculosis diagnosis and treatment among adults attending public health facilities in Gondar town, Northwest Ethiopia.

Method

An institution based cross-sectional study was conducted from February to May, 2016. A total of 296 adults who came to health facilities for treatment for pulmonary TB from February to May, 2016, were included in the study. Data were collected using a structured questionnaire through interviewing and record review, cleaned, coded, and entered into Epi-info version 3.5.3, and transferred into SPSS version 20.0 for further statistical analysis. A p-value of less than 0.05 at multiple linear regression analysis was considered statistically significant.

Result

The mean duration of the total delay (in days) for tuberculosis diagnosis and initiation of treatment was 41.6 days (SD = 16.6). In this study, the mean duration of patient delay and the median health system delay were 33.9 days (SD = 14) and 5 days (IQR = 4–7), respectively. Total delay for TB diagnosis and treatment was shorter among HIV positive people (β:-12.62, 95% CI: −20.72,-4.53). Longer patient delay was noted among rural dwellers (β: 8.0, 95% CI: 5.26, 10.75); increased household income (β:-0.006, 95% CI: −0.008,-0.004) was associated with a shorter delay. Health system delay was positively associated with seeking care from more than one health care providers (β: 0.28, 95% CI: 0.23, 0.34) and seeking initial care from primary level health care facilities (β: 0.10, 95% CI: 0.07, 0.13).

Conclusion

In this study, the majority of patients faced delayed in seeking health care and continued as sources of infection. Longer days of delay for TB diagnosis and treatment were noted among rural residents, who seek health care from informal care providers, and receive initial care from primary level health care facilities. In contrast, the length of delay for TB diagnosis and treatment was shorter among HIV positive people and individuals with increased household income. Therefore, public awareness on the symptoms of tuberculosis and seeking health care early is essential. Moreover, early diagnosis and treatment, especially among the rural dwellers and the poor should be focused.

Microbiologically Confirmed Tuberculosis: Factors Associated with Pre-Treatment Loss to Follow-Up, and Time to Treatment Initiation

Background

The impact of new diagnostics on pre-treatment loss to follow up (Pre-treatment LTFU) has not been widely investigated. The reported rate of pre-treatment LTFU is however lower in studies where Xpert MTB/Rif (Xpert) has been used onsite as opposed to centrally. The use of the Xpert at point of care (POC) could have a role in reducing the pre-treatment LTFU rate among TB patients. We aimed to determine the pre-treatment LTFU rate and the time to treatment initiation as well as to describe associated factors in patients diagnosed with TB using POC Xpert or smear microscopy.

Method

Xpert machines were installed at 7 primary healthcare facilities in inner-city Johannesburg. POC Xpert TB testing was the primary diagnostic method for all patients although there were some patients who were tested using only laboratory-based smear microscopy (during power outages or machine operator off-sick). Data on patients’ demographics, TB diagnostic test (Xpert or smear microscopy), test result, and time to treatment initiation were collected. Associations and predictors of pre-treatment LTFU and time to treatment initiation were explored.

Findings

A total of 1981 people with presumptive TB were tested (1743 using Xpert and 238 using smear). A bacteriological diagnosis of TB was made in 271 patients (90% Xpert; 10% smear). The median time to treatment initiation in the smear group was 9 days (IQR: 4–20) while those tested using Xpert had a median time of 0 days (IQR: 0–0). Pre-treatment LTFU was 22.5% with no difference between diagnostic groups (p = 0.8).

Conclusion

The Pre-treatment LTFU rate of 22.5% found in this study is much higher than the 5% target of the South African National TB Control Program. POC Xpert resulted in a significantly greater proportion of bacteriologically proven TB patients being started on treatment within 30 days of presentation. No risk factors associated with pre-treatment LTFU were identified.

Barriers to initiating tuberculosis treatment in sub-Saharan Africa: a systematic review focused on children and youth

BACKGROUND

Tuberculosis (TB) is the deadliest infectious disease globally, with 10.4 million people infected and more than 1.8 million deaths in 2015. TB is a preventable, treatable, and curable disease, yet there are numerous barriers to initiating treatment. These barriers to treatment are exacerbated in low-resource settings and may be compounded by factors related to childhood.

OBJECTIVE

Timely initiation of tuberculosis (TB) treatment is critical to reducing disease transmission and improving patient outcomes. The aim of this paper is to describe patient- and system-level barriers to TB treatment initiation specifically for children and youth in sub-Saharan Africa through systematic review of the literature.

DESIGN

This review was conducted in October 2015 in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Six databases were searched to identify studies where primary or secondary objectives were related to barriers to TB treatment initiation and which included children or youth 0-24 years of age.

RESULTS

A total of 1490 manuscripts met screening criteria; 152 met criteria for full-text review and 47 for analysis. Patient-level barriers included limited knowledge, attitudes and beliefs regarding TB, and economic burdens. System-level barriers included centralization of services, health system delays, and geographical access to healthcare. Of the 47 studies included, 7 evaluated cost, 19 health-seeking behaviors, and 29 health system infrastructure. Only 4 studies primarily assessed pediatric cohorts yet all 47 studies were inclusive of children.

CONCLUSIONS

Recognizing and removing barriers to treatment initiation for pediatric TB in sub-Saharan Africa are critical. Both patient- and system-level barriers must be better researched in order to improve patient outcomes.

Patients' and health system's delays in the diagnosis and treatment of new pulmonary tuberculosis patients in West Gojjam Zone, Northwest Ethiopia: a cross-sectional study

Background

Tuberculosis (TB) is a major public health concern in the developing world. Early diagnosis and prompt initiation of treatment is essential for effective TB control. The aim of this study was to determine the length and analyze associated factors of patients’ and health system’s delays in the diagnosis and treatment of new pulmonary TB (PTB) patients.

Methods

A cross-sectional study was conducted in 30 randomly selected public health facilities in West Gojjam Zone, Amhara Region, Ethiopia. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study. Patients’ delay (the time period from onset of TB symptoms to first presentation to a formal health provider) and health system’s delay (the time period from first presentation to a formal health provider to first start of TB treatment) were measured. Median patients’ and health system’s delays were calculated. Mixed effect logistic regression was used to analyze predictors of patients’ and health system’s delays.

Results

Seven hundred six patients were enrolled in the study. The median patients’ delay was 18 days (interquartile range [IQR]: 8–34 days) and the median health system’s delay was 22 days (IQR: 4–88 days). Poor knowledge of TB (adjusted odds ratio [AOR], 2.33; 95 % confidence interval [CI], 1.34–4.05), first visit to non-formal health provider (AOR, 47.56; 95 % CI, 26.31–85.99), self-treatment (AOR, 10.11; 95 % CI, 4.53–22.56) and patients’ age (≥45 years) (AOR, 2.99; 95 % CI, 1.14–7.81) were independent predictors of patients’ delay. Smear-negative TB (AOR, 1.88; 95 % CI, 1.32–2.68) and first visit to public health centers (AOR, 2.22; 95 % CI, 1.52–3.25) and health posts (AOR, 5.86; 95 % CI, 1.40–24.39) were found to be independent predictors of health system’s delay.

Conclusions

The health system’s delay in this study was long and contributed more than 50 % of the total delay. Better TB diagnostic tools to complement sputum smear microscopy are needed to early diagnose PTB cases at peripheral health facilities. In addition, due emphasis should be given to increase public awareness about symptoms and consequences of TB disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1995-z) contains supplementary material, which is available to authorized users.

Factors associated with delayed screening of contacts of tuberculosis cases in the Somme, France

AIM

To analyze the factors associated with the time to initiating tuberculosis contact investigations in the Somme department, France.

METHODS

All reported tuberculosis cases and all their contacts screened between 2007 and 2011 were retrospectively included. Univariate and multivariate analyses were conducted to determine the factors associated with a "system delay"≤1 month and a "contact delay"≤0 days.

RESULTS

The mean time between the mandatory notification of a case of tuberculosis and the date set for the contact's screening (system delay) was 35.3 days and the average time between that date and when the contact was actually screened (contact delay) was 12.5 days. In multivariate analysis, a smear-positive sputum sample (OR: 3.68; 95% CI: 1.63-8.30) and a diagnosis at the university hospital (OR: 2.61; 95% CI: 1.14-5.96) were significantly associated with a system delay≤1 month. A smear-positive sputum sample (OR: 1.35; 95% CI: 1.08-1.69), male gender (OR: 1.21; 95% CI: 1.01-1.49), being born in a foreign country (OR: 1.31; 95% CI: 1.02-1.69), being a family member (OR: 1.37; 95% CI: 1.05-1.77), or being another type of close contact of the case (OR: 2.47; 95% CI: 1.81-3.36) were significantly associated with a contact delay≤0 days.

CONCLUSION

System and contact delays were longer than recommended, and the factors associated with the lengthening of these delays need to be taken into account.

Total Delay Is Associated with Unfavorable Treatment Outcome among Pulmonary Tuberculosis Patients in West Gojjam Zone, Northwest Ethiopia: A Prospective Cohort Study

BACKGROUND

delay in diagnosis and treatment of tuberculosis (TB) may worsen the disease, increase mortality and enhance transmission in the community. This study aimed at assessing the association between total delay and unfavorable treatment outcome among newly diagnosed pulmonary TB (PTB) patients.

METHODS

A prospective cohort study was conducted in West Gojjam Zone, Amhara Region of Ethiopia from October 2013 to May 2015. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study from 30 randomly selected public health facilities. Total delay (the time period from onset of TB symptoms to first start of anti-TB treatment) was measured. Median total delay was calculated. Mixed effect logistics regression was used to analyze factors associated with unfavorable treatment outcome.

RESULTS

Seven hundred six patients were enrolled in the study. The median total delay was 60 days. Patients with total delay of > 60 days were more likely to have unfavorable TB treatment outcome than patients with total delay of ≤ 60 days (adjusted odds ratio [AOR], 2.33; 95% confidence interval [CI], 1.04-5.26). Human immunodeficiency virus (HIV) positive TB patients were 8.46 times more likely to experience unfavorable treatment outcome than HIV negative TB patients (AOR, 8.46; 95% CI, 3.14-22.79).

CONCLUSIONS

Long total delay and TB/HIV coinfection were associated with unfavorable treatment outcome. Targeted interventions that can reduce delay in diagnosis and treatment of TB, and early comprehensive management of TB/HIV coinfection are needed to reduce increased risk of unfavorable treatment outcome.

Factors associated with DELAY in diagnosis among tuberculosis patients in Hohoe Municipality, Ghana

Background

Any delay in diagnosis and consequently treatment of TB patients not only increases the infectivity of the disease in the community, but may also lead to more advance disease state, which may result in more complications and expose patients to higher risk of death. The aim of this study was to assess delays in diagnosing new TB patients and the factors associated with these delays in Hohoe Municipality of Ghana.

Methods

A cross sectional study was carried out among 73 new TB Patients, 15 years or older, registered between 1st June, 2013 and 31st May, 2014 in Hohoe Municipality. Questionnaires were administered to patients to evaluate factors related to delay by patients in seeking care, delays at healthcare facilities, and total diagnostic delay. Logistic regression was used to determine the factors associated with patient delay (>30 days), healthcare services delay (>15 days), and total delay (>45 days).

Results

The median total delay was 104 days (inter-quartile range (IQR):17–191). The median patient delay was 59 days (IQR: 5–123), and the median healthcare services delay was 45 days (IQR: 38–128). Not medically insured (AOR = 6.12; 95 % CI: 1.26–29.88; P < 0.025) and perceived stigma (AOR = 5.30; 95 % CI: 1.33–21.18; P < 0.018) were risk factors associated with prolonged patient delay. Multiple healthcare contact following signs and symptoms (AOR = 10.26; 95 %CI: 2.95–35.72; P < 0.0001) was the only risk factor associated with prolonged healthcare services delay.

Conclusion

There is a considerable delay in TB case detection mainly due to patients delay in seeking healthcare. The factors associated with patients’ delay include lack of medical insurance, perceived stigma, and making multiple healthcare encounters. Health system strengthening towards decentralizing TB diagnosis and management, raising public awareness about the disease, training of healthcare providers, and collaborating with non-formal healthcare providers may reduce long delays in the management of TB.

Factors associated with delay in diagnosis and treatment of pulmonary tuberculosis

BACKGROUND

Early treatment of pulmonary tuberculosis (PTB) is necessary for a successful tuberculosis (TB) control program.

OBJECTIVES

The objective of this study was to determine total treatment delay and its associated factors among PTB patients in Ahvaz.

PATIENTS AND METHODS

A retrospective study was performed among newly diagnosed PTB cases registered in 2010 at the Ahvaz health center. Total treatment delay was defined as the time interval between the onsets of cough to the initiation of anti-TB treatment. Tuberculosis diagnosis and treatment was based on the national TB program (NTP). Data analysis was performed using the SPSS software by chi-square and Fisher's exact test with odds ratio (OR) and 95% confidence interval (CI).

RESULTS

The mean age of the patients was 38.9 ± 12.3 years; 83 were male and 56 were female. Of the 139 smear positive PTB cases, 91 (65.5%) cases had received delayed-treatment. The mean time between onset of symptoms, diagnosis and treatment was 73 days (median: 48 days, range: 4-570 days). Female gender (OR (95% CI): 2.9, 1.03-8.23, P = 0.02), smoking (OR (95% CI): 0.49, 0.22-0.96, P = 0.04) and receiving immunosuppressive drugs (OR (95% CI): 8.18, 1.09-75.31, P < 0.05) were associated with longer delayed time.

CONCLUSIONS

Delayed diagnosis and treatment of tuberculosis appears to be the main problem in the TB control program of the region. Delayed time is significantly associated with female gender, smoking and immunosuppressive drugs.

Mycobacterium tuberculosis lineage 7 strains are associated with prolonged patient delay in seeking treatment for pulmonary tuberculosis in Amhara Region, Ethiopia

Recent genotyping studies of Mycobacterium tuberculosis in Ethiopia have reported the identification of a new phylogenetically distinct M. tuberculosis lineage, lineage 7. We therefore investigated the genetic diversity and association of specific M. tuberculosis lineages with sociodemographic and clinical parameters among pulmonary TB patients in the Amhara Region, Ethiopia. DNA was isolated from M. tuberculosis-positive sputum specimens (n=240) and analyzed by PCR and 24-locus mycobacterial interspersed repetitive unit-variable-number tandem-repeat (MIRU-VNTR) analysis and spoligotyping. Bioinformatic analysis assigned the M. tuberculosis genotypes to global lineages, and associations between patient characteristics and genotype were evaluated using logistic regression analysis. The study revealed a high diversity of modern and premodern M. tuberculosis lineages, among which approximately 25% were not previously reported. Among the M. tuberculosis strains (n=138) assigned to seven subgroups, the largest cluster belonged to the lineage Central Asian (CAS) (n=60; 26.0%), the second largest to lineage 7 (n=36; 15.6%), and the third largest to the lineage Haarlem (n=35; 15.2%). Four sublineages were new in the MIRU-VNTRplus database, designated NW-ETH3, NW-ETH1, NW-ETH2, and NW-ETH4, which included 24 (10.4%), 18 (7.8%), 8 (3.5%), and 5 (2.2%) isolates, respectively. Notably, patient delay in seeking treatment was significantly longer among patients infected with lineage 7 strains (Mann-Whitney test, P<0.008) than in patients infected with CAS strains (adjusted odds ratio [AOR], 4.7; 95% confidence interval [CI], 1.6 to 13.5). Lineage 7 strains also grew more slowly than other M. tuberculosis strains. Cases of Haarlem (OR, 2.8; 95% CI, 1.2 to 6.6) and NW-ETH3 (OR, 2.8; 95% CI, 1.0 to 7.3) infection appeared in defined clusters. Intensified active case finding and contact tracing activities in the study region are needed to expedite diagnosis and treatment of TB.