Patient and health system delays in the diagnosis and treatment of tuberculosis in Southern Taiwan.

SETTING: Tainan city, Tainan county and 13 townships of Kaohsiung county, Southern Taiwan. OBJECTIVE: To measure delays in the diagnosis and treatment of sputum-positive tuberculosis (TB) and to determine factors associated with delays in seeking health care (patient delay) and in starting anti-tuberculosis treatment (health system delay). DESIGN: A population-based patient interview study. RESULTS: Median patient delay was 7 days (range 0-730). Median health system delay was 23 days (range 0-489), 13 for smear-positive patients and 37 for smear-negative patients (P < 0.005). Median total delay was 44 days (range 0-730). Age <65 years was associated with longer patient delay. Negative smear, absence of haemoptysis, not having a chest radiograph at the first medical consultation and visiting clinics for first consultation were associated with a longer health system delay. Age <65 years, negative smear and cough as the only presenting symptom were associated with longer total delay. CONCLUSION: Patient delay was substantially shorter than health system delay. To reduce health system delay, clinics need to be involved and the referral mechanism must be strengthened. Physicians should maintain high alert for TB and perform prompt sputum smear examinations.     

Risk factors for delay in the diagnosis and treatment of tuberculosis at a referral hospital in Rwanda.

SETTING: Kigali University Hospital, the main referral centre for TB in Rwanda. OBJECTIVE: To evaluate delays in the diagnosis and treatment of tuberculosis (TB) and associated risk factors. DESIGN: Prospective data collection of patients treated for pulmonary TB (PTB) or extra-pulmonary TB (EPTB) between June and September 2006. RESULTS: Of 104 patients with a mean age of 35 years (range 17-84) recruited into the study, 62% were HIV-positive. EPTB was diagnosed in 60 cases. The median total, health care and patient delays were respectively 57, 28 and 25 days. The health system delay before referral was significantly longer than the delay at our institution (18 vs. 6 days, P<0.0001). Risk factors for a longer health system delay at our institution were smear-negative PTB or EPTB (OR 5.12) and a trial of antibiotics (OR 2.96). The latter was also found to significantly prolong total delay (OR 2.85), as did rural residence (OR 4.86). No significant association was found between patient delay and age, sex, profession or health insurance status. CONCLUSION: Smear-negative PTB and EPTB were associated with longer health system delays. A trial of antibiotics significantly increased the health system delay. Its use, recommended by the World Health Organization in case of smear-negative TB and EPTB in developing countries, needs validation at the tertiary health care level.     

Patient and health service delays in initiating treatment for patients with pulmonary tuberculosis: retrospective cohort study.

SETTING: Catchment population of the North Middlesex University Hospital (NMUH), London, UK. OBJECTIVE: To measure patient and health care delays in treatment of pulmonary tuberculosis. DESIGN: Retrospective cohort study of patients notified with pulmonary tuberculosis between 1 April 2001 and 1 March 2002. RESULTS: The median case finding delays were between 78 and 99 days. Median patient-related delay was between 34.5 and 54 days. Median health care-related delay was 29.5 days. Shorter case finding delays were found in patients born in a high prevalence country, patients presenting first to Accident and Emergency department (A&E), younger patients, and those with sputum smear-positive disease. In those presenting first to A&E, those born in a high prevalence country, and those with sputum-positive disease, this effect was predominantly due to shorter health care delays. Limitations of TB service capacity and organisational factors appeared responsible for up to half of the difference in delay between those presenting to A&E or general practitioners (GPs). CONCLUSION: Patient and health service delays contribute substantially to delays in patients accessing treatment. Considerable reduction in case finding delays may be achieved through changes in the capacity of tuberculosis services, and coordination of associated health services.     

Patient and health system delays in the diagnosis of tuberculosis in Southern Thailand after health care reform.

SETTING: Seven public hospitals in a southern province of Thailand. OBJECTIVES: To measure delays in tuberculosis (TB) diagnosis and to examine the factors associated with these delays, with special focus on the effect of drug store utilisation and health insurance coverage on patient delay. DESIGN: A total of 202 newly diagnosed smear-positive and smear-negative pulmonary TB patients were interviewed using a structured questionnaire. RESULTS: The median patient, health system and total delay were 4.4, 2.8 and 9.4 weeks, respectively. Risk factors for patient delay were age 31-60 years, having mild illness, previous similar symptoms and first presenting to non-qualified providers. Health insurance was not associated with a shorter patient delay. Health system delay was significant longer for patients with health insurance and first presenting to low-level public health facility (i.e., community hospital, health centre, primary care unit or private clinic/hospital). CONCLUSIONS: The public should be informed how to recognise TB symptoms to shorten patient delay. The Thai National Tuberculosis Control Programme needs to supervise the private health sector, including drug stores, for better TB control. Drug store personnel need to be trained to recognise and refer TB suspects. The capacity of low-level public health facilities and private doctors in TB diagnosis needs improvement. A proper referral system should be developed.     

Delays in the diagnosis and treatment of hospitalized patients with smear-positive pulmonary tuberculosis

The aim of present study was to investigate whether there was any delay in the diagnosis and treatment of inpatients with smear-positive pulmonary tuberculosis followed-up in our centre. We reviewed clinical records in February 1999 and identified 134 hospitalized patients with smear-positive pulmonary tuberculosis. Clinical files of the patients were analysed and a questionnaire was completed. Several intervals and delays were calculated. Median application interval was 17.5 days [95% confidence interval (CI) 21.3-32.4 days], median referral interval was 3.5 days (95% CI 6.8-11.4 days), median diagnosis interval was 3 days (95% CI 3.3-4.5 days) and median initiation of treatment interval was 1 day (95% CI 1.1-1.6 days). Patients delay was present in 28.4% of cases. The referral interval was longer than 2 days in 82 patients (institutional delay). Ninety-three patients (69.4%) had delays in the diagnosis and 34 patients (25.4%) had delays in the treatment. There was a doctor's delay in 119 of 134 patients (88.8%) and clinic's delay in 98 patients (73.2%). Our results have suggested that hospitalized patients with smear-positive pulmonary tuberculosis experience several delays. These delays may result in increased risk for transmission of infection. Decrease in the risk of infection for community and medical personal may only be obtained by preventing these delays.     

Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India.

OBJECTIVES: To investigate the factors associated with delay in 1) care-seeking (patient delay), and 2) diagnosis by health providers (health system delay), among smear-positive tuberculosis patients, before large-scale DOTS implementation in South India. METHODS: New smear-positive patients were interviewed using a structured questionnaire. RESULTS: Among 531 participants, the median patient, health system and total delays were 20, 23 and 60 days, respectively. Twenty-nine per cent of patients delayed seeking care for > 1 month, of whom 40% attributed the delay to their lack of awareness about TB. Men postponed seeking care for longer periods than women (P = 0.07). In multivariate analysis, the patient delay was greater if the patient had initially consulted a government provider (adjusted odds ratio [AOR] 2.2, P < or = 0.001), resided at a distance >2 km from a health facility (AOR 1.6, P = 0.04), and was an alcoholic (AOR 1.6, P = 0.04). Health system delay was >7 days among 69% of patients. Factors associated with health system delay were: first consultation with a private provider (AOR 4.0, P < 0.001), a shorter duration of cough (AOR 2.6, P = 0.001), alcoholism (P = 0.04) and patient's residence >2 km from a health facility (AOR 1.8, P = 0.02). The total delay resulted largely from a long patient delay when government providers were consulted first, and a long health system delay when private providers were consulted first. CONCLUSION: Public awareness about chest symptoms and the availability of free diagnostic services should be increased. Government and private physicians should be educated to be aware about the possibility of tuberculosis when examining out-patients. Effective referrals for smear microscopy should be developed between private and public providers.     

Delay in the treatment of pulmonary TB in a changing demographic scenario.

OBJECTIVE: To quantify patient and health care delays in the treatment of pulmonary tuberculosis (PTB) in Emilia-Romagna region, Italy, and to study the association between migration status and delay. DESIGN: All patients with symptomatic PTB, aged >15 years, who were notified in Emilia-Romagna during 2003 and were alive at time of data collection, were included. An individual form was completed for each notified patient by the local health authority officer in charge of surveillance data. RESULTS: Median patient delay, health care delay and total delay were 7, 36 and 65 days, respectively. Recent migrants (stay in Italy < or = 3 years) had the longest patient delay (16 days), while Italian patients had the longest health care delay (60 days). Migration status was independently associated with both patient and health care delay, although the direction of association changed according to which delay was considered. CONCLUSION: Public health interventions aiming to reduce delay in treatment of PTB should improve the access of recent migrants to health care and increase suspicion of TB among Italian patients. Studies on delays in treatment of TB should investigate patient delay and health care delay as distinct outcomes.     

Risk factors associated with default among new pulmonary TB patients and social support in six Russian regions.

SETTING: Tuberculosis (TB) services in six Russian regions in which social support programmes for TB patients were implemented. OBJECTIVE: To identify risk factors for default and to evaluate possible impact of social support. METHODS: Retrospective study of new pulmonary smear-positive and smear-negative TB patients registered during the second and third quarters of the 2003. Data were analysed in a case-control study including default patients as cases and successfully treated patients as controls, using multivariate logistic regression modelling. RESULTS: A total of 1805 cases of pulmonary TB were enrolled. Default rates in the regions were 2.3-6.3%. On multivariate analysis, risk factors independently associated with default outcome included: unemployment (OR 4.44; 95%CI 2.23-8.86), alcohol abuse (OR 1.99; 95%CI 1.04-3.81), and homelessness (OR 3.49; 95%CI 1.25-9.77). Social support reduced the default outcome (OR 0.13; 95%CI 0.06-0.28), controlling for age, sex, region, residence and acid-fast bacilli (AFB) smear of sputum. CONCLUSION: Unemployment, alcohol abuse and homelessness were associated with increased default outcome among new TB patients, while social support for TB patients reduced default. Further prospective randomised studies are necessary to evaluate the impact and to determine the most cost-effective social support for improving treatment outcomes of TB in patients in Russia, especially among populations at risk of default.     

Factors related to patient delay in pulmonary tuberculosis in Estonia

The resurgence of tuberculosis (TB) in Estonia, a post-socialist Eastern European country, has coincided with delayed case detection suggested by increase in advanced forms of pulmonary tuberculosis among newly detected cases. We estimated the determinants of patient delay in conditions of negligible HIV infection, insignificant immigration and free access to medical care with TB. All newly-detected symptomatic culture-positive patients aged > or =16 y with pulmonary TB from southern Estonia during 2002-2003 (n=185) were interviewed. Intervals greater than the median (79 d) and the 75th percentile (140 d) between onset of the first symptom and the first medical visit were defined as prolonged and extreme patient delay, respectively. Male gender was associated with both prolonged and extreme patient delay (OR 2.12; 95% CI 1.06-4.23 and OR 3.28; 95% CI 1.30-8.26, respectively), whereas rural residence was associated with prolonged patient delay (OR 2.08; 95% CI 1.06-4.08). Median patient delay was shortest when the first symptom was fever (22 d) and greatest when it was cough with haemoptysis (196 d). The study shows that even in absence of barriers in accessing health care, the median patient delay can be longer than in most former studies, whereas males and rural residents are at greater risk.     

Diagnostic delay in inflammatory bowel disease increases the risk of intestinal surgery

AIM To investigate the factors affecting diagnostic delay and outcomes of diagnostic delay in inflammatory bowel disease(IBD) METHODS We retrospectively studied 165 patients with Crohn's disease(CD) and 130 patients with ulcerative colitis(UC) who were diagnosed and had follow up durations 6 mo at Korea University Ansan Hospital from January 2000 to December 2015. A diagnostic delay was defined as the time interval between the first symptom onset and IBD diagnosis in which the 76~(th) to 100~(th) percentiles of patients were diagnosed.RESULTS The median diagnostic time interval was 6.2 and 2.4 mo in the patients with CD and UC, respectively. Among the initial symptoms, perianal discomfort before diagnosis(OR = 10.2, 95%CI: 1.93-54.3, P = 0.006) was associated with diagnostic delays in patients with CD; however, no clinical factor was associated with diagnostic delays in patients with UC. Diagnostic delays, stricturing type, and penetrating type were associated with increased intestinal surgery risks in CD(OR = 2.54, 95%CI: 1.06-6.09; OR = 4.44, 95%CI: 1.67-11.8; OR = 3.79, 95%CI: 1.14-12.6, respectively). In UC, a diagnostic delay was the only factor associated increased intestinal surgery risks(OR = 6.81, 95%CI: 1.12-41.4).CONCLUSION A diagnostic delay was associated with poor outcomes, such as increased intestinal surgery risks in patients with CD and UC.     

The effect of geographical distance on TB patient delays in a mountainous province of China

SETTING: One hundred and twenty-nine counties in Yunnan, a mountainous province in China. OBJECTIVE: To document the relationship between patient delays and distance to local county tuberculosis (TB) centres. DESIGN: A computerised medical record-based study of a cohort of 10356 new smear-positive TB cases in 2005. RESULTS: The median total delay was 71 days (interquartile range [IQR] 38-128), with a median long patient delay of 60 days (IQR 28-111) and a relatively short median health care system delay of 4 days (IQR 2-13). Older age (>40 years), being an agriculturer and poor economic status were significantly associated with longer patient delays. Risk of delay increased with increasing geographical distance, with a greater effect on relatively shorter patient delays. Using the first quartile of distance as the reference group, hazard ratios for subsequent quartiles were 0.61 (0.57-0.65), 0.30 (0.28-0.33) and 0.15 (0.14-0.17) for short patient delays (60 days). CONCLUSION: Patients living in remote areas need support to overcome the barrier posed by geographical distance, which has a greater effect in the initial phases of the disease.     

Delay in tuberculosis diagnosis and treatment in four provinces of Argentina.

SETTING: Public health care services in the provinces of Buenos Aires, Santa Fe, Jujuy and Santa Cruz, Argentina. OBJECTIVE: To evaluate delays in tuberculosis (TB) diagnosis and treatment and associated risk factors in departments and administrative areas of four Argentine provinces. DESIGN: Cross-sectional survey including retrospective medical record review and patient interviews. RESULTS: A total of 243 patients with smear-positive pulmonary TB and a mean age of 40 years were included in the study. The mean diagnostic delays were as follows: total delay 92.1 days (median 62.0); patient delay 58.8 days (median 31); health service delay 32.6 days (median 12.5). The mean treatment delay was 0.9 days (median 0). Associations were observed between patient delays of >30 days and residence in Jujuy, age >50 years, dependence on transport to the nearest public health service due to distance and presence of cough. The >60-day total diagnosis delay was associated with age >50 years and need for transport to the nearest public health service. CONCLUSION: Diagnostic delay is an important problem in the areas studied, with patient delay being of most concern. Patient delay was associated with age >50 years, dependence on transport to the nearest public health service due to distance and presence of cough.     

Factors contributing to treatment success among tuberculosis patients: a prospective cohort study in Bangkok

SETTING: Chest Clinic, Ministry of Public Health and health care centres, Bangkok Metropolitan Administration. OBJECTIVE: To determine patient factors predicting successful tuberculosis (TB) treatment. DESIGN: A prospective cohort was conducted during May 2004 to November 2005. Newly diagnosed TB patients aged > or = 15 years were recruited after giving informed consent. Three sets of questionnaires were used to collect data from the patients three times. Data were also gathered from treatment cards. RESULTS: Of 1241 patients, 81.1% were successfully treated. Bivariate analysis indicated that patients' sex, education, occupation, level of knowledge about TB and adverse effects were associated with treatment success. Unconditional logistic regression analysis showed that females had a higher success rate than males (OR = 1.9, 95%CI 1.2-2.9). Patients with regular incomes had twice the likelihood of success of the unemployed (OR = 2.0, 95%CI 1.1-3.5). Patients with high knowledge levels were more likely to complete treatment (OR = 2.0, 95%CI 1.2-3.4), while those with adverse effects were less likely to adhere (OR = 0.6, 95%CI 0.4-0.9). CONCLUSION: The current low treatment success rate may be partly due to inadequate knowledge about TB among patients. Improvements in health education and early detection and management of adverse effects should be prioritised by the National Tuberculosis Programme.     

Health-seeking behaviour of new smear-positive TB patients under a DOTS programme in Tamil Nadu, India, 2003.

BACKGROUND: Although case detection is above 70% in Tamil Nadu after DOTS implementation, an assessment of the timeliness of patient diagnosis and treatment is still needed. OBJECTIVE: To study the health-seeking behaviour of new smear-positive pulmonary tuberculosis (PTB) patients treated at government facilities. METHODS: New smear-positive patients diagnosed and treated between January and March 2003 in government facilities of randomly selected blocks in Tamil Nadu were interviewed using a semi-structured interview schedule. RESULTS: Of 601 patients interviewed, 65% contacted a provider within 28 days. The first contact was governmental for 47% and non-governmental for 53%. Median total, patient and provider delays were respectively 62, 28 and 28 days; provider delay was 9 days with government and 50 with private provider. In multivariate analysis, patient delay was significantly associated with smoking (P < 0.001) and mode of travel (P < 0.01), and provider delay with first consultation with a private provider (P < 0.001) and distance > 5 km from the health facility (P < 0.01). Twenty-five per cent of patients took more than two actions before diagnosis. CONCLUSION: Community awareness of TB needs to be increased. Greater private sector involvement in the Revised National Tuberculosis Control Programme is essential to reduce provider delay. Referral and sputum transportation to the diagnostic facility should be given priority.     

Excess mortality and tuberculosis among individuals with prolonged cough: a population-based study from Vietnam.

SETTING: A demographic surveillance site in north-west Vietnam. OBJECTIVES: To compare notification rates of sputum smear-positive tuberculosis (TB) and mortality rates between the general population and individuals with prolonged cough. DESIGN: A cohort study of 559 prolonged cough cases in a total population of 35,832, observed over 2.5 years. Outcome measures were sputum smear-positive TB and death. RESULTS: The age-standardised smear-positive TB notification rate among cough cases (553/100,000 person-years [py], 95%CI 268-1143) was significantly higher than in the general population (50/100,000 py, 95%CI 43-57), with a relative risk of 11.06 (95%CI 8.28-14.77). Among those who had a chest X-ray suggestive of TB but negative sputum smears prior to the study start, the rate was 6542/100,000 py (95%CI 2906-12,511). The cough cohort had a 2.61 (95%CI 2.38-2.87) times higher risk of dying than the general population. CONCLUSIONS: Individuals with prolonged cough in this study run a significantly increased risk of developing infectious TB and of dying. We recommend further evaluations of improved follow-up systems aimed at identifying and treating sputum smear-negative TB cases before they convert to an infectious stage.     

Risk factors for tuberculosis infection among household contacts in Bangkok, Thailand

A cross-sectional study was conducted to determine the prevalence of tuberculosis infection and risk factors for tuberculosis infection among household contacts aged less than 15 years in Bangkok, Thailand, between August 2002 and September 2003. During the study period, 342 index cases with sputum smear positive pulmonary tuberculosis patients were recruited into the study and their 500 household contacts aged under 15 years were identified. The prevalence of tuberculosis infection among household contacts was found to be 47.80% (95%CI = 43.41-52.19). In multivariate analysis, a generalized estimating equation (GEE) was used to determine the risk factors for tuberculosis infection among household contacts. The results indicated that the risk of tuberculosis infection was significantly associated with close contact (adjusted OR = 3.31, 95%CI = 1.46-7.45), exposure to female index case (adjusted OR = 2.75, 95%CI = 1.25-6.08), exposure to mother with tuberculosis (adjusted OR = 3.82, 95%CI = 1.44-10.14), exposure to father with tuberculosis (adjusted OR = 2.55, 95%CI = 1.19-5.46), exposure to index case with cavitation on chest radiograph (adjusted OR = 4.43, 95%CI = 2.43-8.05), exposure to index case with 3+ sputum smear grade (adjusted OR = 3.85, 95%CI = 1.92-7.70), and living in crowded household (adjusted OR = 2.63, 95%CI = 1.18-5.85). The distribution of tuberculosis infection and risk factors among contact cases are significant for health care staff in strengthening and implementing tuberculosis control programs in Thailand.     

Defining and assessing the maximum number of visits patients should make to a health facility to obtain a diagnosis of pulmonary tuberculosis.

SETTING: All non-private hospitals in Malawi. OBJECTIVES: To determine 1) how many patients with pulmonary tuberculosis (PTB) exceed the maximum number of visits needed for registration as defined by the National Tuberculosis Control Programme, and 2) the factors associated with this delay. DESIGN: Cross-sectional study interviewing hospitalised patients with new smear-positive and smear-negative PTB. RESULTS: Of 380 patients with PTB admitted to the 44 hospitals visited between April and June 2002, 329 (212 smear-positive and 117 smear-negative PTB) were interviewed: 64 (30%) smear-positive PTB patients needed more than five visits, and 44 (37%) smear-negative PTB patients needed more than six visits before being registered and started on treatment. Factors associated with exceeding the maximum number of visits were the first visit being to a health centre, submission of > 1 set of sputum specimens, and > 1 course of antibiotics. The main consequence of exceeding the maximum number of visits was increased duration of cough and increased time spent at health facilities. CONCLUSION: One third of patients exceed the maximum number of visits for registration of PTB. The main consequence of this is an increased duration of cough and an increased time spent at health facilities. Ways to reduce this delay need to be found.     

沈阳市205例住院肺结核患者就诊延迟及影响因素分析

目的分析沈阳市肺结核患者就诊延迟的现状及其影响因素,为制定改善措施提供依据。方法采用前瞻性资料收集的方法对2017-2018年沈阳市第十人民医院(沈阳市胸科医院)结核病二科收治的确诊为肺结核且≥15岁的205例住院患者进行问卷调查和临床资料收集,包括患者一般人口学特征[年龄、性别、体质量指数(BMI)、婚姻状况、文化程度、是否为流动人口、是否饮酒、是否吸烟和有无医疗保险及类型(费别)等],临床特征[包括疾病严重程度、治疗类型(初、复治)、是否耐药、首诊机构、是否因症就诊、有无空洞、痰涂片检查结果],以及对结核病防治知识知晓情况(包括对8条结核病防治核心知识的基本认知,如对结核病的传播途径、可疑症状、结核病防治相关免费政策及对防治专业机构是否了解等情况)等。以患者自出现肺结核症状之日起至首次到医疗机构就诊之日止的时间间隔天数≥14d作为就诊延迟的判断标准,采用χ2检验和多因素logistic回归法对就诊延迟患者的影响因素进行分析。结果205例调查患者中,就诊延迟110例,就诊延迟率为53.7%。多因素logistic回归结果显示,就诊距离较远[OR(95%CI)=3.405(1.102~10.518)]、病情一般[OR(95%CI)=12.384(3.558~43.109)]、治疗类型为初治[OR(95%CI)=2.099(1.109~3.974)],以及饮酒[OR(95%CI)=2.283(1.212~4.299)]是就诊延迟的危险因素。结论沈阳市住院肺结核患者就诊延迟现象明显,就诊距离较远、临床症状一般、初治患者,以及有饮酒史的肺结核患者易出现就诊延迟,应加强对社会人群的结核病相关知识的宣传教育。     

Use of the amplified mycobacterium tuberculosis direct test in a public health laboratory: test performance and impact on clinical care

BACKGROUND: The Amplified Mycobacterium tuberculosis Direct Test (MTD; Gen-Probe; San Diego, CA) is a nucleic-acid amplification test for rapid pulmonary tuberculosis (PTB) diagnosis. In a routine public health setting, test accuracy and impact on clinical decisions are unknown. METHODS: Retrospectively, we evaluated MTD accuracy and impact on clinical decisions in a public health setting. To estimate MTD accuracy, mycobacterial culture was used as the "gold standard." To evaluate MTD impact on clinical decisions, concordance of clinician presumptive diagnosis (at time of MTD and smear availability) and definitive diagnosis, and duration of nonindicated tuberculosis therapy were determined for smear-positive PTB suspects in a period of MTD availability (MTD group) and a prior period of MTD nonavailability (non-MTD group). RESULTS: A total of 1,151 respiratory specimens from 638 PTB suspects were analyzed. MTD sensitivity, specificity, positive predictive value, and negative predictive value were 91.7%, 98.7%, 96.7%, and 96.5% overall, respectively; and 98.7%, 97.8%, 98.7%, and 97.8% for smear-positive patients; and 62.2%, 98.9%, 85.2%, and 96.1% for smear-negative patients. In the MTD group, concordance between definitive and clinician presumptive diagnoses was 78% (95% confidence interval [CI], 64 to 88%), similar to that for the non-MTD group (79%; 95% CI, 68.4 to 89.6%). However, concordance between definitive diagnosis and the MTD test was 98% (95% CI, 94.1 to 100%). Median duration of nonindicated tuberculosis treatment was 6 days for the MTD group vs 31 days for the non-MTD group (p = 0.002). CONCLUSION: In this public health setting, MTD was accurate and rapidly detected more than half of the smear-negative PTB cases. For smear-positive PTB suspects, MTD had excellent concordance with definitive diagnosis, but clinicians often inappropriately initiated TB therapy despite a negative MTD result.