Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia

Background  

Delay in the diagnosis of tuberculosis may worsen the disease, increase the risk of death and enhance tuberculosis transmission in the community. This study aims to determine the length of delay between the onset of symptoms and patients first visit to health care (patient delay), and the length of delay between health care visit and the diagnosis of tuberculosis (health service delay).     

Delays in the diagnosis and treatment of tuberculosis patients in Vietnam: a cross-sectional study

Background  

Treatment delay is an important indicator of access to tuberculosis diagnosis and treatment. Analyses of patient delay (i.e. time interval between onset of symptoms and first consultation of a health care provider) and health care delay (i.e. time interval between first consultation and start of treatment) can inform policies to improve access. This study assesses the patient, health care provider and total delay in diagnosis and treatment of new smear-positive pulmonary tuberculosis patients, and the risk factors for long delay, in Vietnam.     

Patient and health service delay in pulmonary tuberculosis patients attending a referral hospital: a cross-sectional study

Background  

Delays in diagnosis and initiation of effective treatment increase morbidity and mortality from tuberculosis as well as the risk of transmission in the community. The aim of this study was to determine the time taken for patients later confirmed as having TB to present with symptoms to the first health provider (patient delay) and the time taken between the first health care visit and initiation of tuberculosis treatment (health service delay). Factors relating to these 'delays' were analyzed.     

Delay in the treatment of pulmonary tuberculosis: a report from Afghanistan

Objectives  

The aim of this study was to determine the length of delays and to investigate the factors associated with patient (care-seeking) and health-system (treatment initiation following care-seeking) delays, among smear-positive tuberculosis patients in Kunar province, Afghanistan, as delay in diagnosis and treatment results in more severe disease, higher mortality, and a longer period of infectivity in the community.     

Assessing access barriers to tuberculosis care with the Tool to Estimate Patients' Costs: pilot results from two districts in Kenya

Background  

The poor face geographical, socio-cultural and health system barriers in accessing tuberculosis care. These may cause delays to timely diagnosis and treatment resulting in more advanced disease and continued transmission of TB. By addressing barriers and reasons for delay, costs incurred by TB patients can be effectively reduced. A Tool to Estimate Patients' Costs has been developed. It can assist TB control programs in assessing such barriers. This study presents the Tool and results of its pilot in Kenya.     

Cost implications of delays to tuberculosis diagnosis among pulmonary tuberculosis patients in Ethiopia

Background  

Delays seeking care worsen the burden of tuberculosis and cost of care for patients, families and the public health system. This study investigates costs of tuberculosis diagnosis incurred by patients, escorts and the public health system in 10 districts of Ethiopia.     

Impact of early chest radiography and empirical antibiotherapy on delay in the diagnosis of pulmonary tuberculosis

Objective

The treatment of community-acquired pneumonia relies on empirical antibacterial treatment, guided by chest X-ray. We evaluated the impact of this practice on delay in the diagnosis of pulmonary tuberculosis.

Patients and methods

We performed a retrospective monocentric study on 64 documented cases of pulmonary tuberculosis.

Results

Empirical antibacterial treatment was prescribed between the first symptoms and pulmonary tuberculosis diagnosis in 42.2% of cases. The median delay between first contact with a healthcare provider and pulmonary tuberculosis treatment initiation (medical delay) was 13.5 days. The factors associated with medical delay above 30 days were alcohol abuse (OR 7.62; P = 0.02), and late chest X-ray (OR 9.33; P = 0.01). Empirical antibacterial treatment was more frequent in case of late chest X-ray (P = 0.02) and increased the risk of medical delay above 7 days (OR 6.3; P = 0.05).

Conclusion

When lower respiratory tract infection is suspected, early chest X-ray reduces the empirical use of antibacterial agents and decreases delay in the diagnosis of pulmonary tuberculosis.     

Journeys to tuberculosis treatment: a qualitative study of patients, families and communities in Jogjakarta, Indonesia

Background  

Many tuberculosis (TB) patients in Indonesia are diagnosed late. We seek to document patient journeys toward TB diagnosis and treatment and factors that influence health care seeking behavior.     

Health care seeking among pulmonary tuberculosis suspects and patients in rural Ethiopia: a community-based study

Background  

Health care seeking is a dynamic process that is influenced by socio-demographic, cultural and other factors. In Ethiopia, there are limited studies regarding the health seeking behaviour of tuberculosis (TB) suspects and TB patients. However, a thorough understanding of patients' motivation and actions is crucial to understanding TB and the treatment of disease. Such insights would conceivably help to reduce delay in diagnosis, improve treatment adherence and thereby reduce transmission of TB in the community. The objective of this study was to describe and analyze health care seeking among TB suspects and pulmonary TB (PTB) cases in a rural district of the Amhara Region in Ethiopia.     

Patient's site of first access to health system influences length of delay for tuberculosis treatment in Tajikistan

Background  

Tajikistan has the highest incidence rate of tuberculosis (TB) in Central Asia. Its health system still bears many features from Soviet times and is under-funded. Affordability is a major barrier to health care. Little is known about health care seeking of TB patients in post-Soviet countries and their delay until the start of TB therapy. The low estimated case detection rate in Tajikistan suggests major problems with access to care and consequently long delays are likely.     

Sputum microscopy for the diagnosis of HIV-associated pulmonary tuberculosis in Tanzania

Background  

In many resource poor settings only sputum microscopy is employed for the diagnosis of HIV-associated pulmonary tuberculosis; sputum culture may not be available.     

Timing of antiretroviral therapy in Cambodian hospital after diagnosis of tuberculosis: impact of revised WHO guidelines

Objective

To determine if implementation of 2010 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) initiation reduced delay from tuberculosis diagnosis to initiation of ART in a Cambodian urban hospital.

Methods

A retrospective cohort study was conducted in a nongovernmental hospital in Phnom Penh that followed new WHO guidelines in patients with human immunodeficiency virus (HIV) and tuberculosis. All ART-naïve, HIV-positive patients initiated on antituberculosis treatment over the 18 months before and after guideline implementation were included. A competing risk regression model was used.

Findings

After implementation of the 2010 WHO guidelines, 190 HIV-positive patients with tuberculosis were identified: 53% males; median age, 38 years; median baseline CD4+ T-lymphocyte (CD4+ cell) count, 43 cells/µL. Before implementation, 262 patients were identified; 56% males; median age, 36 years; median baseline CD4+ cell count, 59 cells/µL. With baseline CD4+ cell counts ≤ 50 cells/µL, median delay to ART declined from 5.8 weeks (interquartile range, IQR: 3.7–9.0) before to 3.0 weeks (IQR: 2.1–4.4) after implementation (P < 0.001); with baseline CD4+ cell counts > 50 cells/µL, delay dropped from 7.0 (IQR: 5.3–11.3) to 3.6 (IQR: 2.9–5.3) weeks (P < 0.001). The probability of ART initiation within 4 and 8 weeks after tuberculosis diagnosis rose from 23% and 65%, respectively, before implementation, to 62% and 90% after implementation. A non-significant increase in 6-month retention and antiretroviral substitution was seen after implementation.

Conclusion

Implementation of 2010 WHO recommendations in a routine clinical setting shortens delay to ART. Larger studies with longer follow-up are needed to assess impact on patient outcomes.     

The impact of new tuberculosis diagnostics on transmission: why context matters

Objective

To estimate the impact of new tuberculosis diagnostics on tuberculosis transmission given the complex contextual factors that can lead to patient loss before diagnosis or treatment.

Methods

An epidemic model of tuberculosis specifying discrete steps along the tuberculosis diagnostic pathway was constructed. The model was calibrated to the epidemiology of tuberculosis and human immunodeficiency virus (HIV) infection in the United Republic of Tanzania and was used to assess the impact of a new diagnostic tool with 70% sensitivity for smear-negative pulmonary tuberculosis. The influence of contextual factors on the projected epidemic impact of the new diagnostic tool over the decade following introduction was explored.

Findings

With the use of smear microscopy, the incidence of tuberculosis will decline by an average of 3.94% per year. If the new tool is added, incidence will decline by an annual 4.25%. This represents an absolute change of 0.31 percentage points (95% confidence interval: 0.04–0.42). However, the annual decline in transmission with use of the new tool is less when existing strategies for the diagnosis of smear-negative cases have high sensitivity and when symptomatic individuals delay in seeking care. Other influential contextual factors include access to tuberculosis care, patient loss before diagnosis, initial patient default after diagnosis and treatment success rate.

Conclusion

When implementing and scaling up the use of a new diagnostic tool, the operational context in which diagnosis and treatment take place needs to be considered.     

Cutaneous tuberculosis in Tunisia

Introduction

Tuberculosis is endemic in Tunisia. Pulmonary tuberculosis is the most common presentation in our country. Cutaneous presentations are rare (1–2% of cases). The diagnosis of cutaneous tuberculosis (CT) is difficult. Histological and clinical presentations are polymorphous, many differential diagnoses are available, and it is difficult to isolate Mycobacterium.

Objective

We had for aim to study the epidemiological and clinical features of CT in Tunisia, and to compare presentations before and after 1990.

Patients and methods

We conducted a retrospective study between January 1991 and December 2011, in which we included all cases of CT observed at the Infectious Diseases and Dermatology Units of the Tunis la Rabta Hospital.

Results

Hundred and thirty-seven patients were included, with a mean age of 43.8 years; 72.3% were female patients. Hundred and fifty locations were observed, most of which on the head and neck. Scrofuloderma was the most frequent presentation, observed in 65% of cases. The diagnosis was confirmed by histology and/or microbiology in 75.8% of cases. The treatment was prescribed for a mean 11.3 months, leading to full recovery in most cases.

Conclusion

CT is still reported in Tunisia. The diagnosis relies mainly on histology. Controlling this mutilating tuberculosis requires a global control of this disease, and especially lymph node location, given the high rate of scrofuloderma.     

Patterns of delays amongst pulmonary tuberculosis patients in Lagos,Nigeria

Background  

Pulmonary tuberculosis continues to increase due to late patient presentation. The study was conducted at a chest clinic of a general hospital in Lagos, Nigeria, to investigate patterns of delays before treatment amongst tuberculosis patients.     

An evaluation of completeness of tuberculosis notification in the United Kingdom

Background  

There has been a resurgence of tuberculosis worldwide, mainly in developing countries but also affecting the United Kingdom (UK), and other Western countries. The control of tuberculosis is dependent on early identification of cases and timely notification to public health departments to ensure appropriate treatment of cases and screening of contacts. Tuberculosis is compulsorily notifiable in the UK, and the doctor making or suspecting the diagnosis is legally responsible for notification. There is evidence of under-reporting of tuberculosis. This has implications for the control of tuberculosis as a disproportionate number of people who become infected are the most vulnerable in society, and are less likely to be identified and notified to the public health system. These include the poor, the homeless, refugees and ethnic minorities.     

The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys

Background  

The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment.     

Patient delay in cancer studies: a discussion of methods and measures

Background  

There is no validated way of measuring the prevalence and duration of patient delay, and we do not know how people perceive and define the time intervals they are asked to report in patient delay studies. This lack of a validated measure hampers research in patient delay and is counterproductive to efforts directed at securing early diagnosis of cancer.     

Missed opportunities in TB diagnosis: a TB Process-Based Performance Review tool to evaluate and improve clinical care

Background  

Traditional tuberculosis (TB) treatment outcome measures, such as cure rate, do not provide insight into the underlying reasons for missing clinical targets. We evaluated a TB Process-Based Performance Review (TB-PBPR) tool, developed to identify "missed opportunities" for timely and accurate diagnosis of TB. The tool enables performance assessment at the level of process and quality of care.