Long Delays and Missed Opportunities in Diagnosing Smear-Positive Pulmonary Tuberculosis in Kampala, Uganda: A Cross-Sectional Study

Abstract

BackgroundEarly detection and treatment of tuberculosis cases are the hallmark of successful tuberculosis control. We conducted a cross-sectional study at public primary health facilities in Kampala city, Uganda to quantify diagnostic delay among pulmonary tuberculosis (PTB) patients, assess associated factors, and describe trajectories of patients' health care seeking.Methodology/Principal FindingsSemi-structured interviews with new smear-positive PTB patients (≥15 years) registered for treatment. Between April 2007 and April 2008, 253 patients were studied. The median total delay was 8 weeks (IQR 4–12), median patient delay was 4 weeks (inter-quartile range [IQR] 1–8) and median health service delay was 4 weeks (IQR 2–8). Long total delay (>14 weeks) was observed for 61/253 (24.1%) of patients, long health service delay (>6 weeks) for 71/242 (29.3%) and long patient delay (>8 weeks) for 47/242 (19.4%). Patients who knew that TB was curable were less likely to have long total delay (adjusted Odds Ratio [aOR] 0.28; 95%CI 0.11–0.73) and long patient delay (aOR 0.36; 95%CI 0.13–0.97). Being female (aOR 1.98; 95%CI 1.06–3.71), staying for more than 5 years at current residence (aOR 2.24 95%CI 1.18–4.27) and having been tested for HIV before (aOR 3.72; 95%CI 1.42–9.75) was associated with long health service delay. Health service delay contributed 50% of the total delay. Ninety-one percent (231) of patients had visited one or more health care providers before they were diagnosed, for an average (median) of 4 visits (range 1–30). All but four patients had systemic symptoms by the time the diagnosis of TB was made.Conclusions/SignificanceDiagnostic delay among tuberculosis patients in Kampala is common and long. This reflects patients waiting too long before seeking care and health services waiting until systemic symptoms are present before examining sputum smears; this results in missed opportunities for diagnosis.

Treatment Delay among Smear Positive Pulmonary Tuberculosis Patients in South Ethiopia: A Cross-Sectional Study

“…The median total delay of TB patients before taking TB treatment was lower in the present study than in Malawi [26], Nigeria [13] Uganda [19] and Mozambique [18]. As indicated in the national TB, leprosy and TB/HIV control manual, all individuals who had cough for two or more weeks were suspects for TB and will be diagnosed microscopically.…”

“…In contrast to this, HIV infection was the known protective factor for late initiation of treatment. For example, HIV decreases the time interval between onset TB symptoms to treatment in Mozambique [18] and Uganda [19]. This disagreement might be due to difference in the level of awareness about TB among HIV patients in different countries.…”

“…As it is known as the most important risk factor for TB, smoking cigarette also increases the delay for diagnosis and treatment as compared to non-smokers and ex-smokers [14]. The other factors increasing delay for treatment were variables in the socio demographic [6,11,13,[15][16][17], economic [10][11][12], concurrent chronic diseases [11,18] and knowledge about TB [10,11,19]. These findings indicate that variables affecting the prompt treatment of TB vary according to geographical location and population, calling for studies intended to estimate and identify area and population specific factors associated with increased delay of the patients for treatment.…”

The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis

“…494,495 Furthermore, from a programmatic point of view, focusing solely on prevention of infection risk late in the course of the disease overlooks the fact that most transmission probably occurs before diagnosis in the community. [496][497][498][499] Enforced confinement is a poor strategy to prevent transmission at a community level, might drive the epidemic underground, and is not justified as a routine measure.…”

Proteomic progress in studying tuberculosis from 2010 to 2011

“…One is due to no reliable biomarker for diagnosis. The gold standard for TB diagnosis is strain culture that usually costs as long as 8 weeks and the sensitivity is as low as 50% or less [4,5]. The other is no new drug.…”