Why does it take so long? The reasons behind tuberculosis treatment delay in Portugal

Analysis of care-seeking and diagnosis delay among pulmonary tuberculosis patients in Beijing, China

Background

Tuberculosis (TB) remains a significant public health challenge in China. Early detection and diagnosis of TB cases are crucial to interrupt disease transmission and prevent its progression. This study aims to describe the delay in seeking care and diagnosis among patients with pulmonary tuberculosis (PTB) and identify the influencing factors in two counties in Beijing.

Methods

A retrospective analysis was carried out to investigate care-seeking and diagnosis delay in two counties in Beijing. Basic information of PTB patients from January 1 to December 31, 2021, was extracted from the Tuberculosis Information Management System of China (TBIMS), and all enrolled patients were interviewed via telephone using a standard questionnaire. Statistical description was performed using the median and interquartile range (IQR). Chi-square test and multivariate logistic regression model were used to analyze the influencing factors.

Results

537 patients were enrolled. The median duration of care-seeking and diagnosis delay was 11 (IQR: 5-26) days and 8 (IQR: 0-18) days, with 41.71 and 35.20% of patients experiencing delays (>14 days). The study found that being asymptomatic (OR = 2.791, 95%CI: 1.710-4.555) before seeking medical care and not attending work during treatment (OR = 2.990, 95%CI: 1.419-6.298) were identified as risk factors for care-seeking delay. Patients who were tracked (OR = 2.632, 95%CI: 1.062-6.521) and diagnosed at tuberculosis control and prevention institutions (OR = 1.843, 95%CI: 1.061-3.202) had higher odds of diagnostic delays. 44.69% of patients presented a total delay (>28 days), with a median duration of 25 (IQR: 13-39) days. A multivariate logistic regression analysis showed that healthy examination (OR = 0.136, 95%CI: 0.043-0.425) was a protective factor for total delay.

Conclusion

Public interventions are necessary to improve the efficiency of PTB patients detection and treatment in Beijing. Medical services should focus on the target population and improve access to medical care to further reduce delays for PTB patients.

Analysis on time delay of tuberculosis among adolescents and young adults in Eastern China

Background

Tuberculosis (TB) is recognized as a significant global public health concern. Still, there remains a dearth of comprehensive evaluation regarding the specific indicators and their influencing factors of delay for adolescents and young adults.

Methods

All notified pulmonary TB (PTB) patients in Jiaxing City were collected between 2005 and 2022 from China's TB Information Management System. Logistic regression models were conducted to ascertain the factors that influenced patient and health system delays for PTB cases, respectively. Furthermore, the impact of the COVID-19 pandemic on local delays has been explored.

Results

From January 1, 2005 to December 31, 2022, a total of 5,282 PTB cases were notified in Jiaxing City, including 1,678 adolescents and 3,604 young adults. For patient delay, female (AOR: 1.18, 95%CI: 1.05-1.32), PTB complicated with extra-pulmonary TB (AOR: 1.70, 95% CI: 1.28-2.26), passive case finding (AOR: 1.46, 95% CI: 1.07-1.98) and retreatment (AOR: 1.52, 95% CI: 1.11-2.09) showed a higher risk of delay. For health system delay, minorities (AOR: 0.69, 95% CI: 0.53-0.90) and non-students (AOR: 0.83, 95% CI: 0.71-0.98) experienced a lower delay. Referral (AOR: 1.46, 95% CI: 1.29-1.65) had a higher health system delay compared with clinical consultation. Furthermore, county hospitals (AOR: 1.47, 95% CI: 1.32-1.65) and etiological positive results (AOR: 1.46, 95% CI: 1.30-1.63) were associated with comparatively high odds of patient delay. Contrarily, county hospitals (AOR: 0.88, 95% CI: 0.78-1.00) and etiological positive results (AOR: 0.67, 95% CI: 0.59-0.74) experienced a lower health system delay. Besides, the median of patient delay, health system delay, and total delay during the COVID-19 pandemic were significantly lower than that before.

Conclusion

In general, there has been a noteworthy decline in the notification rate of PTB among adolescents and young adults in Jiaxing City while the declining trend was not obvious in patient delay, health system delay, and total delay, respectively. It also found factors such as gender, case-finding method, and the hospital level might influence the times of seeking health care and diagnosis in health agencies. These findings will provide valuable insights for refining preventive and treatment strategies for TB among adolescents and young adults.

Tuberculosis national registries and data on diagnosis delay - Is there room for improvement?

INTRODUCTION AND OBJECTIVES

Excessive delay in the diagnosis of Tuberculosis may have a negative impact on the epidemiological control and elimination of this disease. An accurate determination and analysis of delay times may help identify where and how to improve Tuberculosis diagnosis according to local needs. The Portuguese Tuberculosis Surveillance System - SVIG-TB - is the main source of data regarding diagnosis delay. However, to our knowledge, there has been no recent evaluation of its data. This study's primary aim was to conduct a thorough quantitative and qualitative evaluation of data obtained from the SVIG-TB registry concerning the delay in Tuberculosis diagnosis in Matosinhos, a Portuguese municipality.

METHODS

All patients living in the Matosinhos municipality diagnosed with Tuberculosis between January 1st 2012 and December 31st 2019 were identified and individual SVIG-TB records retrieved. Patient-related, Healthcare-related and Total delay in Tuberculosis diagnosis were determined based on data obtained from this source and compared to data recovered from patient record review. Missing data, registering errors and differences in diagnosis delay between these two sources were analysed and compared. Subsequently, diagnosis delay data from a recent Portuguese nationwide SVIG-TB paper, covering years 2010 to 2014, was compared to local SVIG-TB and patient record review data.

RESULTS

This study identified a significantly greater percentage of cases with missing data on delay in SVIG-TB records when compared to Patient Record Review (57.2% versus 1.11%). The median patient-related, healthcare-related and Total delay in Tuberculosis diagnosis were of 17, 30 and 68 days, respectively, in the SVIG-TB based data. A significant underestimation of healthcare-related and total Tuberculosis diagnosis delay was identified in SVIG-TB data when compared to Patient Record Review. There was no significant difference between Patient-related delays determined from these two sources. Compared to the national study results, missing values were more common in this data set (57.2 vs 44.6%), mainly due to the absence of patient-related delay data. Median Total and Healthcare-related delays were significantly greater in Matosinhos Municipality, regardless of the data source (SVIG-TB or Patient Record Review). The patient-related delay was, conversely, shorter.

CONCLUSIONS

SVIG-TB has been crucial in guiding National Public Health policies on the path towards Tuberculosis elimination in Portugal. However, there is still room for improvement. These results provide a basis for further reflection on the shortcomings and potential of SVIG-TB in guiding the national Tuberculosis program.

Latent tuberculosis infection prevalence in second generation immigrants from high to low TB burden countries

BACKGROUND

Latent tuberculosis infection (LTBI) diagnosis in a country with a low tuberculosis burden is complicated. Since the prevalence of LTBI in second generation immigrants has not been well recognized, we conducted a cross-sectional study which aimed to explore the differences in LTBI prevalence between offspring of immigrants from high tuberculosis (TB) burden countries and those whose parents were born in countries with a low TB burden.

METHODS

Between May 2014 and April 2018 young native Israelis who were required to perform pre-occupational tuberculin skin tests (TST) (medical and paramedical personnel or teaching assistants of immigrants from high TB burden countries) and who had a TST result of 10mm and above were tested for QuantiFERON-TB In Tube (QFT-GIT). Statistical comparisons were made between second generation immigrants and those with both parents from a low TB burden country.

RESULTS

Of 102 patients, 71 were born to parents both of whom were from low-risk countries, 14 to one parent from a high-risk country and 17 to parents both of whom were from a high-risk country. The odds ratio for LTBI was 4.5 (95% CI, 1.2...17.2; p=0.03) if both parents were born in a high-risk country compared to both parents being from a low-risk country and 4.01 (95% CI, 1.12...14.3; p=0.03) higher compared to persons for whom at least one parent was born in a low-risk country.

CONCLUSION

The risk for latent TB is significantly higher in second generation immigrants if both parents were born in a high-risk country. IGRA should be considered before treatment to patients with a positive TST if at least one parent was born in a low-risk country in order to confirm LTBI.

A temporal analysis on patient and health service delays in pulmonary tuberculosis in Portugal: inter and intra‑regional differences and in(equalities) between gender and age

BACKGROUND

Tuberculosis (TB) diagnosis and treatment delays increase the period of infectiousness, making TB control difficult and increasing the fatality rates. This study aimed to determine the evolution of health care service delay (time between the patient's first contact with the health service and the diagnosis/start of treatment) and patient delay (time between onset symptoms date and the date of first contact with health services) for Pulmonary Tuberculosis (PTB) in Portugal between 2008 and 2017 across different regions, age groups and gender.

METHODS

An exploratory analysis was performed, trends of both delays were studied, and 36 months forecasts were generated. We used the permutation test to test differences between groups and the Seasonal and Trend decomposition using Loess (STL) method and Autoregressive Integrated Moving Average (ARIMA) models for forecasting for both Health and Patient delays. We used data from notified PTB cases in mainland Portugal between 2008 and 2017, provided by the national surveillance system.

RESULTS

Health delays remained relatively constant while patient delays increased. Females had significantly higher health delays in some regions. Individuals older than 64 had higher health delays than younger individuals, while patient delay for working-age individuals between 15 and 64 years old, presents higher patient delay.

CONCLUSIONS

Forecasts presage that the upward trend of the delays is unlikely to fall in the coming years. It is important to understand the evolution of the delays and predict how these will evolve. Our understanding of the delays behaviours will contribute to better health policies and resources allocation.

The probability of diagnostic delays for tuberculosis and its associated risk factors in northwest Iran from 2005 to 2016: a survival analysis using tuberculosis surveillance data

OBJECTIVES

Early diagnosis is essential for effective tuberculosis (TB) control programs. Therefore, this study examined the risk of delays in TB diagnosis and associated factors in Ardabil Province in northwest Iran from 2005 to 2016.

METHODS

This longitudinal retrospective cohort study was conducted using data obtained from the Iranian National Tuberculosis Control Program at the provincial level between 2005 and 2016. The total delay in diagnosis was defined as the time interval (days) between the onset of symptoms and TB diagnosis. Survival analysis was conducted to analyze the delay in diagnosis. Associated factors were identified using a Cox proportional hazards model.

RESULTS

A total of 1,367 new TB cases were identified. The 12-year median diagnostic delay was 45 days (interquartile range [IQR], 30-87). The annual median diagnostic delay decreased from 68 days (IQR, 33-131) in 2005 to 31 days (IQR, 30-62) in 2016. The probability of a delay in TB diagnosis decreased by 5.0% each year (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.04 to 1.07). Residence in a non-capital county (HR, 0.83; 95% CI, 0.74 to 0.92) and referral from the private health system (HR, 0.74%; 95% CI, 0.65 to 0.84) were significantly associated with an increased risk of delay in TB diagnosis over the 12-year study period.

CONCLUSIONS

The median delay decreased during the study period. We identified factors associated with a longer delay in TB diagnosis. These findings may be useful for further TB control plans and policies in Iran.

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.

The circuits of healthcare: Understanding healthcare seeking behaviour-A qualitative study with tuberculosis patients in Lisbon, Portugal

BACKGROUND

Understanding health delivery service from a patient´s perspective, including factors influencing healthcare seeking behaviour, is crucial when treating diseases, particularly infectious ones, like tuberculosis. This study aims to trace and contextualise the trajectories patients pursued towards diagnosis and treatment, while discussing key factors associated with treatment delays. Tuberculosis patients' pathways may serve as indicator of the difficulties the more vulnerable sections of society experience in obtaining adequate care.

METHODS

We conducted 27 semi-structured interviews with tuberculosis patients attending a treatment centre in a suburban area of Lisbon. We invited nationals and migrant patients in active treatment to participate by sharing their illness experiences since the onset of symptoms until the present. The Health Belief Model was used as a reference framework to consolidate the qualitative findings.

RESULTS

By inductive analysis of all interviews, we categorised participants' healthcare seeking behaviour into 4 main types, related to the time participants took to actively search for healthcare (patient delay) and time the health system spent to diagnose and initiate treatment (health system delay). Each type of healthcare seeking behaviour identified (inhibited, timely, prolonged, and absent) expressed a mindset influencing the way participants sought healthcare. The emergency room was the main entry point where diagnostic care cascade was initiated. Primary Health Care was underused by participants.

CONCLUSIONS

The findings support that healthcare seeking behaviour is not homogeneous and influences diagnostic delays. If diagnostic delays are to be reduced, the identification of behavioural patterns should be considered when designing measures to improve health services' delivery. Healthcare professionals should be sensitised and perform continuous capacity development training to deal with patients´ needs. Inhibited and prolonged healthcare seeking behaviour contributes significantly to diagnostic delays. These behaviours should be detected and reverted. Timely responses, from patients and the healthcare system, should be promoted.

Delayed diagnosis of active pulmonary tuberculosis - potential risk factors for patient and healthcare delays in Portugal

BACKGROUND

Early diagnosis and treatment of pulmonary tuberculosis (PTB) is essential for an effective control of the tuberculosis (TB) epidemic. Delayed diagnosis and treatment of TB increases the chance of complications and mortality for the patients, and enhances TB transmission in the population. Therefore, the aim of this study was to characterize patient, healthcare and total delay in diagnosing PTB and assess the effect of clinical and sociodemographic factors on the time until first contact with healthcare or reaching a PTB diagnosis.

METHODS

Retrospective cohort study that included active PTB patients notified in the National Tuberculosis Surveillance System (SVIG-TB), between 2008 and 2017. Descriptive statistics, Kaplan-Meier estimates, logrank test and Cox proportional hazards model were used to characterize patient, healthcare and total delay and estimate the effect of clinical and sociodemographic variables on these delays. Significance level was set at 0.05.

RESULTS

Median patient, healthcare and total delays was 37 days (Interquartile range (IQR): 19-71), 8 days (IQR: 1-32) and 62 days (IQR: 38-102), respectively. The median patient delay showed a constant increase, from 33 days in 2008 to 44 days in 2017. The median total delay presented a similar trend, increasing from 59 days in 2008 to 70 days in 2017. Healthcare delay remained constant during the study period. More than half of the PTB cases (82.9%) had a delay > 1 month between symptom onset and diagnosis. In the final Cox model, alcohol abuse, unemployment and being from a high TB incidence country were factors significantly associated with longer patient delay, while being female, having more than 45 years, oncologic and respiratory diseases were associated with longer healthcare delay. Being female, having more than 45 years and being from a high TB incidence country were associated with longer total delay.

CONCLUSIONS

Patient delay and total delay have increased in recent years. Older patients, patients with alcohol problems, other comorbidities, unemployed or from countries with high TB incidence would benefit from the development of specific public health strategies that could help reduce the delay in TB diagnosis observed in our study. This study emphasizes the need to promote awareness of TB in the general population and among the healthcare community, especially at ambulatory care level, in order to reduce the gap between beginning of symptoms and TB diagnosis.

Tuberculosis amongst foreign-born and nationals: different delays, different risk factors

BACKGROUND

Delay in Tuberculosis (TB) diagnosis affects foreign-born and nationals in different ways, especially in low-incidence countries. This study characterises total delay and its components amongst foreign-born individuals in Portugal. Additionally, we identify risk factors for each type of delay and compare their effects between foreign-born and nationals.

METHODS

We analysed data from the Portuguese TB surveillance system and included individuals with pulmonary TB (PTB), notified between 2008 and 2017. We described patient, healthcare, and total delays. Cox regression was used to identify factors associated with each type of delay. All analyses were stratified according to the origin country: nationals (those born in Portugal) and foreign-born.

RESULTS

Compared with nationals, foreign-born persons presented statistically significant and longer median total and patient delays (Total: 67 vs. 63; Patient: 44 vs. 36 days), and lower healthcare services delays (7 vs. 9 days). Risk factors for delayed diagnosis differed between foreign-born and nationals. Being unemployed, having drug addiction, and having comorbidities were identified as risk factors for delayed diagnosis in national individuals but not in foreigners. Alcohol addiction was the only factor identified for healthcare delay for both populations: foreign-born (Hazard Ratio 1.34 [95% confidence interval 1.17;1.53]); nationals (Hazard Ratio 1.20 [95% confidence interval 1.13;1.27]).

CONCLUSIONS

Foreign-born individuals with PTB take longer to seek health care. While no specific risk factors were identified, more in-depth studies are required to identify barriers and support public health intervention to address PTB diagnosis delay in foreign-born individuals.

Oral anti-tuberculosis drugs: An urgent medication reconciliation at hospitals in Indonesia

Background: Four oral anti-tuberculosis drugs are conceived to be the most effective ones to eradicate Mycobacterium tuberculosis bacteria and to obviate the resistant organisms. However, the patients’ adherence and medication discrepancies are obstacles to achieving the goal. This study aimed to define the anti-tuberculosis drugs used in the hospitals and to detect the discrepancies in the continuity of the tuberculosis treatment.

Design and Methods: This retrospective cross-sectional study was based on medical records of adult patients, and was conducted in two district tertiary care hospitals. Only 35 out of 136 patient records from Hospital A and 33 out of 85 records from Hospital B met the inclusion criteria.

Results: The most common systemic anti-infective drugs in the study were ceftriaxone (51.80 DDD/100 patient-days) used in Hospital A and isoniazid (59.53 DDD/100 patient-days) used in Hospital B. The number of rifampicin prescriptions was less than that of isoniazid. Each patient received an average of two DDD/100 patient-days, which is an under dosage for an effective treatment.

Conclusion: This study showed a medication discrepancy of tuberculosis therapy. Tuberculosis patients’ medical histories are not under the full attention of treating physicians wherever they are admitted. Thus, medication reconciliation is needed to accomplish the goal of a Tuberculosis-free world in 2050.

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study

OBJECTIVES

Missed opportunities to diagnose tuberculosis are costly to patients and society. In this study, we (1) estimate the frequency and duration of diagnostic delays among patients with active pulmonary tuberculosis and (2) determine the risk factors for experiencing a diagnostic delay.

DESIGN

A retrospective cohort study of patients with tuberculosis using longitudinal healthcare encounters prior to diagnosis.

SETTING

Commercially insured enrollees from the Commercial Claims and Encounters or Medicare Supplemental IBM Marketscan Research Databases, 2001-2017.

PARTICIPANTS

All patients diagnosed with, and receiving treatment for, pulmonary tuberculosis, enrolled at least 365 days prior to diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated the number of visits with tuberculosis-related symptoms prior to diagnosis that would be expected to occur in the absence of delays and compared this estimate to the observed pattern. We computed the number of visits representing a delay and used a simulation-based approach to estimate the number of patients experiencing a delay, number of missed opportunities per patient and duration of delays (ie, time between diagnosis and earliest missed opportunity). We also explored risk factors for missed opportunities.

RESULTS

We identified 3371 patients diagnosed and treated for active tuberculosis that could be followed up for 1 year prior to diagnosis. We estimated 77.2% (95% CI 75.6% to 78.7%) of patients experienced at least one missed opportunity; of these patients, an average of 3.89 (95% CI 3.65 to 4.14) visits represented a missed opportunity, and the mean duration of delay was 31.66 days (95% CI 28.51 to 35.11). Risk factors for delays included outpatient or emergency department settings, weekend visits, patient age, influenza season presentation, history of chronic respiratory symptoms and prior fluoroquinolone use.

CONCLUSIONS

Many patients with tuberculosis experience multiple missed diagnostic opportunities prior to diagnosis. Missed opportunities occur most commonly in outpatient settings and numerous patient-specific, environment-specific and setting-specific factors increase risk for delays.

Multidrug-Resistant Tuberculosis in Portugal: Patients’ Perception of the Challenges Faced during Treatment

<b><i>Introduction:</i></b> The increase in drug-resistant tuberculosis (TB) threatens global progress in eliminating TB, and constitutes a major challenge for patients, health-care workers and health services. Treatment for multidrug-resistant TB (MDR-TB) can last almost 2 years, and is more expensive, more toxic, and less effective than treating TB caused by drug-sensitive bacilli. This study aims to analyze patients’ narratives about the challenges they face during MDR-TB treatment and identify the support factors that help patients being treated in the most populous district of Portugal. <b><i>Methods:</i></b> Semi-structured interviews were conducted with patients being treated for MDR-TB. The interviews were coded using thematic analysis. They were audio-recorded, transcribed, and transported into NVivo v12 for data management and coding. <b><i>Results:</i></b> Depression, social discrimination, and the side effects of drugs are the main challenges faced by patients with MDR-TB. A good relationship of the patients with the health team, emotional support, and supervised treatment stand out as the factors that generate better adherence and treatment success. <b><i>Conclusion:</i></b> In addition to modern diagnostic techniques and new treatments, MDR-TB can be fought by focusing on the care and needs of patients. We suggest that the Lisbon Tuberculosis Program adopts the following measures: build the health-care team’s capacity to identify symptoms of depression early, increase public awareness of the disease, expand the multidisciplinary team, and expand the options for individualized social support for patients.

Treatment interruption patterns and adverse events among patients on bedaquiline containing regimen under programmatic conditions in India

BACKGROUND

The study aimed to analyze frequency and severity of adverse events (AEs) and other reasons for interruption of treatment and loss to follow up (LTFU) during first six months of treatment among tuberculosis patients on bedaquiline containing regimens.

METHODS

This pilot exploratory observational study included 275 patients enrolled consecutively over two years who received bedaquiline containing regimen under programmatic conditions in India.

RESULTS

Among 275 patients with median age of 25 years, 86 (31.3%) patients had at least one interruption with 122 total episodes of interruption. Among these 70 were temporary, 35 were permanent interruptions and 17 were LTFU. The AEs due to drugs were the commonest reason for interruption observed in 81.4% of temporary interruption group and 97.1% of permanent interruption group. Among a total 192 adverse event episodes, (49.5%) were minor (grade 1-2) and (50.5%) were serious (grade 3-5). Personal factors were the commonest reason for interruption observed in LTFU (94.1%) group. The most common temporarily interrupted drug was bedaquiline in 8.7% and permanently stopped drug was linezolid in 5% of patients.

CONCLUSIONS

Our study observed that drug related AEs are important risk factors associated with treatment interruptions in bedaquiline containing regimens. Bedaquiline is the most common temporarily interrupted drug due to AEs.