Patterns of delays in diagnosis amongst patients with smear-positive pulmonary tuberculosis at a teaching hospital in Turkey

Factors associated with diagnostic delay of pulmonary tuberculosis among children and adolescents in Quzhou, China: results from the surveillance data 2011-2021

PURPOSE

Tuberculosis is a high-burden disease and a major health concern in China, especially among children and adolescents. The purpose of this study was to assess risk factors for diagnostic delay in students with pulmonary tuberculosis in Quzhou City in eastern China.

PATIENTS AND METHODS

Cases of PTB in students and relevant information in Quzhou from 2011 to 2021 were collected using the TB Management Information System. The outcome of interest was diagnostic delay (i.e. ≥ 28 days between symptom onset and treatment initiation). Risk factors for diagnostic delay were identified using multivariable logistic regression.

RESULTS

A total of 629 students in Quzhou were diagnosed with PTB during the study period, of whom 55.5% were male. The median diagnostic delay was 18 days (Inter Quartile Range, [IQR]: 8-38) and 38.0% of the students had a diagnostic delay. Living in a rural area (adjusted odds ratio, [AOR]: 1.56, 95% confidence interval [CI:] 1.11-2.19), developing PTB symptoms in the first quarter of the year (AOR: 2.18, 95% CI: 1.40-3.40), and no sputum smear result (AOR: 8.73, 95% CI: 1.68-45.30) were significantly associated with a diagnostic delay. Discovery through health examinations (AOR: 0.33, 95% CI: 0.17-0.63) was associated with reduced risk of diagnostic delay.

CONCLUSION

Schools in rural areas should pay special attention to increasing student awareness of the symptoms of tuberculosis and provide health education on tuberculosis prevention and control to students and staff.

Determination of related factors about diagnostic and treatment delays in patients with smear-positive pulmonary tuberculosis in Turkey

Background/aim

This study aimed to analyze delays in diagnosis and treatment by defining the related demographic and clinical factors, to reveal obstacles, and to develop essential attempts to help reduce treatment delays.

Materials and methods

We created a questionnaire on the subject of delays in diagnosis and treatment in tuberculosis (TB) control to be administered to the patients. The forms were distributed to dispensaries across the country by the General Directorate of Public Health via an official letter.

Results

The study included 853 new patients with smear-positive pulmonary TB. The mean patient delay was 18.06 ± 22.27 days, the mean diagnosis delay was 35.63 ± 34.86 days, and the mean treatment delay was 0.90 ± 2.39 days. We found no association between sex, age, literacy, residential location, the presence of chronic respiratory diseases, and patient delay. It was determined that patient delay was shorter for patients with hemoptysis, fever, dyspnoea, and chest pain. In women, the diagnosis delay was longer than in men.

Conclusion

In the diagnosis process of patients with tuberculosis, it was determined that there was an improvement in the patient delay; however, the improvement in the diagnosis delay was still not acceptable as an ideal duration.

Total delay and associated factors in pulmonary tuberculosis patients in Golestan province

Background

Delay in diagnosis and treatment of TB is a critical component in TB control program which thereby spreading illness in the community. Sicnce Golestan province has the high risk with high rates of tuberculosis in the country, therefore, the analysis of the factors associated with treatment delay in this province for effective interventions and proper planning is considered necessary.

Methods

689 patients documents of TB cases in the health department of Golestan University of Medical Sciences in 2016 were enrolled in this survey. The response variable in this study was having the delay or not (via determining the 34 day as cut-off point in the interval between the date of onset of the symptoms and the date of treatment start-up). The data were analyzed using SPSS 24 software and final significant level for multivariate logistic regression model was considered 0.05.

Results

Median (mean) treatment delay was calculated 49(77.75) days. In the current study 60.4% of patients had total delay greater than 34 days. In final model variables such as type of PTB (OR=0.645), contact history (patients who had no contact with TB patients (OR=1.441)) and patients who their contact history were unknown (OR=1.654)) had significant relationship with delay in starting treatment after 34 days of onset of symptoms of PTB patients in Golestan (p<0.05).

Conclusion

It should beam emphasis on increasing the community's awareness of the symptoms of tuberculosis and effective collaboration should be made between the Infectious Disease Control Center and the private and public sectors.

Delays in Isolating Patients Admitted to Hospital with Pulmonary Tuberculosis in Korea

BACKGROUND

Delays in isolating patients admitted to hospital with active pulmonary tuberculosis (PTB) can contribute to nosocomial transmission; however, in Korea, patients with clinically diagnosed PTB are not routinely isolated while awaiting microbiological confirmation of the diagnosis. We aimed to assess the extent of delays in isolating patients admitted with PTB and to identify the factors associated with delayed isolation.

METHODS

We retrospectively reviewed the electronic medical records of patients aged ≥ 18 years with active PTB, between January 2008 and December 2017, from two Korean hospitals.

RESULTS

Among 1,062 patients, 612 (57.6%) were not isolated on admission day. The median time from admission to isolation was 1 day (interquartile range: 0-2 days). The independent risk factor most strongly associated with delayed isolation was admission to departments other than pulmonology or infectious diseases departments (adjusted odds ratio [aOR], 5.302; 95% confidence interval [CI], 3.177-8.847; P < 0.001). Factors associated with isolation on admission day were a past history of tuberculosis (TB) (aOR, 0.669; 95% CI, 0.494-0.906; P = 0.009), night sweats (aOR, 0.530; 95% CI, 0.330-0.851; P = 0.009), and apical infiltrates on chest radiographs (aOR, 0.452; 95% CI, 0.276-0.740; P = 0.002).

CONCLUSION

Concerning patients subsequently diagnosed with active PTB, > 50% were not isolated on admission day. We suggest that the patients with clinically suspected PTB including the elderly who have a past history of TB, night sweats, or apical infiltration on chest radiographs, be presumptively isolated on admission, without waiting for microbiological confirmation of the diagnosis.

Empirical evidence of delays in diagnosis and treatment of pulmonary tuberculosis: systematic review and meta-regression analysis

Background

Delays in diagnosis and treatment of pulmonary tuberculosis are a major set-back to global tuberculosis control. There is currently no global evidence on the average delays thus, the most important contributor to total delay is unknown. We aimed to estimate average delay measures and to investigate sources for heterogeneity among studies assessing delay measures.

Methods

Systematic review of studies reporting mean (± standard deviation) or median (interquartile range, IQR) of patient, doctor, diagnostic, treatment, health system and/or total delays in journal articles indexed in PubMed. We pooled mean delays using random-effects inverse variance meta-analysis, investigated for variations in pooled estimates in subgroup analyses and explored for sources of heterogeneity using pre-specified explanatory variables.

Results

The systematic review included 198 studies (831,724 patients) from 78 countries. The median number of patients per study was 243 (IQR; 160–458) patients.

Overall, the pooled mean total delay was 87.6 (95% CI: 81.4–93.9) days. The most important and largest contributor to total delay was patient delay with a pooled mean delay of 81 (95% CI: 70–92) days followed by doctor’s delay and treatment delay with pooled mean delays of 29.5 (95% CI: 25.9–33.0) and 7.9 (95% CI: 6.9–8.9) days respectively. There was considerable heterogeneity in all pooled analyses (I² > 95%). In the meta-regression models of mean delays, studies excluding extra-pulmonary tuberculosis patients reported increased mean doctor’s delay by 45 days on average, non-use of chest x-ray and conducting studies in high income countries decreased mean treatment delay by 20 and 22 days on average, respectively.

Conclusion

Strategies to address patients’ delay could have important implications for the success of the global tuberculosis control programmes.

Diagnostic Delay among Adults with Pulmonary Tuberculosis in a High Gross Domestic Product Per Capita Country: Reasons and Magnitude of the Problem

BACKGROUND

To determine the mean and median delays in pulmonary tuberculosis (PTB) diagnosis among adults in one of the world's highest gross domestic product per capita countries and identify patient and health system-related reasons for these delays.

METHODS

This is a cross-sectional, face-to-face, prospective study of 100 subjects with confirmed PTB, conducted at main tuberculosis (TB) admitting facilities in Qatar. The mean and median diagnostic delays were measured. The Chi-square test with two-sided P < 0.05 was considered to determine the association between factors and diagnostic delay.

RESULTS

The mean and median total diagnostic delays of PTB were 53 (95% confidence interval [CI] 42.61-63.59) and 30 (interquartile range; Q1-Q3, 15-60) days, respectively. The mean patient factor delay was 45.7 (95% CI 28.1-63.4) days, and the median was 30 (interquartile range; Q1-Q3, 15-60) days. The mean health system factor delay was 46.3 (95% CI 35.46-57.06) days, and the median was 30 (interquartile range; Q1-Q3, 18-60) days. The most common cause of patient factor delay was neglect of TB symptoms by patients (in 39% of cases), and for health-care system factor delay was a failure (mostly at general and private care levels) to suspect PTB by doctors (in 57% of cases). There were no significant associations between the presence of language barrier, patient occupation or nationality, and diagnostic delay.

CONCLUSIONS

Despite a favorable comparison to other countries, there is a substantial delay in the diagnosis of PTB in Qatar. Relevant actions including health education on TB are required to minimize this delay.

Pulmonary tuberculosis: Diagnostic delay in Tunisia

OBJECTIVE

Early diagnosis and prompt effective therapy are crucial to fight against tuberculosis (TB), particularly in regions with a high prevalence. We aimed to evaluate TB diagnostic delays and identify the associated risk factors.

METHODS

We conducted a survey in various health facilities in Tunisia between March 24th and October 30th, 2014. We included all patients aged ≥ 18 years who presented with pulmonary TB (PTB) and who had been initiated on an anti-TB treatment. We evaluated the time between respiratory symptom onset and treatment initiation. Treatment delays were divided into three categories: delays due to the patient, to the healthcare system, and overall delays.

RESULTS

We included 352 patients in the study (242 men and 110 women). The mean age was 42.2 years±17.7. The median time from symptom onset to treatment initiation was 52.56 days. Patient delays were longer for men, for patients presenting with alcohol dependence, and for patients who already knew they were sick. Healthcare system delays were associated with older age, female patients, patients consulting a private physician, and outpatients.

CONCLUSION

TB symptoms should be better explained to the population and healthcare professionals should be better trained to both reduce such delays and initiate treatment as early as possible.

Chest tuberculosis: Radiological review and imaging recommendations

Chest tuberculosis (CTB) is a widespread problem, especially in our country where it is one of the leading causes of mortality. The article reviews the imaging findings in CTB on various modalities. We also attempt to categorize the findings into those definitive for active TB, indeterminate for disease activity, and those indicating healed TB. Though various radiological modalities are widely used in evaluation of such patients, no imaging guidelines exist for the use of these modalities in diagnosis and follow-up. Consequently, imaging is not optimally utilized and patients are often unnecessarily subjected to repeated CT examinations, which is undesirable. Based on the available literature and our experience, we propose certain recommendations delineating the role of imaging in the diagnosis and follow-up of such patients. The authors recognize that this is an evolving field and there may be future revisions depending on emergence of new evidence.

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.

Patient and doctor delays in smear-negative and smear-positive pulmonary tuberculosis patients attending a referral hospital in Istanbul, Turkey

OBJECTIVES

To measure delays from onset of symptoms to initiation of treatment in patients with smear-negative and smear-positive pulmonary tuberculosis and to identify reasons for these delays.

METHODS

A total of 136 newly diagnosed pulmonary tuberculosis patients were interviewed using a structured questionnaire.

RESULTS

The patients were divided into two groups. Group 1 included 65 smear-negative patients. There were 71 smear-positive patients in group 2. The median application interval was 10 days in group 1 and 14 days in group 2. While 24.6% of the patients had patient delay in group 1, patient delay was present in 33.8% of the patients in group 2 (P > 0.05). The median health care system interval was 41 days in group 1 and 16 days in group 2 (P < 0.0001). The most common reason for patient delay was neglect of symptoms by patient in both groups. A low index of suspicion for tuberculosis by physicians was the most common reason for doctor delays.

CONCLUSIONS

Delays are common problem in smear-negative and smear-positive pulmonary tuberculosis patients. Delays should be reduced to reach an effective tuberculosis control. Education of public and physicians about tuberculosis is the most important effort to reduce delays.

[Diagnosis delay of pleural and pulmonary tuberculosis]

Tuberculosis (TB) is still being endemic in our country. Time until management determines both evolution and prognosis of this condition. The aim of this work is to evaluate the delay in diagnosis of TB in a respiratory unit from a university hospital series. The authors conducted a cross-sectional study including patients with pulmonary TBC and/or pleural. An evaluation of time management was conducted from the beginning of symptoms and various consultations with reference to the date of hospitalization and treatment set up. One hundred patients were included (pulmonary TB: 68 cases, pleural TB 23 cases, miliary pulmonary TB: 4 cases, pulmonary TB associated with other extrathoracic locations: 5 cases). The mean time of patient delay and total delay institution were respectively 43.6, 25.7 and 69.3 days. Variables responsible for long delays were: number of consultations more than 3 before hospitalization, empirical antibiotic therapy, of a regional hospital first consultation and the presence of extra-respiratory impairment. The patient delay was considered long. A reorganization of the TB control program, in particular by partial decentralization of care and health education is imperative in order to improve the quality of tuberculosis management in our country.

Health system delay in pulmonary tuberculosis treatment in a country with an intermediate burden of tuberculosis: a cross-sectional study

BACKGROUND

Delayed diagnosis and treatment of tuberculosis increase both the severity of the disease and the duration of infectivity. A number of studies have addressed the issue of health system delays in the treatment of tuberculosis, but mostly in countries with a high or low incidence of the disease. Our understanding of delay is quite limited in settings with an intermediate burden of tuberculosis. We explore the duration and factors associated with delays in the Croatian health system which has free health care and a sufficient network of health services providing tuberculosis diagnosis and care.

METHODS

A total of 241 consecutive adults with culture-confirmed pulmonary tuberculosis were interviewed in seven randomly selected Croatian counties and their medical records were evaluated. A health system delay was defined as the number of days from the first consultation with a physician to the initiation of anti-tuberculosis treatment. A long delay was defined as a period exceeding the median delay, while an extreme delay was considered to be above the 75th percentile delay.

RESULTS

The median health system delay was 15 days while the 75th percentile was 42 days (the 5th and 95th percentile being 1 and 105 days respectively). Almost 30% of tuberculosis patients remained undiagnosed for more than 30 days after the initial health care visit. Female patients (p = 0.005), patients with a negative sputum smear (p = 0.002) and patients having symptoms other than the usual ones (0.027) were found to be in significant correlation with a long delay. In a multivariate model, a long delay remained associated with the same variables (p = 0.008, p = 0.003, and p = 0.037, respectively).A significant association was demonstrated between both the female gender (p = 0.042) and a negative sputum smear (p < 0.001) and extreme delay, while only a negative sputum smear (p < 0.001) remained significant in the multivariate analysis.

CONCLUSIONS

Our findings suggest that some groups of tuberculosis patients experienced a health system delay. In such a setting where tuberculosis incidence is decreasing, which leads to a lack of physician experience and expertise, training in tuberculosis is required. Such measure may be useful in reducing the number of missed opportunities for tuberculosis diagnosis.

Prescribed and self-medication use increase delays in diagnosis of tuberculosis in the country of Georgia

SETTING

Georgia has a high burden of tuberculosis (TB), including multidrug-resistant TB. Enhancing early diagnosis of TB is a priority to reduce transmission.

OBJECTIVE

To quantify delays in TB diagnosis and identify risk factors for delay in the country of Georgia.

DESIGN

In a cross-sectional study, persons with newly diagnosed, culture-confirmed pulmonary TB were interviewed within 2 months of diagnosis and medical and laboratory records were abstracted.

RESULTS

Among 247 persons enrolled, the mean and median total TB diagnostic delay was respectively 89.9 and 59.5 days. The mean and median patient delay was 56.2 and 23.5 days, while health care system delay was 33.7 and 14.0 days. In multivariable analysis, receipt of a medication prior to TB diagnosis was associated with increased overall diagnostic delay (adjusted odds ratio [aOR] 2.28, 95%CI 1.09-4.79); antibiotic use prior to diagnosis increased the risk of prolonged health care delay (aOR 4.16, 95%CI 1.97-8.79). TB cases who had increased patient-related diagnostic delay were less likely to have prolonged health care diagnostic delay (aOR 0.38, 95%CI 0.19-0.74).

CONCLUSION

Prolonged delays in detecting TB are common in Georgia. Interventions addressing the misuse of antibiotics and targeting groups at risk for prolonged delay are warranted to reduce diagnostic delays and enhance TB control.

Health-care seeking behaviour for tuberculosis symptoms in Croatia

BACKGROUND

Early detection and treatment of tuberculosis (TB) patients have been key principles of TB control. Therefore, it is important to understand the causes of delay and to estimate their magnitude in order to plan interventions that yield the maximum benefit.

METHODS

A total of 240 subjects aged ≥ 15 year with pulmonary TB were interviewed. Patient delay was defined as the period (in days) from the appearance of any symptoms to the first visit to a medical provider.

RESULTS

The median patient delay was 38 days. When using the median as a cut-off to define long patient delay, being an ex-smoker (P = 0.036), current smoker (P = 0.030), coughing (P = 0.021) and losing weight (P = 0.050) were found to be significant. Having high level of education (P = 0.014) was associated with short delay. Being an ex-smoker (P = 0.050, adjusted odds ratio (aOR) = 1.940, 95% CI 1.001-3.759), current smoker (P = 0.029, aOR = 2.077, 95% CI 1.076-4.012) and having a cough (P = 0.022, aOR = 2.032, 95% CI 1.108-3.727), were significant in multivariate logistic regression, while having high level of education remained associated with short delay (P = 0.016, aOR = 0.286, 95% CI 0.103-0.791). The most common reasons for delay were supposed influenza or symptoms improving over time (34.5%) and underestimated symptoms (32.9%).

CONCLUSION

People with smoking habits and health-seeking behaviour that may favour advanced disease and prolonged infectiousness as well as people with the lowest level of education contributed to TB delay. To reduced patient delay, efforts should be made to increase TB knowledge, which has to be adjusted to the less-educated segments of the population.

Patient delay determinants for patients with suspected tuberculosis in Yogyakarta province, Indonesia

OBJECTIVES

Indonesia has a high incidence of tuberculosis (TB), despite the successful introduction of the directly observed treatment short-course strategy (DOTS strategy). DOTS depends on passive case finding. It is therefore important to identify determinants of patient delay and reasons for visiting a DOTS healthcare provider when seeking care. The aim of this study was to assess these determinants in TB suspects (coughing for at least 2 weeks).

METHODS

Cross-sectional data were gathered with a structured questionnaire in which psychosocial determinants were based on an extended version of the theory of planned behaviour (TPB). The study was conducted in five governmental lung clinics of Yogyakarta province. In total, 194 TB suspects that registered at the lung clinics were interviewed.

RESULTS

The median patient delay was 14 days (range 0-145). Ordinal regression analyses showed that visiting a private healthcare provider when first seeking health care, reporting travel distance/travel time as reason for choosing a certain healthcare provider when first seeking health care, discussing the symptoms with family and a reported short travel time, but no factors of TPB, were significantly associated with a shorter patient delay. An important factor negatively associated with visiting a DOTS clinic was the reported travel time.

CONCLUSION

Accessibility of the healthcare provider was the main determinant of patient delay, but the role of psychosocial factors cannot be fully excluded. Urban and suburban areas have relatively good access to (private) health care, hence the short delay. Thus, future studies should be focussed on extending the DOTS strategy to the private sector.

Diagnostic delay amongst tuberculosis patients in Jogjakarta Province, Indonesia is related to the quality of services in DOTS facilities

OBJECTIVES

To understand determinants of care-seeking patterns and diagnostic delay amongst tuberculosis (TB) patients diagnosed at direct observed treatment short course (DOTS) facilities in Jogjakarta, Indonesia.

METHODS

Cross-sectional survey amongst newly diagnosed TB patients in 89 DOTS facilities whose history of care-seeking was reconstructed through retrospective interviews gathering data on socio-demographic determinants, onset of TB symptoms, type of health facilities visited, duration of each care-seeking action were recorded.

RESULTS

Two hundred and fifty-three TB patients were included in the study whose median duration of patients' delay was 1 week and whose total duration of diagnostic delay was 5.4 weeks. The median number of visits was 4. Many of the patients' socio-demographic determinants were not associated with the care-seeking patterns, and no socio-demographic determinants were associated with the duration of diagnostic delay. More than 60% of TB patients started their care-seeking processes outside DOTS facilities, but the number of visits in DOTS facilities was greater during the overall care-seeking process. Surprisingly, patient's immediate visits to a DOTS facility did not correspond to shorter diagnostic delay.

CONCLUSION

Diagnostic delay in Jogjakarta province was not associated with patients' socio demographic factors, but rather with the health system providing DOTS services. This suggests that strengthening the health system and improving diagnostic quality within DOTS services is now a more rational strategy than expanding the TB programme to engage more providers.

Time delays in diagnosis of pulmonary tuberculosis: a systematic review of literature

BACKGROUND

Delay in diagnosis of pulmonary tuberculosis results in increasing severity, mortality and transmission. Various investigators have reported about delays in diagnosis of tuberculosis. We aimed at summarizing the data on these delays in diagnosis of tuberculosis.

METHODS

A systematic review of literature was carried out. Literature search was done in Medline and EMBASE from 1990 to 2008. We used the following search terms: delay, tuberculosis, diagnosis, and help-seeking/health-seeking behavior without language restrictions. In addition, indices of four major tuberculosis journals were hand-searched. Subject experts in tuberculosis and authors of primary studies were contacted. Reference lists, review articles and text book chapters were also searched. All the studies were assessed for methodological quality. Only studies carried out on smear/culture-positive tuberculosis patients and reporting about total, patient and health-care system delays were included.

RESULTS

A total of 419 potential studies were identified by the search. Fifty two studies qualified for the review. The reported ranges of average (median or mean) total delay, patient delay, health system delay were 25-185 days, 4.9-162 days and 2-87 days respectively for both low and high income countries. Average patient delay was similar to health system delay (28.7 versus 25 days). Both patient delay and health system delay in low income countries (31.7 days and 28.5 days) were similar to those reported in high income countries (25.8 days and 21.5 days).

CONCLUSION

The results of this review suggest that there is a need for revising case-finding strategies. The reported high treatment success rate of directly observed treatment may be supplemented by measures to shorten the delay in diagnosis. This may result in reduction of infectious cases and better tuberculosis control.

A systematic review of delay in the diagnosis and treatment of tuberculosis

BACKGROUND

Early diagnosis and immediate initiation of treatment are essential for an effective tuberculosis (TB) control program. Delay in diagnosis is significant to both disease prognosis at the individual level and transmission within the community. Most transmissions occur between the onset of cough and initiation of treatment.

METHODS

A systematic review of 58 studies addressing delay in diagnosis and treatment of TB was performed. We found different definitions of, for example, debut of symptoms, first appropriate health care provider, time to diagnosis, and start of treatment. Rather than excluding studies that failed to meet strict scientific criteria (like in a meta-analysis), we tried to extract the "solid findings" from all of them to arrive on a more global understanding of diagnostic delay in TB.

RESULTS

The main factors associated with diagnostic delay included human immunodeficiency virus; coexistence of chronic cough and/or other lung diseases; negative sputum smear; extrapulmonary TB; rural residence; low access (geographical or sociopsychological barriers); initial visitation of a government low-level healthcare facility, private practitioner, or traditional healer; old age; poverty; female sex; alcoholism and substance abuse; history of immigration; low educational level; low awareness of TB; incomprehensive beliefs; self-treatment; and stigma.

CONCLUSION

The core problem in delay of diagnosis and treatment seemed to be a vicious cycle of repeated visits at the same healthcare level, resulting in nonspecific antibiotic treatment and failure to access specialized TB services. Once generation of a specific diagnosis was in reach, TB treatment was initiated within a reasonable period of time.