Why do symptomatic patients delay obtaining care for tuberculosis?

From symptom onset to treatment initiation: protocol for a narrative study exploring the journey of older adults with tuberculosis in the English Midlands, UK

INTRODUCTION

Time from symptom onset to treatment initiation in tuberculosis (TB) remains stubbornly prolonged despite reductions in disease incidence. Delays may contribute to increased morbidity, mortality, onward spread of disease and poor patient experiences. Most delays occur prior to hospital referral. The average primary care healthcare provider in England is unlikely to see TB on a regular basis. Little is known about primary care diagnostic and referral challenges.Adults aged 65 years or older are more likely to experience delays. However, little is known about their journey from symptom onset to treatment initiation.

METHODS AND ANALYSIS

We will carry out a narrative study including adults aged 65 years or older, living in the English Midlands and receiving treatment for active TB. Twelve English and 12 Urdu or Punjabi speakers will be recruited from TB clinics and interviewed. Their primary care records will be accessed, and the primary care story and secondary care letters will be extracted. Each of the data sources will be analysed using dialogical narrative analysis. Data will be triangulated within participants and across the data set.

ETHICS AND DISSEMINATION

This study received approval from the Health Research Authority and the Research Ethics Committee in April 2022. Risk management and equity considerations have been made a priority. Findings will be disseminated through publication in open access peer-reviewed journals, presentations to policy makers, primary healthcare and secondary healthcare professionals, and through public facing materials developed in conjunction with patients, members of the pubic, TB services and charities.

Prior Screening for Latent Tuberculosis Among Patients Diagnosed With Tuberculosis Disease: Missed Opportunities?

Background

California has the largest number of tuberculosis (TB) disease cases in the United States. This study in a large California health system assessed missed opportunities for latent tuberculosis (LTBI) screening among patients with TB disease.

Methods

Kaiser Permanente Southern California patients who were ≥18 years old with membership for ≥24 months during the study period from 1 January 2008 to 31 December 2019 were included. Prior LTBI test (tuberculin skin test or interferon-γ release assay) or diagnosis code prior to TB disease diagnosis was assessed among patients with observed TB disease (confirmed by polymerase chain reaction and/or culture). In the absence of current treatment practices, more patients screened for LTBI may have developed TB disease. We estimated hypothetical TB disease cases prevented by multiplying LTBI progression rates by the number of LTBI-positive patients prescribed treatment.

Results

A total of 1289 patients with observed TB disease were identified; 148 patients were LTBI positive and 84 were LTBI negative. Patients not prescreened for LTBI made up 82.0% of observed TB disease cases (1057/1289). Adding the hypothetical maximum estimate for prevented cases decreased the percentage of patients who were not prescreened for LTBI to 61.7% [1057/(1289 + 424)].

Conclusions

One-fifth of patients were screened for LTBI prior to their active TB diagnosis. Assuming the upper bound of cases prevented through current screening, almost 62% of TB disease patients were never screened for LTBI. Future work to elucidate gaps in LTBI screening practices and to identify opportunities to improve screening guidelines is needed.

Impact of United States 2017 Immigration Policy changes on missed appointments at two Massachusetts Safety-Net Hospitals

INTRODUCTION

Studies have shown mixed findings regarding the impact of immigration policy changes on immigrants' utilization of primary care.

METHODS

We used a difference-in-differences analysis to compare changes in missed primary care appointments over time across two groups: patients who received care in Spanish, Portuguese, or Haitian Creole, and non-Hispanic, white patients who received care in English.

RESULTS

After adjustment for age, sex, race, insurance, hospital system, and presence of chronic conditions, immigration policy changes were associated with an absolute increase in the missed appointment prevalence of 0.74 percentage points (95% confidence interval: 0.34, 1.15) among Spanish, Portuguese and Haitian-Creole speakers. We estimated that missed appointments due to immigration policy changes resulted in lost revenue of over $185,000.

CONCLUSIONS

We conclude that immigration policy changes were associated with a significant increase in missed appointments among patients who receive medical care in languages other than English.

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.

The Cutaneous Leishmaniasis and the Sand Fly: Knowledge and Beliefs of the Population in Central Morocco (El Hajeb)

Background

Cutaneous leishmaniasis is a neglected parasitic dermal disease transmitted to humans through the bite of an infected female sand fly. Morocco hopes to eliminate all forms of leishmaniasis by 2030. These dermatoses pose a real public health problem in the country. Although the information is available on the disease, individual knowledge of cutaneous leishmaniasis and sand fly is not yet developed. Exploring people's beliefs and popular behaviours about cutaneous leishmaniasis and its vector allows health officials to know the sociocultural aspects of the disease and to improve prevention and control actions.

Objectives

To identify the knowledge of cutaneous leishmaniasis and its vector in the population in central Morocco.

Methods

Based on the epidemiological data of leishmaniases in the province of El Hajeb, we conducted a field survey and personal interviews in April and May 2019, among 281 persons belonging to the localities where leishmaniases were registered.

Results

Our results show that the participants use the concept of "Chniwla" (61.6%) for sand fly and the concept of "Hboub Chniwla" (50.8%) for cutaneous leishmaniasis; 24.6% of the respondents do not know how the disease is transmitted to humans and 43.7% use traditional treatments and home remedies to cure themselves. 44% of participants believe that sand fly does not transmit the disease to humans and only 6.4% were aware of their responsibility in vector control.

Conclusions

The study concluded that there is a need to simplify the scientific terminology in the health education of citizens regarding these dermatoses and their vector by integrating the popular concepts obtained in this study to raise public awareness and facilitate their involvement as active actors in the prevention of cutaneous leishmaniasis.

Challenges in Recruiting African-Born, US-Based Participants for HIV and Tuberculosis Research

Research is critical for developing HIV and tuberculosis (TB) programming for U.S. African-born communities, and depends on successful recruitment of African-born people. From January 2014 to June 2016, we recruited African-born people for HIV and TB research in King County, Washington. We compared the characteristics of study participants and the underlying populations of interest, and assessed recruitment strategies. Target enrollment for the HIV study was 167 participants; 51 participants (31%) were enrolled. Target enrollment for the TB study was 218 participants; 38 (17%) were successfully recruited. Of 249 prior TB patients we attempted to contact by phone, we reached 72 (33%). Multiple recruitment strategies were employed with variable impact. Study participants differed from the underlying populations in terms of gender, country of origin and language. Inequities in research participation and in meaningful opportunities for such participation may exacerbate existing health disparities.

Responding to a Mumps Outbreak Impacting Immigrants and Low-English-Proficiency Populations

OBJECTIVES

To examine outbreak response-associated costs, lessons learned, and challenges encountered during a local health department's response to a mumps outbreak.

DESIGN

We conducted semistructured interviews with individuals directly involved in the response to a mumps outbreak and analyzed outbreak response-associated cost data.

SETTING

In March-July 2018, a mumps outbreak occurred in Chester County, Pennsylvania. The outbreak primarily affected an immigrant community, some of whom spoke little or no English and were uninsured and/or undocumented. This necessitated an urgent response from the Chester County Health Department, which implemented a variety of public health interventions, including outreach to local health care providers and the execution of vaccination clinics at 2 local mushroom farms where case contacts worked. A total of 39 suspected or confirmed mumps cases were reported in Chester County, and 22 suspected or confirmed cases were reported by 2 neighboring jurisdictions.

PARTICIPANTS

Health department employees (n = 7) and community partners (n = 2). Areas of expertise included emergency preparedness, nursing, medicine, disease surveillance, and epidemiology.

MAIN OUTCOME MEASURE

Operational challenges encountered and lessons learned during the mumps outbreak response, including outbreak response-associated costs, which could inform other communities' planning and preparedness for outbreaks in similar populations and improve outbreak response operations.

RESULTS

Immigration status emerged as a key challenge, which highlighted the importance of building trust through community outreach and partnerships and the need for culturally competent communication. In addition, vaccine availability, accessibility, and cost played a major role in response operations and necessitated the involvement of community partners to mitigate these barriers. Outbreak response-associated costs totaled $35 305.

CONCLUSIONS

The challenges that occurred in this outbreak are broadly relevant to outbreaks that affect similar immigrant communities. Health departments that serve such populations can utilize these lessons to develop improved outbreak response plans that account for these challenges.

Do cognitive heuristics underpin symptom appraisal for symptoms of cancer?: A secondary qualitative analysis across seven cancers

OBJECTIVES

To explore the evidence for cognitive heuristics or "rules of thumb" used within patients' reports of symptom appraisal and decisions to seek help for symptoms of cancer.

METHODS

A secondary analysis of interviews from existing studies that explored symptom appraisal in patients who had sought help for potential symptoms of cancer. Transcripts from n = 50 in-depth interviews with patients referred with symptoms suspicious of cancer (pancreas, colorectal, oral, lung, melanoma, breast, and prostate) were re-analysed using a deductive thematic approach underpinned by the heuristics outlined in the Common Sense Model of Illness Self-regulation as set within the Model of Pathways to Treatment.

RESULTS

The most dominant heuristic in patient reports was the Rate of change rule (ie, symptoms that are worsening, increasing, or have a sudden onset [rather than improving, stable or decreasing in number] are more likely to indicate illness). There was also support for the Duration rule, Pattern rule, Chronology rule, Severity (of interference) rule, Age-illness rule, Novelty rule, Similarity rule, Location rule, and Optimistic bias rule. There was a lack of evidence for the Prevalence and Stress-illness rules.

CONCLUSIONS

People do appear to use heuristics to guide their appraisal of symptoms and their perceived need for healthcare. Heuristics may be an important aspect underlying symptom misinterpretation, thus making them key targets for interventions. For instance, campaigns could tackle cognitive biases rather than focusing on specific symptom awareness. Myth-busting messages could highlight that intermittent, mild symptoms, and symptoms that are not worsening can be signs of a serious health problem.

Patient predictors of health-seeking behaviour for persons coughing for more than two weeks in high-burden tuberculosis communities: the case of the Western Cape, South Africa

Background

This study aimed to analyse the patient predictors of health-seeking behaviour for persons coughing for more than 2 weeks to better understand this vulnerable and important population.

Methods

The study analysed data from a cohort study (SOCS - Secondary Outcome Cohort Study) embedded in a community randomised trial ZAMSTAR (Zambia and South Africa TB and AIDS Reduction Study) in eight high-burden TB communities in the Western Cape, South Africa. These datasets are unique as they contain TB-related data as well as data on health, health-seeking behaviour, lifestyle choices, employment, socio-economic status, education and stigma. We use uni- and multivariate logistic regressions to estimate the odds ratios of consulting for a cough (of more than 2 weeks duration) for a range of relevant patient predictors.

Results

Three hundred and forty persons consulted someone about their cough and this represents 37% of the 922 participants who reported coughing for more than 2 weeks. In the multivariate analysis, respondents of black ethnic origin (OR 1.99, 95% CI 1.28–3.12, P < 0.01), those with higher levels of education (OR 1.05 per year of education, 95% CI 1.00–1.10, P = 0.05), and older respondents (OR 1.02 per year, 95% CI 1.01–1.04, P < 0.01) had a higher likelihood of consulting for their chronic cough. Individuals who smoked (OR 0.63, 95% CI 0.45–0.88, P < 0.01) and those with higher levels of socio-economic status (OR 0.81, 95% CI 0.71–0.92, P < 0.01) were less likely to consult. We find no evidence of stigma playing a role in health-seeking decisions, but caution that this may be due to the difficulty of accurately and reliably capturing stigma due to, amongst other factors, social desirability bias.

Conclusions

The low levels of consultation for a cough of more than 2 weeks suggest that there are opportunities to improve case-finding. These findings on health-seeking behaviour can assist policymakers in designing TB screening and active case-finding interventions that are targeted to the characteristics of those with a chronic cough who do not seek care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3992-6) contains supplementary material, which is available to authorized users.

Determinants of patient and health system delay among Italian and foreign-born patients with pulmonary tuberculosis: a multicentre cross-sectional study

OBJECTIVES

The aim of this cross-sectional study was to identify key factors associated with patient delay (PD), health system delay (HSD) and total delay (TOTD) in patients with tuberculosis (TB) to inform control programmes.

SETTING

The study was conducted in four Italian regions in 2014-2016. Data were obtained using a questionnaire including: sociodemographic and lifestyle data, TB comorbidities, patient knowledge and attitudes towards TB, stigma, access to TB care and health-seeking behaviours.

PARTICIPANTS

Patients' inclusion criteria were being diagnosed as a new smear positive pulmonary TB case and living in one of the participating Italian regions. Overall, 344 patients from 30 healthcare centres were invited to participate and 253 patients were included in the analysis (26.5% non-response rate); 63.6% were males and 55.7% were non-Italian born.

OUTCOME MEASURES

Risk factors for PD, HSD and TOTD in patients with TB were assessed by multivariable analysis. Adjusted ORs (aOR) and 95% CIs were calculated.

RESULTS

Median PD, HSD and TOTD were 30, 11 and 45 days, respectively. Factors associated with longer PD were: stigma (aOR 2.30; 95% CI 1.06 to 4.98), chest pain (aOR 2.67; 95% CI 1.24 to 6.49), weight loss (aOR 4.66; 95% CI 2.16 to 10.05), paying for transportation (aOR 2.66; 95% CI 1.24 to 5.74) and distance to the health centre (aOR 2.46; 95% CI 1.05 to 5.74) (the latter three were also associated with TOTD). Shorter HSD was associated with foreign-born and female status (aOR 0.50; 95% CI 0.27 to 0.91; aOR 0.28; 95% CI 0.15 to 0.53, respectively), dizziness (aOR 0.18, 95% CI 0.04 to 0.78) and seeking care at hospital (aOR 0.35; 95% CI 0.18 to 0.66). Prior unspecific treatment was associated with longer HSD (aOR 2.25; 95% CI 1.19 to 4.25) and TOTD (aOR 2.55; 95% CI 1.18 to 5.82). Haemoptysis (aOR 0.12; 95% CI 0.03 to 0.43) and repeated visits with the same provider (aOR 0.29; 95% CI 0.11 to 0.76) showed shorter TOTD.

CONCLUSIONS

This study identifies several determinants of delays associated with patient's behaviours and healthcare qualities. Tackling TB effectively requires addressing key risk factors that make individuals more vulnerable by the means of public health policy, cooperation and advocacy to ensure that all patients have easy access to care and receive high-quality healthcare.

Tuberculosis, human rights and ethics considerations along the route of a highly vulnerable migrant from sub-Saharan Africa to Europe

Migrant health is a critical public health issue, and in many countries attention to this topic has focused on the link between migration and communicable diseases, including tuberculosis (TB). When creating public health policies to address the complex challenges posed by TB and migration, countries should focus these policies on evidence, ethics, and human rights. This paper traces a commonly used migration route from sub-Saharan Africa to Europe, identifying situations at each stage in which human rights and ethical values might be affected in relation to TB care. This illustration provides the basis for discussing TB and migration from the perspective of human rights, with a focus on the right to health. We then highlight three strands of discussion in the ethics and justice literature in an effort to develop more comprehensive ethics of migrant health. These strands include theories of global justice and global health ethics, the creation of 'firewalls' to separate enforcement of immigration law from protection of human rights, and the importance of non-stigmatization to health justice. The paper closes by reflecting briefly on how TB programs can better incorporate human rights and ethical principles and values into public health practice.

Comparison of Early and Late Tuberculosis Deaths in Korea

The cause of death in patients with tuberculosis (TB) may differ according to the phase of anti-tuberculosis treatment. However, there are limited data regarding this issue in Korea. We compared the cause of death of TB patients who died during the early intensive and late continuation phase of treatment. Twenty (56%) of the 36 early deaths were due to TB-related causes, whereas 34 (89%) of the 38 late deaths were due to TB-unrelated causes. This finding suggests that TB-related early deaths mainly attributable to delayed diagnosis should be improved to further reduce the overall TB deaths.

Barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review of qualitative literature

Tuberculosis disproportionately affects hard-to-reach populations, such as homeless people, migrants, refugees, prisoners, or drug users. These people often face challenges in accessing quality health care. We did a systematic review of the qualitative literature to identify barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by people from hard-to-reach populations in all European Union (EU), European Economic Area, EU candidate, and Organisation for Economic Co-operation and Development countries. The 12 studies included in this review mainly focused on migrants. Views on perceived susceptibility to and severity of tuberculosis varied widely and included many misconceptions. Stigma and challenges regarding access to health care were identified as barriers to tuberculosis diagnosis and treatment uptake, whereas support from nurses, family, and friends was a facilitator for treatment adherence. Further studies are required to identify barriers and facilitators to the improved identification and management of tuberculosis in hard-to-reach populations to inform recommendations for more effective tuberculosis control programmes.

Pathogenic Policy: Immigrant Policing, Fear, and Parallel Medical Systems in the US South

Medical anthropology has a vital role in identifying health-related impacts of policy. In the United States, increasingly harsh immigration policies have formed a multilayered immigrant policing regime comprising state and federal laws and local police practices, the effects of which demand ethnographic attention. In this article, I draw from ethnographic fieldwork in Atlanta, Georgia, to examine the biopolitics of immigrant policing. I underscore how immigrant policing directly impacts undocumented immigrants' health by producing a type of fear based governance that alters immigrants' health behaviors and sites for seeking health services. Ethnographic data further point to how immigrant policing sustains a need for an unequal, parallel medical system, reflecting broader social inequalities impacting vulnerable populations. Moreover, by focusing on immigrant policing, I demonstrate the analytical utility in examining the biopolitics of fear, which can reveal individual experiences and structural influents of health-related vulnerability.

Patient and Healthcare System Delays in the Start of Pulmonary Tuberculosis Treatment Among Tribal Patients Registered Under DOTS, Odisha

INTRODUCTION

Tuberculosis (TB) is a highly infectious disease which continues to be an important public health problem worldwide.

AIM

This study puts an effort to determine patient and health system delay in diagnosis and treatment and association to specific types of delay among tribals in Mayurbhanj district, Odisha.

MATERIALS AND METHODS

A total of 261 TB patients reporting to 4 TB Units of Mayurbhanj were interviewed using pre-tested structured questionnaire. Extra-pulmonary TB patients and death cases were excluded. Data entry and analysis was carried out in Epi-info 3.32 version. Chi-square test was used to test the association between dependant variable (patient and health system delays) with different independent variables (age, sex, reasons for delay etc.).

RESULTS

Median patient, health system and total delay were 24, 3 and 24 days respectively. Risk factors that were significantly associated with patient delay were education (95% CI= 1.01-1.11, p=0.015), cost of treatment/transport (95% CI=0.87-1.01, p=0.020), distance (95% CI=1.00-1.29, p=0.002) and lack of awareness about TB (95% CI=1.01-1.34, p=0.001). Health system delay risk factors were distance (95% CI=0.32-0.96, p=0.043), delay due to administrative verification (95% CI=1.18-57.97, p= 0.005) and delay due to traditional healers/ private practitioners (95% CI=1.61-15.45, p=0.0008).

CONCLUSION

This study revealed longer patient delay compared to health system delay. Therefore, public awareness in tribal dialect about chest symptoms and availability of free diagnostics services should be increased along with involvement of traditional healers.

Factors Influencing Delayed Health Care Seeking Among Pulmonary Tuberculosis Suspects in Rural Communities in Ntcheu District, Malawi

Delayed diagnosis and treatment of tuberculosis (TB) among individuals suspected of having TB may lead to continued transmission of Mycobacterium tuberculosis in communities, higher mortality rates, and increase in government health expenditure because of prolonged illness due to late diagnosis and treatment initiation. The study explored factors leading to delayed health care seeking among individuals living in Ntcheu District, Malawi. Two key informant interviews, 16 in-depth interviews, and three focus group discussions were conducted. Participants were aged 18 years and older and never had TB. Data were analyzed using content analysis and factors were identified: inadequate knowledge about cause and transmission of TB, low self-awareness of personal risk to TB, cultural and traditional beliefs about sources of TB, stigma, and strong belief in witchcraft as a cause of illness. The TB Control Program needs to invest in social mobilization and education of communities to mitigate early health care seeking.

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.

Investigation of Knowledge and Perception of Tuberculosis Among Hispanics in Utah County, Utah

This study aimed to assess extent of knowledge and perceptions of TB within the growing Hispanic community of Utah County, Utah, and the need for focused community educational intervention within that demographic. A mixed-method approach was used and included a survey of 166 adult males and females, and two focus groups with Hispanic women. TB was better known for its ability to kill (92.8 %) than for being contagious (64.5 %); while most knew that TB mainly affects the lungs (77.7 %) and is spread through coughing (75.3 %). Few believed that overcrowded living conditions were a risk factor for TB (30.1 %). Many believed that TB could be cured with medicine (75.3 %). And 65.7 % reported they had been tested for TB, and 7 % had been told by a doctor they had TB. Focus group data showed while most had knowledge of major TB symptoms, some had key misperceptions about disease transmission, testing, TB vaccine, and various protective factors. Enhanced education and dissemination of information on TB, to include an emphasis on symptoms, testing, and treatment within this demographic is recommended. A culturally-appropriate intervention should utilize a participatory approach, to include the local health department in partnership with various Hispanic community-based organizations.

Barriers to health care for undocumented immigrants: a literature review

With the unprecedented international migration seen in recent years, policies that limit health care access have become prevalent. Barriers to health care for undocumented immigrants go beyond policy and range from financial limitations, to discrimination and fear of deportation. This paper is aimed at reviewing the literature on barriers to health care for undocumented immigrants and identifying strategies that have or could be used to address these barriers. To address study questions, we conducted a literature review of published articles from the last 10 years in PubMed using three main concepts: immigrants, undocumented, and access to health care. The search yielded 341 articles of which 66 met study criteria. With regard to barriers, we identified barriers in the policy arena focused on issues related to law and policy including limitations to access and type of health care. These varied widely across countries but ultimately impacted the type and amount of health care any undocumented immigrant could receive. Within the health system, barriers included bureaucratic obstacles including paperwork and registration systems. The alternative care available (safety net) was generally limited and overwhelmed. Finally, there was evidence of widespread discriminatory practices within the health care system itself. The individual level focused on the immigrant’s fear of deportation, stigma, and lack of capital (both social and financial) to obtain services. Recommendations identified in the papers reviewed included advocating for policy change to increase access to health care for undocumented immigrants, providing novel insurance options, expanding safety net services, training providers to better care for immigrant populations, and educating undocumented immigrants on navigating the system. There are numerous barriers to health care for undocumented immigrants. These vary by country and frequently change. Despite concerns that access to health care attracts immigrants, data demonstrates that people generally do not migrate to obtain health care. Solutions are needed that provide for noncitizens’ health care.

Neglected diseases prioritized in Brazil under the perspective of metabolomics: A review

This review article compiles in a critical manner literature publications regarding seven neglected diseases (ND) prioritized in Brazil (Chagas disease, dengue, leishmaniasis, leprosy, malaria, schistosomiasis, and tuberculosis) under the perspective of metabolomics. Both strategies, targeted and untargeted metabolomics, were considered in the compilation. The majority of studies focused on biomarker discovery for diagnostic purposes, and on the search of novel or alternative therapies against the ND under consideration, although temporal progression of the infection at metabolic level was also addressed. Tuberculosis, followed by schistosomiasis, malaria and leishmaniasis are the diseases that received larger attention in terms of number of publications. Dengue and leprosy were the least studied and Chagas disease received intermediate attention. NMR and HPLC-MS technologies continue to predominate among the analytical platforms of choice in the metabolomic studies of ND. A plethora of metabolites were identified in the compiled studies, with expressive predominancy of amino acids, organic acids, carbohydrates, nucleosides, lipids, fatty acids, and derivatives.

Risk Factors and Current Health-Seeking Patterns of Migrants in Northeastern Mexico: Healthcare Needs for a Socially Vulnerable Population

This study identified risk factors for health and access to healthcare services of migrants during their journey across Mexico to the United States. Data were collected in shelters located in Monterrey, the largest city of northeastern Mexico, through a basic clinical examination and a survey completed by 75 migrants; 92% of them were undocumented Central Americans. During their transit, they are at a high risk of contracting, developing, and transmitting diseases. The need of working to survive affects health-seeking behavior and a constant fear of being traced keeps migrants away from public health services, which delays diagnosis and treatment of diseases. Negligent lifestyles, such as smoking, drinking (31.8% of men and 11.1% of women), and drug abuse (13% of men and 11% of women), were found. Regarding tuberculosis (TB), undocumented migrants are usually not screened, even though they come from countries with a high TB burden. Besides, they might be overexposed to TB because of their living conditions in overcrowded places with deficient hygiene, protection, and malnutrition (54.7% of the sample). Possible comorbidities like acquired immune deficiency syndrome (AIDS; 4%) and diabetes (2.7%, but probably under-diagnosed) were referred. Migrants have little TB knowledge, which is independent of their level of education or a previous experience of deportation. About one-third of the migrants were totally unfamiliar with TB-related symptoms, while 36% had correct knowledge of basic TB symptoms. We conclude that a shortage of information on the highly vulnerable migratory population combined with a lack of social support and health education among migrants may play a significant role in the spread of communicable diseases. We recommend that health authorities address this urgent, binational, public health concern in order to prevent outbreaks of emerging infections.

Examining the impact of patient characteristics and symptomatology on knowledge, attitudes, and beliefs among foreign-born tuberculosis cases in the US and Canada

Foreign-born individuals represent the majority of TB cases in the US/Canada. Little is known about their TB knowledge, attitudes, and beliefs (KAB). Cross-sectional survey was conducted in 22 sites in the US/Canada among foreign-born adults with active TB. Multiple regression was used to examine KAB factors against covariates. Of 1,475 participants interviewed, most answered the six knowledge items correctly. Significant predictors of correct knowledge included region of origin, education, income, age, visa status, place of diagnosis, BCG vaccination, and TB symptoms. Significant predictors of higher perceived risk/stigma scores included region of origin, age, place of diagnosis, English fluency, time in the US/Canada, TB symptoms, and household rooms. This study examines associations between TB KAB and patient and disease characteristics in foreign-born individuals in the US/Canada. The findings call for improved health education, along with efforts to reduce stigma and enhance realistic risk assessments.

[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.

Who avoids going to the doctor and why? Audience segmentation analysis for application of message development

This exploratory study examines the prevalent and detrimental health care phenomenon of patient delay in order to inform formative research leading to the design of communication strategies. Delayed medical care diminishes optimal treatment choices, negatively impacts prognosis, and increases medical costs. Various communication strategies have been employed to combat patient delay, with limited success. This study fills a gap in research informing those interventions by focusing on the portion of patient delay occurring after symptoms have been assessed as a sign of illness and the need for medical care has been determined. We used CHAID segmentation analysis to produce homogeneous segments from the sample according to the propensity to avoid medical care. CHAID is a criterion-based predictive cluster analysis technique. CHAID examines a variety of characteristics to find the one most strongly associated with avoiding doctor visits through a chi-squared test and assessment of statistical significance. The characteristics identified then define the segments. Fourteen segments were produced. Age was the first delineating characteristic, with younger age groups comprising a greater proportion of avoiders. Other segments containing a comparatively larger percent of avoiders were characterized by lower income, lower education, being uninsured, and being male. Each segment was assessed for psychographic properties associated with avoiding care, reasons for avoiding care, and trust in health information sources. While the segments display distinct profiles, having had positive provider experiences, having high health self-efficacy, and having an internal rather than external or chance locus of control were associated with low avoidance among several segments. Several segments were either more or less likely to cite time or money as the reason for avoiding care. And several older aged segments were less likely than the remaining sample to trust the government as a source for health information. Implications for future research are discussed.

Total delay in treatment among smear positive pulmonary tuberculosis patients in five primary health centers, southern Ethiopia: a cross sectional study

Introduction

The global burden of Tuberculosis (TB) remains enormous. Delay in TB diagnosis may lead to a higher infectious pool in the community and a more advanced disease state at presentation increasing the risk of mortality. This study is conducted to determine the total delay before treatment among smear positive Pulmonary Tuberculosis (PTB) patients.

Methods

A health institution based cross sectional study was conducted in five primary health centers in southern Ethiopia from June to December 2012. A total of 328 smear positive PTB patients were enrolled in the study. A structured and pre-tested questionnaire was used. Median patient, diagnostic, and treatment delays were calculated to determine the total delay. Multiple logistic regression analysis was used to identify factors associated with total delay.

Results

The median patient, diagnostic, treatment and total delays measured in days were 30 (IQR 20.2, 60), 7 (IQR: 3, 14), 3 (IQR: 1, 4) and 45 (IQR: 34.5, 69.5) days respectively. Patients for whom treatment was not initiated within 45 days of onset of symptom(s) (total delay) constituted 49% of the study participants (59.5% among males and 39.2% among females; P<0.001). Total delay was found to be associated with: being female [AOR  = 0.34, 95% CI: 0.18–0.62], having attended tertiary level education [AOR  = 0.11, 95% CI: 0.02–0.55], perceived severity of stigma during the current TB disease course [AOR = 2. 18, 95% CI: 1.07, 4.42] and living in houses with higher family size [AOR = 0.26, 95% CI: 0.11, 0.61].

Conclusion

Total delay in treatment of TB is still high in the study area. Patient's sex, perceived stigma, educational status and family size are significantly contributing for total delay. Therefore, a concerted effort should be taken in order to improve health seeking behavior of the community on TB and to reduce delays from seeking care after experiencing TB symptoms.

Barriers and delays in tuberculosis diagnosis and treatment services: does gender matter?

Background. Tuberculosis (TB) remains a global public health problem with known gender-related disparities. We reviewed the quantitative evidence for gender-related differences in accessing TB services from symptom onset to treatment initiation. Methods. Following a systematic review process, we: searched 12 electronic databases; included quantitative studies assessing gender differences in accessing TB diagnostic and treatment services; abstracted data; and assessed study validity. We defined barriers and delays at the individual and provider/system levels using a conceptual framework of the TB care continuum and examined gender-related differences. Results. Among 13,448 articles, 137 were included: many assessed individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial: 64% versus 36%; physical: 100% versus 0%; stigma: 85% versus 15%; health literacy: 67% versus 33%; and provider-/system-level: 100% versus 0%) and longer delays (presentation to diagnosis: 45% versus 0%) than men. Conclusions. Many studies found no quantitative gender-related differences in barriers and delays limiting access to TB services. When differences were identified, women experienced greater barriers and longer delays than men.

An evaluation of systematic tuberculosis screening at private facilities in Karachi, Pakistan

Background

In Pakistan, like many Asian countries, a large proportion of healthcare is provided through the private sector. We evaluated a systematic screening strategy to identify people with tuberculosis in private facilities in Karachi and assessed the approaches' ability to diagnose patients earlier in their disease progression.

Methods and Findings

Lay workers at 89 private clinics and a large hospital outpatient department screened all attendees for tuberculosis using a mobile phone-based questionnaire during one year. The number needed to screen to detect a case of tuberculosis was calculated. To evaluate early diagnosis, we tested for differences in cough duration and smear grading by screening facility. 529,447 people were screened, 1,010 smear-positive tuberculosis cases were detected and 942 (93.3%) started treatment, representing 58.7% of all smear-positive cases notified in the intervention area. The number needed to screen to detect a smear-positive case was 124 (prevalence 806/100,000) at the hospital and 763 (prevalence 131/100,000) at the clinics; however, ten times the number of individuals were screened in clinics. People with smear-positive TB detected at the hospital were less likely to report cough lasting 2–3 weeks (RR 0.66 95%CI [0.49–0.90]) and more likely to report cough duration >3 weeks (RR 1.10 95%CI [1.03–1.18]). Smear-positive cases at the clinics were less likely to have a +3 grade (RR 0.76 95%CI [0.63–0.92]) and more likely to have +1 smear grade (RR 1.24 95%CI [1.02–1.51]).

Conclusions

Tuberculosis screening at private facilities is acceptable and can yield large numbers of previously undiagnosed cases. Screening at general practitioner clinics may find cases earlier than at hospitals although more people must be screened to identify a case of tuberculosis. Limitations include lack of culture testing, therefore underestimating true TB prevalence. Using more sensitive and specific screening and diagnostic tests such as chest x-ray and Xpert MTB/RIF may improve results.

Factors associated with treatment delay among tuberculosis patients referred from a tertiary hospital in Dhaka City: a cross-sectional study

SETTING

A tertiary medical college hospital in Dhaka City Corporation area, Dhaka, Bangladesh.

OBJECTIVES

To identify factors associated with treatment delay among tuberculosis (TB) patients referred from a public diagnostic centre to various DOTS treatment centres in Dhaka City Corporation area, Bangladesh.

METHODS

A cross-sectional study was conducted among 123 patients referred from the Dhaka Medical College Hospital to different DOTS treatment centres during July-October 2012. Factors associated with treatment delay (>1 day between referral and initiation of DOTS treatment) were identified.

RESULTS

Among the 123 patients referred from the hospital, treatment delay was found to range between 2 and 17 days (median 2). In bivariate analysis, treatment delay was found to be significantly associated with the patient's diagnostic category. In multivariate analysis, World Health Organization (  WHO) Category II patients were found to be four times more likely to have treatment delay than WHO Category I patients, and married patients were much more likely to have treatment delays than unmarried patients.

CONCLUSION

The study findings suggest that the main factors contributing to treatment delay among TB patients were history of previous anti-tuberculosis treatment, marital status and age. Patients should be given extensive information about the dangers of treatment delay before referring them to DOTS treatment centres.

Epidemiology of tuberculosis in an urban slum of Dhaka City, Bangladesh

Background

The objectives of this study were to assess the tuberculosis (TB) burden and to provide an insight into the type of circulating M. tuberculosis species in urban slums of Bangladesh. We also aimed to test the feasibility of a larger transmission study in this setting.

Methods

This cross-sectional study was conducted in an urban slum of Dhaka city. The household members were actively screened to assess the presence of TB-related signs and symptoms; cough ≥3 weeks and body mass index (BMI) <17 kg/m². Sputum specimens from suspects were collected for acid fast bacilli (AFB) microscopy, culture and drug susceptibility testing. Genotyping of M. tuberculosis was done using spoligotyping and variable number tandem repeats of mycobacterial interspersed repetitive units typing.

Results

Among 9,877 adult screened for pulmonary TB (PTB), 25 were positive for AFB on microscopy and/or culture and the prevalence of new PTB cases was estimated to be 253/100,000. Only one child TB case was diagnosed among 5,147 child screened. Out of 26 cases, 21(81%) had cough for several duration and 5(19%) did not present with cough at the time of screening. One multidrug resistant case was found. Fifty two percent of all TB cases had BMI <17 kg/m2 (p = <0.001). Among the 20 analyzed isolates, 13 different spoligotype patterns were identified in which 5 clusters contained 12 strains and 8 strains had unique pattern.

Conclusions

The study revealed high prevalence of TB in urban slums. Screening using low BMI can be beneficial among risk group population. It is important to conduct larger study to validate clinical variables like cough <3 weeks and low BMI to define TB suspect and also to investigate the transmission of TB in slum settings.

Patient and health system delay among patients with pulmonary tuberculosis in Beira city, Mozambique

BACKGROUND

TB control is based on the rapid identification of cases and their effective treatment. However, many studies have shown that there are important delays in diagnosis and treatment of patients with TB. The purpose of this study was to assess the prevalence of and identify risk factors associated with patient delay and health system delay among newly diagnosed patients with pulmonary TB.

METHODS

A cross sectional study was carried out in Beira city, Mozambique between September 2009 and February 2010. Patients in the first month of treatment were consecutively selected to this study if they had a diagnosis of pulmonary TB, had no history of previous TB treatment, and were 18 years or older and provided informed consent. Data was obtained through a questionnaire administered to the patients and from patients' files.

RESULTS

Among the 622 patients included in the study the median age was 32 years (interquartile range, 26-40) and 272 (43.7%) were females. The median total delay, patient delay and health system delay was 150 days (interquartile range, 91-240), 61 days (28-113) and 62 days (37-120), respectively. The contribution of patient delay and health system delay to total delay was similar. Farming, visiting first a traditional healer, low TB knowledge and coexistence of a chronic disease were associated with increased patient delay. More than two visits to a health facility, farming and coexistence of a chronic disease were associated with increased health system delay.

CONCLUSIONS

This study revealed a long total delay with a similar contribution of patient delay and health system delay. To reduce the total delay in this setting we need a combination of interventions to encourage patients to seek appropriate health care earlier and to expedite TB diagnosis within the health care system.

Area-level socioeconomic disadvantage and severe pulmonary tuberculosis: U.S., 2000-2008

OBJECTIVES

Lower socioeconomic status (SES) is associated with increased risk of tuberculosis (TB) and diagnostic delays, but the extent to which this association reflects an underlying gradient in advanced status of pulmonary TB is unknown. We conducted a multilevel retrospective cohort analysis examining the relationship between socioeconomic characteristics and pulmonary TB disease status, as measured via sputum smears and chest radiography results.

METHODS

We included 862 incident TB patients reported in King County, Washington, from 2000-2008. We abstracted patient-level measures from charts and surveillance data. We obtained socioeconomic characteristics of TB patients, as well as those of the areas where TB patients lived, from the 2000 U.S. Census. A socioeconomic position (SEP) index was derived to measure SES.

RESULTS

Of those with known results, 814 of 849 patients (96%) displayed abnormal radiography findings. A total of 239 graded patients (39%) had positive smears, 136 (57%) of whom had grades of moderate (3+) or numerous (4+) acid-fast bacilli. In unadjusted analyses, patients living in lower SEP areas did not appear to have higher probabilities of more advanced disease. In multivariate models adjusting for individual demographic and socioeconomic measures, as well as area-based demographic variables, block-group SEP was not significantly associated with more advanced pulmonary disease.

CONCLUSIONS

Lower SEP was not significantly associated with greater pulmonary disease severity after controlling for individual age, race, sex, and origin, and block-group race, ethnicity, and origin. These findings suggest that the severity of pulmonary TB at diagnosis is not synonymous with delayed diagnosis.

Management and transference of patients diagnosed with tuberculosis in a rural hospital in Southern Ethiopia

Treatment of new tuberculosis (TB) cases in Directly Observed Treatment Short Course (DOTS) programmes is believed to be the most valuable strategy for TB control. The aim of this study is to describe the experience of diagnosed cases of TB in a district hospital situated in a rural zone of Ethiopia and of "transferred out" TB cases from the hospital to their local health facilities using the DOTS programme spanning a period of 8years. Data collection was obtained by using a TB register book in a rural district hospital from 2004 to 2011. The collected information included the type of TB, age, HIV status, and treatment outcomes using standardized definitions; 6459 patients with all forms of TB were diagnosed. Twenty-eight percent were smear-positive pulmonary TB (PTB) cases, 28.97% were smear-negative PTB cases, and 42.8% were extra-pulmonary TB (EPTB). The global "transferred out" rate was 78.5% (5073/6459); the "transferred out" rate after diagnosis at hospital and before starting DOTS was 72.6% (4689/6459), and after finishing the intensive phase and admission was 21.8% (385/1770). The proportion of total cases "transferred out" in smear-negative PTB cases (70.2%) was less than smear-positive PTB cases (79.2%) (odd ratio [OR]: 0.81; 95% confidence interval [CI]: 0.76-0.87) and was higher in EPTB cases (83.3%) (OR: 1.15; 95% CI: 1.05-1.19). The percentage of "transferred out" after hospital admission was higher in HIV-positive cases (16.8%) than in HIV-negative cases (8.5%) (OR: 2.13; 95% CI: 1.28-3.53). In conclusion, district hospitals are still important facilities for the diagnosis of TB cases, particularly EPTB.

Provider's perspectives on the impact of Immigration and Customs Enforcement (ICE) activity on immigrant health

INTRODUCTION

Increasing Immigration and Customs Enforcement (ICE) activities such as raids, detention, and deportation may be affecting the health and well-being of immigrants. This study sought to understand the impact of ICE activities on immigrant health from the perspective of health care providers.

METHODS

An online survey of primary care and emergency medicine providers was conducted to determine whether ICE activity was negatively affecting immigrant patients.

RESULTS

Of 327 providers surveyed, 163 responded (50%) and 156 (48%) met criteria for inclusion. Seventy-five (48%) of them observed negative effects of ICE enforcement on the health or health access of immigrant patients. Forty-three providers gave examples of the impact on emotional health, ability to comply with health care recommendations, and access.

CONCLUSIONS

Health care providers are witnessing the negative effects of ICE activities on their immigrant patients' psychological and physical health. This should be considered an important determinant of immigrant health.

Pulmonary tuberculosis diagnostic delays in Chad: a multicenter, hospital-based survey in Ndjamena and Moundou

Background

Tuberculosis remains one of the leading causes of morbidity and mortality in low-resource countries. One contagious patient can infect 10 to 20 contacts in these settings. Delays in diagnosing TB therefore contribute to the spread of the disease and sustain the epidemic.

Objectives

The aim of this study was to assess delays in diagnosing tuberculosis and the factors associated with these delays in the public hospitals in Moundou and Ndjamena, Chad.

Methods

A structured questionnaire was administered to 286 new tuberculosis patients to evaluate patient delay (time from the onset of symptoms to the first formal or informal care), health-care system delay (time from the first health care to tuberculosis treatment) and total delay (sum of the patient and system delays). Logistic regression was used to identify risk factors associated with long diagnostic delays (defined as greater than the median).

Results and discussion

The median [interquartile range] patient delay, system delay and total delay were 15 [7–30], 36 [19–65] and 57.5 [33–95] days, respectively. Low economic status (aOR [adjusted odds ratio] =2.38 [1.08-5.25]), not being referred to a health service (aOR = 1.75 [1.02- 3.02]) and a secondary level education (aOR = 0.33 [0.12-0.92]) were associated with a long patient delay. Risk factors for a long system delay were a low level of education (aOR = 4.71 [1.34-16.51]) and the belief that traditional medicine and informal care can cure TB (aOR = 5.46 [2.37-12.60]).

Conclusion

Targeted strengthening of the health-care system, including improving patient access, addressing deficiencies in health-related human resources, and improving laboratory networks and linkages as well as community mobilization will make for better outcomes in tuberculosis diagnosis.

Treatment delay among pulmonary tuberculosis patients in pastoralist communities in Bale Zone, Southeast Ethiopia

Background

Tuberculosis (TB) is a major public health problem in Africa with Ethiopia being the most affected. Treatment delay is an important indicator of access to TB diagnosis and treatment. However, little is known about factors associated with treatment delay of pulmonary TB among pastoralists. Health facility based cross sectional study was conducted on 129 pulmonary TB patients in pastoralist community. The study was conducted in three health centers and a hospital. Time between onset of TB symptoms and first visit to a professional health care provider (patient delay), and the time between first visits to the professional health care provider to the date of diagnosis (provider's delay) were analyzed using SPSS 16.0 statistical software.

Findings

A total of 129 new smear positive pulmonary TB patients participated in the study. The median total delay was 97 days. The median patient and health provider delays were 63 and 34 days, respectively. Ninety six percent of the patients were delayed for more than the twenty one days cutoff point. Patient delay was positively associated with first visit to traditional healer/private clinic/drug shop, rural residence, being illiterate, living in more than 10 kilometers from health facility; severity of illness at first presentation to health facility. Provider delay was positively associated with rural residence, being illiterate, patient with good functional status, patients in contact with more than two health providers, and place of first visit being traditional healer/private clinic/drug shop.

Conclusions

This study showed that majority of smear positive patients delayed either for diagnosis or treatment, thus continue to serve as reservoirs of infection. This indicates that there is a need for intervention to decrease patient and provider delays. Effort to reduce delays in pastoralist communities should focus on improving access to services in rural communities, engaging traditional and private health providers and should target illiterate individuals.

The model of pathways to treatment: conceptualization and integration with existing theory

BACKGROUND

Studying and understanding pathways to diagnosis and treatment is vital for the development of successful interventions to encourage early detection, presentation, and diagnosis. An existing framework posited to describe the decisional and behavioural processes that occur prior to treatment (Andersen et al.'s General Model of Total Patient Delay) does not appear to match the complex and dynamic nature of the pathways into and through the health care system or provide a clear framework for research. Therefore a revised descriptive framework, the Model of Pathways to Treatment, has been proposed.

PURPOSE

This paper presents the concepts and definitions of the Model of Pathways to Treatment and specifies how the model can encompass existing psychological theory, with particular focus on the Appraisal and Help-seeking intervals. The potential and direction for future work is also discussed.

STATEMENT OF CONTRIBUTION

WHAT IS ALREADY KNOWN ON THIS SUBJECT?: • The use of theory is often lacking in existing research into delays in presentation, diagnosis and treatment of illness. WHAT DOES THIS STUDY ADD?: • A detailed account of the concepts and definitions of a revised framework: the Model of Pathways to Treatment. • Specification of how the Model of Pathways to Treatment can encompass existing psychological theory such as the Common Sense Model of Illness Self-regulation and Social Cognitive Theory.

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.

[Determinants of tuberculosis diagnosis delay in limited resources countries]

BACKGROUND

Delayed diagnoses of pulmonary tuberculosis contribute to the spread of the epidemic.

METHODS

This study aims to identify risk factors associated with patient delay (from symptoms onset to the first visit), health system delay (from the first visit to the tuberculosis treatment initiation) and total delay (sum of the patient and the health system delay) in low income and high tuberculosis burden countries. A systematic literature review has been performed using the keywords: "tuberculosis"; "delay", care seeking"; "health care seeking behavior"; "diagnosis" and "treatment". Only quantitative studies showing delays for pulmonary tuberculosis adult cases were included in this review.

RESULTS

Low income, gender, rural life, unemployment, ageing and misunderstanding the microbial cause of tuberculosis are associated with delayed diagnoses. Systemic factors including low health care coverage, patient expenditures and entry into the health system by consulting a traditional healer or a non-skilled professional delay the beginning of tuberculosis treatment.

CONCLUSION

Delays can be used as indicators to evaluate tuberculosis control programs. Active case finding in the households of contagious patients can help to diminish diagnostic delays in low-income countries with high endemicity.

Unexpected decline in tuberculosis cases coincident with economic recession - United States, 2009

BACKGROUND

Since 1953, through the cooperation of state and local health departments, the U.S. Centers for Disease Control and Prevention (CDC) has collected information on incident cases of tuberculosis (TB) disease in the United States. In 2009, TB case rates declined -11.4%, compared to an average annual -3.8% decline since 2000. The unexpectedly large decline raised concerns that TB cases may have gone unreported. To address the unexpected decline, we examined trends from multiple sources on TB treatment initiation, medication sales, and laboratory and genotyping data on culture-positive TB.

METHODS

We analyzed 142,174 incident TB cases reported to the U. S. National Tuberculosis Surveillance System (NTSS) during January 1, 2000-December 31, 2009; TB control program data from 59 public health reporting areas; self-reported data from 50 CDC-funded public health laboratories; monthly electronic prescription claims for new TB therapy prescriptions; and complete genotyping results available for NTSS cases. Accounting for prior trends using regression and time-series analyses, we calculated the deviation between observed and expected TB cases in 2009 according to patient and clinical characteristics, and assessed at what point in time the deviation occurred.

RESULTS

The overall deviation in TB cases in 2009 was -7.9%, with -994 fewer cases reported than expected (P < .001). We ruled out evidence of surveillance underreporting since declines were seen in states that used new software for case reporting in 2009 as well as states that did not, and we found no cases unreported to CDC in our examination of over 5400 individual line-listed reports in 11 areas. TB cases decreased substantially among both foreign-born and U.S.-born persons. The unexpected decline began in late 2008 or early 2009, and may have begun to reverse in late 2009. The decline was greater in terms of case counts among foreign-born than U.S.-born persons; among the foreign-born, the declines were greatest in terms of percentage deviation from expected among persons who had been in the United States less than 2 years. Among U.S.-born persons, the declines in percentage deviation from expected were greatest among homeless persons and substance users. Independent information systems (NTSS, TB prescription claims, and public health laboratories) reported similar patterns of declines. Genotyping data did not suggest sudden decreases in recent transmission.

CONCLUSIONS

Our assessments show that the decline in reported TB was not an artifact of changes in surveillance methods; rather, similar declines were found through multiple data sources. While the steady decline of TB cases before 2009 suggests ongoing improvement in TB control, we were not able to identify any substantial change in TB control activities or TB transmission that would account for the abrupt decline in 2009. It is possible that other multiple causes coincident with economic recession in the United States, including decreased immigration and delayed access to medical care, could be related to TB declines. Our findings underscore important needs in addressing health disparities as we move towards TB elimination in the United States.

Feasibility and willingness-to-pay for integrated community-based tuberculosis testing

Background

Community-based screening for TB, combined with HIV and syphilis testing, faces a number of barriers. One significant barrier is the value that target communities place on such screening.

Methods

Integrated testing for TB, HIV, and syphilis was performed in neighborhoods identified using geographic information systems-based disease mapping. TB testing included skin testing and interferon gamma release assays. Subjects completed a survey describing disease risk factors, healthcare access, healthcare utilization, and willingness to pay for integrated testing.

Results

Behavioral and social risk factors among the 113 subjects were prevalent (71% prior incarceration, 27% prior or current crack cocaine use, 35% homelessness), and only 38% had a regular healthcare provider. The initial 24 subjects reported that they would be willing to pay a median $20 (IQR: 0-100) for HIV testing and $10 (IQR: 0-100) for TB testing when the question was asked in an open-ended fashion, but when the question was changed to a multiple-choice format, the next 89 subjects reported that they would pay a median $5 for testing, and 23% reported that they would either not pay anything to get tested or would need to be paid $5 to get tested for TB, HIV, or syphilis. Among persons who received tuberculin skin testing, only 14/78 (18%) participants returned to have their skin tests read. Only 14/109 (13%) persons who underwent HIV testing returned to receive their HIV results.

Conclusion

The relatively high-risk persons screened in this community outreach study placed low value on testing. Reported willingness to pay for such testing, while low, likely overestimated the true willingness to pay. Successful TB, HIV, and syphilis integrated testing programs in high risk populations will likely require one-visit diagnostic testing and incentives.

Tuberculosis outbreak investigations in the United States, 2002-2008

To understand circumstances of tuberculosis transmission that strain public health resources, we systematically reviewed Centers for Disease Control and Prevention (CDC) staff reports of US outbreaks in which CDC participated during 2002–2008 that involved >3 culture-confirmed tuberculosis cases linked by genotype and epidemiology. Twenty-seven outbreaks, representing 398 patients, were reviewed. Twenty-four of the 27 outbreaks involved primarily US-born patients; substance abuse was another predominant feature of outbreaks. Prolonged infectiousness because of provider- and patient-related factors was common. In 17 outbreaks, a drug house was a notable contributing factor. The most frequently documented intervention to control the outbreak was prioritizing contacts according to risk for infection and disease progression to ensure that the highest risk contacts were completely evaluated. US-born persons with reported substance abuse most strongly characterized the tuberculosis outbreaks in this review. Substance abuse remains one of the greatest challenges to controlling tuberculosis transmission in the United States.

The impact of Immigration and Customs Enforcement on immigrant health: perceptions of immigrants in Everett, Massachusetts, USA

U.S. immigrants have faced a changing landscape with regard to immigration enforcement over the last two decades. Following the passage of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, and the creation of the Immigration and Customs Enforcement (ICE) agency after the attacks of September 11, 2001, detention and deportation activity increased substantially. As a result, immigrants today are experiencing heightened fear of profiling and deportation. Little research exists on how these activities affect the health and well-being of U.S. immigrant communities. This study sought to address this gap by using community-based participatory research to investigate the impact of enhanced immigration enforcement on immigrant health in Everett, Massachusetts, USA, a city with a large and diverse immigrant population. Community partners and researchers conducted 6 focus groups with 52 immigrant participants (documented and undocumented) in five languages in May 2009. The major themes across the groups included: 1) Fear of deportation, 2) Fear of collaboration between local law enforcement and ICE and perception of arbitrariness on the part of the former and 3) Concerns about not being able to furnish documentation required to apply for insurance and for health care. Documented and undocumented immigrants reported high levels of stress due to deportation fear, which affected their emotional well-being and their access to health services. Recommendations from the focus groups included improving relationships between immigrants and local police, educating immigrants on their rights and responsibilities as residents, and holding sessions to improve civic engagement. Immigration enforcement activities and the resulting deportation fear are contextual factors that undermine trust in community institutions and social capital, with implications for health and effective integration processes. These factors should be considered by any community seeking to improve the integration process.

Impact of immigration on the molecular epidemiology of tuberculosis in Rhode Island

While foreign-born persons constitute only 11% of the population in the state of Rhode Island, they account for more than 65% of incident tuberculosis (TB) annually. We investigated the molecular-epidemiological differences between foreign-born and U.S.-born TB patients to estimate the degree of recent transmission and identify predictors of clustering. A total of 288 isolates collected from culture-confirmed TB cases in Rhode Island between 1995 and 2004 were fingerprinted by spoligotyping and 12-locus mycobacterial interspersed repetitive units. Of the 288 fingerprinted isolates, 109 (37.8%) belonged to 36 genetic clusters. Our findings demonstrate that U.S.-born patients, Hispanics, Asian/Pacific islanders, and uninsured patients were significantly more likely to be clustered. Recent transmission among the foreign-born population was restricted and occurred mostly locally, within populations originating from the same region. Nevertheless, TB transmission between the foreign-born and U.S.-born population should not be neglected, since 80% of the mixed clusters of foreign- and U.S.-born persons arose from a foreign-born source case. We conclude that timely access to routine screening and treatment for latent TB infection for immigrants is vital for disease elimination in Rhode Island.

Tuberculosis knowledge, attitudes, and beliefs in foreign-born and US-born patients with latent tuberculosis infection

Foreign-born individuals comprise the majority of patients treated for latent tuberculosis infection (LTBI) in the US. It is important to understand this population's tuberculosis-related knowledge, attitudes, and beliefs (KAB) as they may affect treatment acceptance and completion. KAB in 84 US-born and 167 foreign-born LTBI patients enrolled in a clinical trial assessing treatment completion at an urban public hospital were assessed at baseline. Demographic and substance use information was also collected.

RESULTS

Of 251 participants, 66.5% were foreign-born. While misconceptions existed among both US and foreign-born regarding transmission and contagiousness of LTBI, overall knowledge scores did not differ significantly between groups. With respect to attitudinal factors, foreign-born participants were less likely to acknowledge that they had LTBI and felt more "protected" from developing TB. Improved understanding of foreign-born patients' KAB may contribute to the reduction of barriers to treatment and improved outcomes.

Experiences of being diagnosed with tuberculosis among immigrants in Norway — Factors associated with diagnostic delay: A qualitative study

Aims: The aim of this paper is to explore experiences of being diagnosed with tuberculosis (TB) among immigrants in Norway, with a view to factors associated with diagnostic delay. Methods: A qualitative study was conducted among 22 participants diagnosed with TB who originated from Somalia or Ethiopia. Results: One-third of the participants reported less than 2 months from onset of symptoms to treatment were initiated. The factors associated with little delay included a medical history that gave suspicion of TB, presenting with typical TB symptoms, or being screened for TB at arrival. Two-thirds of the participants told about extensive diagnostic processes. Persistent cough not accompanied by symptoms such as: weight loss and weakness; mild, diffuse, atypical, and/or intermittent symptoms; and a sense of not being a likely victim of TB could delay patients’ first initiative to seek help. Participants experienced that the diagnostic process in the health services could endure for months, even years. The diagnosis could be difficult to confirm, but health professionals appeared to have difficulties with associating their symptoms with TB. This resulted in delays in initiating diagnostic tests for TB, especially in cases of extra-pulmonary TB. Conclusions: Public health efforts to increase awareness about TB transmission, its diversity in manifestations, and its progression from latent to active disease, may decrease patient delay. An increased awareness among health professionals about typical and atypical symptoms of TB, aspects of the patient’s history, and being aware and sensitive to patients’ own interpretation of symptoms may reduce diagnostic delay in the health services.