Abstract
BackgroundDelays 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.MethodsSystematic 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.ResultsThe 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.ConclusionStrategies to address patients’ delay could have important implications for the success of the global tuberculosis control programmes.
Highlights
Delays in diagnosis and treatment of pulmonary tuberculosis are a major set-back to global tuberculosis control
Patient’s delay was defined as the time lag from first symptom onset to first visit to a qualified doctor or health facility; doctor’s delay as the time lag from first visit to a qualified doctor/health facility to diagnosis of pulmonary tuberculosis; diagnostic delay as the time lag from first symptom onset to the diagnosis of pulmonary tuberculosis; treatment delay as the time lag from diagnosis of pulmonary tuberculosis to the first treatment initiation; health system delay as the time lag from first contact with a qualified doctor/health facility to the time of initiation of treatment, while total delay was defined as the time lag from awareness of first symptom onset to initiation of treatment [6,7,8,9,10]
Hybrid delay measures include diagnostic delay which is the sum of patient’s and doctor’s delays; health system’s delay is the sum of doctor’s delay and treatment delay; while total delay is the sum of the three primary delay measures (Fig. 1)
Summary
Delays in diagnosis and treatment of pulmonary tuberculosis are a major set-back to global tuberculosis control. Tuberculosis is one of the three major diseases of poverty alongside Malaria and Human Immunodeficiency Virus infection ravaging resource-limited settings [1]. It is the ninth leading cause of death worldwide and the leading cause of death from a single infectious agent, recently overtaking HIV in 2016 [2]. Tuberculosis is of public health significance worldwide and TB-related mortality accounted for US$616bn loss globally between 2000 and 2015; a further projected loss of US$ 984bn has been estimated for the period 2015–2030 if no serious action is taken to reduce disease burden [3]. Health workers’ index of suspicion may be low especially in settings where the disease is not endemic
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