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Diagnosis Delay among Newly Tuberculosis Patients Admitted in a Community Hospital

Dr. Humberto Guanche Garcell

By Dr. Humberto Guanche Garcell

Dr. Humberto Guanche Garcell MD MPH Hospital Epidemiologist. Hospital ¨Joaquín Albarrán¨. Assistance Professor by the Cuban Medical University and Assistance Researcher by the Cuban Academy of Sciences. La Habana, Cuba

Garcell HG, Zenón VER, Arias AV, Serrano RNA (2017) Diagnosis Delay among Newly Tuberculosis Patients Admitted in a Community Hospital. J Epid Prev Med 3(1): 127.

Abstract

Objective: To determine the diagnostic delay in newly diagnosed tuberculosis (TB) patients admitted to a community hospital in Qatar.

Design: The study was conducted from January 2013 today 2016. The following information was collected from patient file: Age, sex, nationality, tuberculosis type, time of symptoms onset, time of the confirmatory test, and the time of visiting an HCP before the admission encounter.

Results: Of the 390 TB patients included in the study, 281 (72.1%) were from South East Asian countries, 325 (83.3%) patients were males and 65 (16.7%) were females, mean age was 32.4 years. Of the 390 patients, 89.7% (350 patients) had pulmonary tuberculosis and 40(10.3%) patients had non-pulmonary localization. The median total delay was 30 days (15;60 days), while the patient delay was 10 days (4;27 days) and the system delay was 3 days (3;7.8 days). For pulmonary tuberculosis, the total delay was 30 days and for non-pulmonary localization was 15 days.

Conclusion: The study provides an insight about the delay in the diagnosis of TB at a community hospital in Qatar. Additional studies should be conducted to evaluate the delay in a representative national sample and to identify the factors associated with patients’ delays, which could be used to strengthen the national program for tuberculosis control.

Introduction

In Qatar, around 750 new tuberculosis patients are confirmed every year, being more than 95% expatriate workers for the construction and oil industries [1,2]. This immigrant population came from countries with high incidence of TB, with the majority being from South East Asian countries [3]. As per national regulations, all the expatriates workers are screened (chest X ray for all, PPD test, Quantiferon, AFB smear or additional test if required) to rule out tuberculosis upon arrival in the country, without further evaluation regardless the time living in Qatar.

The risk of community transmission is influenced by multiple factors including the incidence of tuberculosis in the population, living condition, ventilation, nutritional status and smoking among others [4]. The risk of community transmission has not been clearly assessed in Qatar. Nevertheless, specific factors that could possibly be related to the incidence of tuberculosis in the countries of origin include nutritional status, overcrowded living conditions and other socioeconomic factors [4–6]. Also, important are health care seeking behavior, delay in diagnosis and treatment, including the patient and the healthcare system delay. Published reports describe the diagnostic delay (mean or median) in Afghanistan (356 days), India (65 days), Iran (73 days), Nepal (39.5 days) and Pakistan (56 days) [7–11]. According to a multinational study about diagnostic delay carried out in the Eastern Mediterranean Region (EMR) in 2003- 2004 the mean duration of delay between the onset of symptoms until treatment with anti-tuberculosis drugs ranged  from  one  and a half months to four months in different countries [12]. The mean delay was 46 days in Iraq, 57 in Egypt, 59.2 in Yemen, 79.5  in Somalia, 80.4 in the Syrian Arab Republic, 100 in Pakistan, and 127 in the Islamic Republic of Iran. There are no previous published studies about diagnosis delay in Qatar.

The population living in Qatar is 2.2 million with around 2/3 of expatriates mainly from South East Asian Countries, which stay in the country during a variable time before travel back to their home countries but usually every two years [1,4]. The Cuban Hospital provide secondary healthcare services to a community located in Western Qatar and receive patients with tuberculosis from local areas or transfer from other facilities due to beds crisis. The aim of this study was to determine the diagnostic delay in newly diagnosed tuberculosis patients admitted to The Cuban Hospital in Qatar.

Method

The study was conducted from January 2013 today 2016, among newly confirmed tuberculosis patients (325 males and 65 females) admitted to the Cuban Hospital (TCH) in Qatar. TCH is a 75-beds facility located in Western Qatar, which admits patients with tuberculosis from any location in the country.

Patient delay was considered as the period of time from onset of symptoms related to TB to the first contact with a healthcare professional (HCP). Health-system delay is the period from the first visit to an HCP until the confirmation test was performed and appropriate treatment was initiated. The total delay is the time from the symptom onset until the confirmation test was performed.

The following information was recorded: age, sex, nationality, tuberculosis type (pulmonary, extrapulmonary), time from symptoms  onset,  time  of  the  confirmatory  test  (acid-fast  bacilli smear, PCR for mycobacterium tuberculosis complex or histopathological study), and the time of visiting an HCP before the admission encounter. The nationalities of the patients were grouped according to the World Health Organization classification of countries (http://who.int/en/).

All the information was collected from the patient´s files. The study was approved by the hospital board. This retrospective study meets the criteria for exemption from ethics review.

Analysis

All the information was entered in an excel sheet and analyzed in JMP 10.0 (http://www.jmp.com/). Descriptive statistical techniques were used including proportion and percentile distribution.

Results

The study population comprised 390 TB patients, of which 281 (72.1%) were from South East Asian countries. The predominant nationalities were the Nepalese (30%), Indian (22.8%) and Bangladeshi (11.8%). Of the study population, 83.3% were males; the mean age was 32.4 years (16–86 years). Pulmonary tuberculosis was found in 89.7% of the study population (Table 1).

Table 1: Socio-demographic and clinical characteristics of the study patients. (* mean (SD) ** PCR for mycobacterium tuberculosis complex)

Variables
Results of 390 patients
Nationality
South East Asia 281 (72.1%)
Africa 54 (13.8%)
Western Pacific 42 (10.8%)
Eastern Mediterranean Region 12 (3.1%)
Europe 1 (0.3%)
Sex
Male 325 (83.3%)
Female 65 (16.7%)
Age (years) * 32.4 (10.8)
Localization
Pulmonary 350 (89.7%)
Pleural 20 (5.1%)
Ganglionar 8 (2.1%)
Meningitis 7 (1.8%)
Miliary 5 (1.3%)
Diagnostic performed
Acid fast bacilli 298 (76.4%)
PCR 77 (19.7%)
Histopathological 4 (1.0)
Others 11 (2.8%)

Information about the total delay was collected from all the patients included in the study, while information about  patient and system delay was collected from the available 164 patient´s files. The median total delay (25th percentile, 75th percentile) was 30 days (15;60 days), while the patient delay was 10 days (4;27 days) and the system delay was 3 days (3;7.8 days). For pulmonary tuberculosis, the total delay was 30 days (15;60 days) and for non- pulmonary localization it was 15 days (7;60 days) (Figure 1).

  Figure 1: Box plot for diagnostic delay among tuberculosis patients (days).

figure 1

Discussion

The early diagnosis and prompt treatment are essential elements for tuberculosis control. The delay in the diagnosis poses a significant risk of transmission in the community, related to patient or system factors. In Qatar, in addition to the screening during the hiring of new workers, the test to rule out tuberculosis which is AFB smear, PCR, Culture is only available in hospital facilities, where the patients should be referred from primary healthcare facilities.

This study provides information about the delay in diagnosis of tuberculosis in our community with higher patient delay and  for pulmonary tuberculosis, in comparison with system delay and non-pulmonary localization. The diagnostic delays observed in  the studied patients are lower than those reported from EMR and countries of origin of the patients [7–13]. A systematic review of the Indian literature found that the patient, diagnostic and treatment delay were 18.4, 31.0 and 2.5 days, respectively, and the median total delay of 55.3 days [14].

Our results could be related with the resources and performance of the national program of TB. Nevertheless, it is important to consider the higher median delay in pulmonary tuberculosis which could be associated with increased risk of community transmission. Immigrants could acquire tuberculosis in their countries and this could be diagnosed months or years after the entry into the country, or due to local transmission from infectious cases living in the same environment [6,15]. Also, the longer patient delay could be related to socio-demographic, clinical and financial factors [16], although these factors could differ among different countries and the patient´s population. A population-based study is required to identify the specific contribution of these factors in the diagnostic delay in Qatar. In addition, the availability of screening test at primary care facilities, currently available in few facilities, will contribute to reduce the diagnostic delay and the risk of community transmission.

There are some limitations in our study. Overall, general information is documented (e.g. date of symptom onset) in patients files but few details about the previous history of contact with healthcare system during the symptomatic period is available, which explains the differences in total delay and patient/system delay. This bias could be addressed with a prospective survey using standardized questionnaires. Also, even when the patients came from other facilities in Qatar, the studied patient did not represent the overall picture of tuberculosis patients in the country. The number of patients studied could be considered as  strength  of this study taken into consideration the annual number of newly diagnosed cases reported in the country.

In  conclusion,  the  study  provides  insight  about  the  delay  in diagnosis of tuberculosis in a community hospital in Qatar. Additional studies should be conducted to evaluate the delay in a representative national sample and identify the factors associated with patients’ delays that could be used to strengthen the national program of tuberculosis.

 

 

References

  1. Annual Health Report, 2012. Hamad Medical Corporation. Chapter 6. Vital Health. Statistic and Preventive Medicine. [Cited 2014 May 01] Available from: http://site.hmc.org.qa/msrc/AHR2012/pdf/ch6.pdf.
  2. Tuberculosis country World Health Organization. [cited 2017 April 01] Available from: http://www.who.int/tb/country/data/profiles/en.
  3. Garcell HG, Hernandez TM, Abdo EA, Arias Evaluation of the timeliness and completeness of communicable  disease  reporting:  Surveillance  in The Cuban Hospital, Qatar. Qatar Med J. 2014;2014(1):50-6. doi: 10.5339/qmj.2014.9. eCollection 2014..
  4. Sayegh Suzan. Tuberculosis in Current situation, assessment and trends from 2012-2015. American University of Beirut. Jul, 2015.
  5. Garcell GH, Ramirez Zenón VE. Diagnostic delay of tuberculosis in Qatar: results of an exploratory Qatar Foundation Annual Research Conference Proceedings 2016: HBPP1416. DOI: http://dx.doi. org/10.5339/qfarc.2016.HBPP1416.
  6. Salas-Coronas J, Rogado-González MC, Lozano-Serrano AB, Cabezas- Fernández [Tuberculosis and immigration]. Enferm Infecc Microbiol Clin. 2016;34(4):261-9. doi: 10.1016/j.eimc.2015.12.010.
  7. Sabawoon W, Sato H, Kobayashi Delay in the treatment of pulmonary tuberculosis: a report from Afghanistan. Environ Health Prev Med. 2012;17(1):53-61. doi: 10.1007/s12199-011-0219-9.
  8. Mistry N, Rangan S, Dholakia Y, Lobo E,  Shah  S,  Patil    Durations  and Delays in Care Seeking, Diagnosis and Treatment Initiation in Uncomplicated Pulmonary Tuberculosis Patients in Mumbai, India. PLoS One. 2016;11(3):e0152287. doi: 10.1371/journal.pone.0152287.
  9. Alavi SM, Bakhtiyariniya P, Albagi A. Factors Associated With Delay in Diagnosis and Treatment of Pulmonary Tuberculosis. Jundishapur J 2015;8(3):e19238. doi: 10.5812/jjm.19238. eCollection 2015 Mar.
  10. Ben Amar J, Hassairi M, Ben Salah N, Charfi R, Tritar F, Fourati R, et al. Pulmonary tuberculosis: Diagnostic delay in Tunisia. Med Mal Infect. 2016;46(2):79-86. doi: 10.1016/j.medmal.2015.11.012.
  11. Saqib MA, Awan IN, Rizvi SK, Mirza ZS, Tahseen S, et Delay in diagnosis of tuberculosis in Rawalpindi, Pakistan. BMC Res Notes. 2011;4:165. doi: 10.1186/1756-0500-4-165.
  12. Diagnostic and treatment delay in tuberculosis. World Health Organization. Eastern Mediterranean Region. Available from: http://emro.who.int/dsaf/dsa710.pdf.
  13. Rifat M, Hall J, Oldmeadow C, Husain A, Milton AH. Health system delay in treatment of multidrug-resistant tuberculosis patients in BMC Infect Dis. 2015;15:526. doi: 10.1186/s12879-015-1253-9.
  14. Sreeramareddy CT, Qin ZZ, Satyanarayana S, Subbaraman R, Pai M. Delays in diagnosis and treatment of pulmonary tuberculosis in India: a systematic Int J Tuberc Lung Dis. 2014;18(3):255-66. doi: 10.5588/ijtld.13.0585.
  15. van der Werf MJ, Kramarz Tackling tuberculosis in migrants. Lancet Infect Dis. 2016;16(8):877-8. doi: 10.1016/S1473-3099(16)00148-1.
  16. Cai J, Wang X, Ma A, Wang Q, Han X, Li Factors Associated with Patient and Provider Delays for Tuberculosis Diagnosis and Treatment in Asia: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(3):e0120088. doi: 10.1371/journal.pone.0120088. eCollection 2015.