Delays in diagnosis and treatment of pulmonary tuberculosis in India: a systematic review

Abstract

Objective: To systematically review Indian literature on delays in tuberculosis (TB) diagnosis and treatment.

Methods: We searched multiple sources for studies on delays in patients with pulmonary TB and those with chest symptoms. Studies were included if numeric data on any delay were reported. Patient delay was defined as the interval between onset of symptoms and the patient's first contact with a health care provider. Diagnostic delay was defined as the interval between the first consultation with a health care provider and diagnosis. Treatment delay was defined as the interval between diagnosis and initiation of anti-tuberculosis treatment. Total delay was defined as time interval from the onset of symptoms until treatment initiation.

Results: Among 541 potential citations identified, 23 studies met the inclusion criteria. Included studies used a variety of definitions for onset of symptoms and delays. Median estimates of patient, diagnostic and treatment delay were respectively 18.4 (IQR 14.3-27.0), 31.0 (IQR 24.5-35.4) and 2.5 days (IQR 1.9-3.6) for patients with TB and those with chest symptoms combined. The median total delay was 55.3 days (IQR 46.5-61.5). About 48% of all patients first consulted private providers; an average of 2.7 health care providers were consulted before diagnosis. Number and type of provider first consulted were the most important risk factors for delay.

Conclusions: These findings underscore the need to develop novel strategies for reducing patient and diagnostic delays and engaging first-contact health care providers.

Figure 1

Conceptual framework on definitions of “delays” (this is a schematic; the size/length of components do not represent actual durations). [adapted from Yimer et al.]

Figure 2

Study selection flow chart

Figure 3. Distribution of patient delay (PD), diagnostic delay (DxD), treatment delay (RxD), and total delay (TD) among PTB patients and chest symptomatics in India

Box plots depict the median (central line), inter quartile range (IQR) (box) and range (whiskers). PTB - pulmonary TB CS - chest symptomatic

Figure 4. Patient delay, diagnostic delay and total delay* among PTB and chest symptomatic patients, with studies ordered chronologically

*The total delays were extracted from the primary studies (not by summing up patient delay, diagnostic delay and treatment delay to get the total when it was not reported by the authors).