Factors Associated with Delay in Treatment Initiation for Pulmonary Tuberculosis

Background: Delays in treatment initiation for tuberculosis (TB) may lead to worse clinical outcomes and increased transmission. We aimed to determine factors associated with treatment delays, to guide public health action.

Methods: We extracted data on clinical characteristics and documented potential barriers to treatment from all pulmonary TB cases with clinical case review data from 2011 to 2015 and linked these to TB surveillance data. We described the distribution of delays from symptom onset to first presentation ("presentation delay") and from presentation to treatment ("healthcare delay"). We calculated time ratios (TRs) to determine the association between sociodemographic and clinical factors and delay outcomes.

Results: Median presentation delay was 30 days (interquartile range (IQR) 11-72 days). Language barriers were associated with 40% longer presentation delay (TR 1.40, 1.01-1.94). Median healthcare delay was 40 days (IQR 13-89 days), and mostly consisted of the time taken before deciding to refer to TB specialists (median 26 days, IQR 4-73 days). Shorter healthcare delay was associated with positive sputum smear (TR 0.58, 0.47-0.70), UK residency <2 years (TR 0.47, 0.32-0.67), male sex (TR 0.74, 0.60-0.91) and secondary care referral (TR 0.63, 0.51-0.78).

Conclusions: Our findings support continued initiatives to enable access to care for migrant populations to minimise presentation delay. Multifaceted approaches to increase clinician awareness of TB clinical presentations, to implement systems enabling early case recognition, to maximise the yield from sputum smear investigations and to ensure rapid diagnosis of smear negative cases are required to achieve further TB control.