Health System Delay and Risk Factors in Pulmonary Tuberculosis Diagnosis Before and During the COVID-19 Epidemic: a Multi-center Survey in China

Overview

Journal Front Public Health

Specialty Public Health

Date 2025 Mar 13

PMID 40078758

Authors

Mingkuan Fan

Yushu Liu

Kui Liu

Xiaoqiu Liu

Yuhong Li

Tao Li

Canyou Zhang

Hui Zhang

Jun Cheng

Affiliations

Soon will be listed here.

Abstract

Background: Understanding health system delay (HSD) in pulmonary tuberculosis (PTB) diagnosis aids in tailoring interventions for case detection and curbing transmission. However, recent nationwide studies on HSD in PTB diagnosis have been scarce. This study assesses HSD and its risk factors in China, taking into account the impact of the COVID-19 epidemic.

Methods: Patients diagnosed with PTB between 2019 and 2022 were selected using a multistage stratified clustering method. A semi-structured questionnaire was employed to assess HSD, which was defined as the interval between the patient's initial visit to a health facility and the definitive PTB diagnosis. The HSD was then compared between 2019 (before the epidemic) and 2020-2022 (during the epidemic). Factors associated with long health system delay (LHSD, defined as HSD > 14 days) were examined using both univariate and multivariate analyses with chi-square tests and binary logistic regression, respectively.

Results: In total, 958 patients with PTB were analyzed: 478 before and 480 during the epidemic. The HSD was 14 (interquartile range, 7-30) days for all patients, and the HSD before and during the epidemic also shared this value. A total of 199 patients (20.8%) had LHSD. LHSD was more prevalent in patients presenting solely with cough and expectoration (Odds ratio [OR]: 1.482, 95% confidence interval [CI]: 1.015-2.162) and those visiting ≥2 health facilities before definitive diagnosis (2 health facilities: OR = 2.469, 95%CI: 1.239-4.920; ≥3 health facilities: OR = 8.306, 95%CI: 4.032-17.111). Additionally, patients with negative bacteriological results were independently associated with higher LHSD risk (OR = 1.485, 95%CI: 1.060-2.080).

Conclusion: In China, HSD in PTB diagnosis remains relatively low and is primarily mediated by factors associated with health providers. No significant impact on HSD from the COVID-19 epidemic has been found. Implementing targeted training programs to enhance health providers' awareness of chronic respiratory symptoms and maintain vigilance for PTB; strengthening presumptive PTB identification capabilities at grassroots health facilities, and promoting the use of (MTB) bacteriological technologies are recommended to shorten the HSD.

References

Said K, Hella J, Mhalu G, Chiryankubi M, Masika E, Maroa T . Diagnostic delay and associated factors among patients with pulmonary tuberculosis in Dar es Salaam, Tanzania. Infect Dis Poverty. 2017; 6(1):64. PMC: 5364704. DOI: 10.1186/s40249-017-0276-4. View

Xia Y, Huang F, Chen H, Wang N, Du X, Chen W . The Impact of COVID-19 on Tuberculosis Patients' Behavior of Seeking Medical Care - China, 2020. China CDC Wkly. 2021; 3(26):553-556. PMC: 8392940. DOI: 10.46234/ccdcw2021.143. View

Uplekar M, Weil D, Lonnroth K, Jaramillo E, Lienhardt C, Dias H . WHO's new end TB strategy. Lancet. 2015; 385(9979):1799-1801. DOI: 10.1016/S0140-6736(15)60570-0. View

Scott A, Limbada M, Perumal T, Jaumdally S, Kotze A, van der Merwe C . Integrating molecular and radiological screening tools during community-based active case-finding for tuberculosis and COVID-19 in southern Africa. Int J Infect Dis. 2024; 145:107081. DOI: 10.1016/j.ijid.2024.107081. View

Zhu B, Fu Y, Liu J, Mao Y . Spatial distribution of 12 class B notifiable infectious diseases in China: A retrospective study. PLoS One. 2018; 13(4):e0195568. PMC: 5886686. DOI: 10.1371/journal.pone.0195568. View

Davies P, Pai M . The diagnosis and misdiagnosis of tuberculosis. Int J Tuberc Lung Dis. 2008; 12(11):1226-34. View

Wang X, He W, Lei J, Liu G, Huang F, Zhao Y . Impact of COVID-19 Pandemic on Pre-Treatment Delays, Detection, and Clinical Characteristics of Tuberculosis Patients in Ningxia Hui Autonomous Region, China. Front Public Health. 2021; 9:644536. PMC: 8175850. DOI: 10.3389/fpubh.2021.644536. View

Lee J, Garg T, Lee J, McGrath S, Rosman L, Schumacher S . Impact of molecular diagnostic tests on diagnostic and treatment delays in tuberculosis: a systematic review and meta-analysis. BMC Infect Dis. 2022; 22(1):940. PMC: 9748908. DOI: 10.1186/s12879-022-07855-9. View

Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C . The impact of the COVID-19 epidemic on tuberculosis control in China. Lancet Reg Health West Pac. 2021; 3:100032. PMC: 7511841. DOI: 10.1016/j.lanwpc.2020.100032. View

10.

Turner R . Cough in pulmonary tuberculosis: Existing knowledge and general insights. Pulm Pharmacol Ther. 2019; 55:89-94. DOI: 10.1016/j.pupt.2019.01.008. View

11.

Jia Y, Jiang W, Xiao X, Lou Z, Tang S, Chen J . Patient delay, diagnosis delay, and treatment outcomes among migrant patients with tuberculosis in Shanghai, China, 2018-2020: a mixed-methods study. BMJ Open. 2024; 14(10):e082430. PMC: 11529733. DOI: 10.1136/bmjopen-2023-082430. View

12.

Peri A, Bernasconi D, Galizzi N, Matteelli A, Codecasa L, Giorgio V . Determinants of patient and health care services delays for tuberculosis diagnosis in Italy: a cross-sectional observational study. BMC Infect Dis. 2018; 18(1):690. PMC: 6302482. DOI: 10.1186/s12879-018-3609-4. View

13.

Liu K, Ge R, Luo D, Zheng Y, Shen Z, Chen B . Delay analysis of pulmonary tuberculosis in the eastern coastal county of China from 2010 to 2021: evidence from two surveillance systems. Front Public Health. 2023; 11:1233637. PMC: 10450766. DOI: 10.3389/fpubh.2023.1233637. View

14.

Neuhaus J, Segal M . Design effects for binary regression models fitted to dependent data. Stat Med. 1993; 12(13):1259-68. DOI: 10.1002/sim.4780121307. View

15.

Chimbatata N, Zhou C, Chimbatata C, Mhango L, Diwan V, Xu B . Barriers to prompt TB diagnosis-a comparative study between northern Malawi and eastern rural China. Trans R Soc Trop Med Hyg. 2018; 111(11):504-511. DOI: 10.1093/trstmh/try002. View

16.

Isangula K, Haule R . Leveraging AI and Machine Learning to Develop and Evaluate a Contextualized User-Friendly Cough Audio Classifier for Detecting Respiratory Diseases: Protocol for a Diagnostic Study in Rural Tanzania. JMIR Res Protoc. 2024; 13:e54388. PMC: 11077412. DOI: 10.2196/54388. View

17.

Zhang G, Yu Y, Zhang W, Shang J, Chen S, Pang X . Influence of COVID-19 for delaying the diagnosis and treatment of pulmonary tuberculosis-Tianjin, China. Front Public Health. 2022; 10:937844. PMC: 9755169. DOI: 10.3389/fpubh.2022.937844. View

18.

Zhu X, Tao N, Zhang Q, Song W, An Q, Liu S . Association between diagnostic delay and prognosis of pulmonary tuberculosis in Shandong, China: a retrospective study. BMC Pulm Med. 2022; 22(1):309. PMC: 9372940. DOI: 10.1186/s12890-022-02101-z. View

19.

Wako W, Wasie A, Wayessa Z, Fikrie A . Determinants of health system diagnostic delay of pulmonary tuberculosis in Gurage and Siltie zones, South Ethiopia: a cross-sectional study. BMJ Open. 2021; 11(10):e047986. PMC: 8549662. DOI: 10.1136/bmjopen-2020-047986. View

20.

Getnet F, Demissie M, Assefa N, Mengistie B, Worku A . Delay in diagnosis of pulmonary tuberculosis in low-and middle-income settings: systematic review and meta-analysis. BMC Pulm Med. 2017; 17(1):202. PMC: 5729407. DOI: 10.1186/s12890-017-0551-y. View