Factors Associated With Diagnostic Delay of Pulmonary Tuberculosis in China Caihong Xu National Center for Tuberculosis Control and Prevention Xiaomeng Zhang Tianjin center for tuberculosis control Yan Liu Peking UnionMedical CollegeBeijingChina Yinyin Xia National Center for Tuberculosis Control and Prevention Li Wang Institute of Basic Medical Sciences Chinese Academy of Medical Sciences Lixia Wang National Center for Tuberculosis Control and Prevention Hui Zhang ( [email protected] ) National Center for Tuberculosis Control and Prevention, China Centre for Disease Control (CDC) https://orcid.org/0000-0002-3989-2304 Research Article Keywords: Diagnosis, Delay, Pulmonary tuberculosis Posted Date: April 13th, 2021 DOI: https://doi.org/10.21203/rs.3.rs-404351/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/19 Abstract Background Tuberculosis (TB) is still a great challenge to public health in China. Most of the transmission occurs between the onset of symptoms and initiation of treatment. Diagnosis delay is a major barrier to effective management of the disease. Determining the factors associated with patient and provider delay of TB diagnosis and treatment may contribute to TB prevention and control. Methods A cross-sectional survey of pulmonary tuberculosis registed in the National Tuberculosis programme was conducted in 22 counties of 6 provinces in China. All consecutively registered patients during January to June 2017 were interviewed using a structured questionnaire. The time from the onset of symptoms to the date of diagnosis was analyzed. Bivariate and logistics regression were applied to analyze the risk factors of delay. Results The median time from onset of symptoms to diagnosis was 23 days (interquartile range [IQR]: 5-53days). The risk of delayed diagnosis was higher in the central (OR=3.27, 95%CI 1.39-7.68) and eastern regions (OR=1.48, 95%CI 1.04-2.10) than in the western regions. Rural TB patients have a longer diagnosis delay than those in urban areas (OR=1.44, 95%CI 1.00-2.08). The asymptomatic TB patients had a longer diagnosis delay than TB patients with clinical symptoms (OR=0.20, 95%CI 0.13-0.31). Conclusions A high propotion of TB patients showed diagnostic delay in China especially in some low economic level areas. Multiple measures should be taken to shorten the delay, such as to increase public awareness of the disease and expansion the quality assured facility in economic less-developed regions. Trial registration Not applicable Introduction Tuberculosis (TB) remains to be a major public health threat, it is estimated that there were 10 million new cases of TB worldwide and more than 1.2 million deaths from TB1. The diagnosis delay present a major obstacle to the control of TB epidemic. This is a serious concern due to the fact that each of the patient may infect 10–15 people each year, eventually creating a public health problem and even lead to economic hardship2. Ensuring universal access to quality-assured and early diagnosis of TB will diminish Page 2/19 transmission, avert deaths and prevent suffering caused by TB, which can help countries to move towards elimination of the disease. China is one of the TB high burden country which accounting for 8.4% of the global TB burden and 50% of the burden in Western Pacic region[1, 2] 1–2(1, 2). The fth national tuberculosis prevalence survey showed that, from 1990 to 2010, the prevalence of pulmonary tuberculosis decreased from 611/100,000 to 442/100,000, the decline rate was only 28%[3] 3(3). The unsatised decline of pulmonary tuberculosis (PTB) might due to long diagnostic delay of tuberculosis. The Directly Observed Treatment, Short-course [DOTS] strategy has been adopted in China since 1990s.The key elements of DOTS strategy were early diagnosis and prompt treatment initiation. Considering the TB burden and human capacity, passive case- nding strategy has always been the main approach applied by National Tuberculosis Programme (NTP) in China, which contributes more than 95% TB patients notication4. Under the passive-case nding principle, symptomatic TB patients voluntarily visit any kind of health facilities to seek medical care, all the suspected TB patients and conrmed TB patients should be referred to TB designated medical facilities. People undetected for long time or late detection may worse the disease, increase mortality and result in sustained spread of tuberculosis in the community. Identifying reasons for delay in diagnosis is important for the health system to nd ways to treat patients as early as possible, and hence reduce the suffering of patients and transmission of the disease. Information on diagnostic delay is important for evaluation and improvement of the TB control programmes. Some small-scale studies of diagnostic delay have been conducted in China5–10, which reported diagnostic delay were very signicantly from around 30 days in Shanghai5 to 60 days in Shanxi province6. Factors attributing to the delay in diagnosis are also likely to vary in different settings, poverty, non-residents, lack of health knowledge and default of health insurance et al were reported related to long delay in diagnosis. But no nationally representative data are available. We conducted a nation-wide study of diagnostic delay in 22 counties, with the aims to evaluate the extend of diagnostic delay in tuberculosis case nding and identify risk factors associated with long diagnostic delay within in NTP in China. Method Study design This was a cross-sectional study involving primary data collection. Setting General setting China is a developing country has total population of 1.4 billion and 2851 counties, the per capita gross national product was10 349 US$ in 201911.The health care delivery system is “mixed” with a dominant Page 3/19 role for public sector institutions12. National TB Programme (NTP) The National center for tuberculosis control and prevention (NCTB), which belongs to China center for disease control (CDC), manages the NTP. TB basic management units (BMU) are established at county level. One authorized TB designated medical facility (TB designated hospital, TB dispensary or CDC) is responsible for TB diagnosis and treatment at each BMU level. TB patients are provided free chest radiography, sputum smear test and rst-line drugs in TB designated medical facilities. Study population Eligible were all drug-susceptible tuberculosis patients who had been diagnosed during January and June 2017 within in NTP. Sampling strategy We adopted multi-stage stratied cluster sampling. The stratifying factors were region (east/middle/west) and residence (rural/urban). The steps followed in sampling have been summarized in Annex I. Sample size Assuming diagnose delay was 30%13, relative precision as 0.2 and α error as 0.05, average cluster (dened at county level) size of 50, between-cluster variation of 0.4, design effect of 4.36 and anticipating a non-response rate of 10%, the nal sample size was 960, to be sampled from 22 clusters. (see AnnexII) Survey instrument A structured questionnaire was developed addressing health seeking behavior of TB patients based on clinical experience and review of relevant literature. The questionnaire collected information including: 1) demographic and socio-economic variables: sex, age, education level, area of residence, economic status, 2) clinical presentations: cough, fever, night sweats, hemoptysis, weight loss, anorexia, fatigue, and dyspnea 3) health care seeking experiences of the subjects from the onset of symptoms to obtaining a TB diagnosis. It was pre-tested prior to the start of the study in one Changping district BMU in Beijing and modications were made to arrive to the nal version. Each interview lasted approximately 20 minutes. A written consent was secured from every eligible tuberculosis patient before inclusion into the survey. Informed consent and responses for children under 18 years of age were obtained from the closest accompanying relative. Diagnostic delay was used to reect the promptness of patient’s access to TB care. Diagnostic delay was dened as the time interval from the onset of symptoms to the conrmed TB diagnosis longer than 14 Page 4/19 days. Data management and analysis Data were double entered and validated using EpiData (version 3.1 EpiData Association, Odense, Denmark) during July to December 2017. The analysis was conducted using STATA (version 12.1, copyright 1985-2011 StataCorp LP USA). Beyond the descriptive statistics, associations between the dependent variables (diagnosis delay) and the independent variables were analyzed by calculating the ORs test and respective 95% condence intervals (CI). Independent variables that showed marginal associations (P<0.20) in the bivariate analysis were used in a logistic regression analysis in order to identify independent predictors of diagnosis delay >14 days. The association of predictor variables with the dependent variables was assessed by using 95% CI and adjusted odds ratio (AOR). A p-value of <0.05 was regarded as statistically signicant. Results Socio-demographic characteristics of patients Table 1 shows the characteristics of the participants A total of 974 tuberculosis patients were included in our study. Among them, 387(39.7%) and 380(39.0%) came from eastern and western regions respectively. 396(40.7%) patients were aged 45–64 and 682(70.0%) patients were male. The majority of the participants were completed primary and middle school education, which accounting for 58.8%. 467(48.0%) were irregular earning, and 566(58.1%) of the participants were their family prime income earner. 894 (91.8%) were newly diagnosed TB patients and 615(63.1%) participants were not hospitalized. 810(87.4%) participants had symptom, and the main symptom of the participants were cough (76.5%), followed by expectoration (55.1%). 589(60.5%) participants had chronic disease and 659(67.7%) were registered at TB designated hospitals.