title: A systematic review of delay in the diagnosis and treatment of tuberculosis.
abstract: BACKGROUND
  Early diagnosis and immediate initiation of treatment are essential for an effective tuberculosis (TB) control program. Delay in diagnosis is significant to both disease prognosis at the individual level and transmission within the community. Most transmissions occur between the onset of cough and initiation of treatment.
  
  
  METHODS
  A systematic review of 58 studies addressing delay in diagnosis and treatment of TB was performed. We found different definitions of, for example, debut of symptoms, first appropriate health care provider, time to diagnosis, and start of treatment. Rather than excluding studies that failed to meet strict scientific criteria (like in a meta-analysis), we tried to extract the "solid findings" from all of them to arrive on a more global understanding of diagnostic delay in TB.
  
  
  RESULTS
  The main factors associated with diagnostic delay included human immunodeficiency virus; coexistence of chronic cough and/or other lung diseases; negative sputum smear; extrapulmonary TB; rural residence; low access (geographical or sociopsychological barriers); initial visitation of a government low-level healthcare facility, private practitioner, or traditional healer; old age; poverty; female sex; alcoholism and substance abuse; history of immigration; low educational level; low awareness of TB; incomprehensive beliefs; self-treatment; and stigma.
  
  
  CONCLUSIONS
  The core problem in delay of diagnosis and treatment seemed to be a vicious cycle of repeated visits at the same healthcare level, resulting in nonspecific antibiotic treatment and failure to access specialized TB services. Once generation of a specific diagnosis was in reach, TB treatment was initiated within a reasonable period of time.
authors.affiliation: Department of International Health, Institute of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, N-0318 Oslo, Norway. dgstorla@online.no
authors.forename: Dag Gundersen
authors.initials: DG
authors.lastname: Storla
authors.forename: Solomon
authors.initials: S
authors.lastname: Yimer
authors.forename: Gunnar Aksel
authors.initials: GA
authors.lastname: Bjune
mesh_terms: D003951:Diagnostic Errors; D005260:Female; D015658:HIV Infections / Q000150:complications; D006801:Humans; D008297:Male; D019370:Observation; D010342:Patient Acceptance of Health Care; D012307:Risk Factors; D012959:Socioeconomic Factors; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy*