title: 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.
authors.affiliation: Department of Population Medicine, Faculty of Medicine and Health Science, University Tunku Abdul Rahman, Bandar Sungai Long, 43000, Selangor, Malaysia.
authors.forename: Chandrashekhar T
authors.initials: CT
authors.lastname: Sreeramareddy
authors.affiliation: McGill University & McGill International TB Centre, Dept of Epidemiology & Biostatistics, 1020 Pine Ave West, Montreal, QC H3A 1A2, Canada.
authors.forename: Zhi Zhen
authors.initials: ZZ
authors.lastname: Qin
authors.affiliation: McGill University & McGill International TB Centre, Dept of Epidemiology & Biostatistics, 1020 Pine Ave West, Montreal, QC H3A 1A2, Canada.
authors.forename: Srinath
authors.initials: S
authors.lastname: Satyanarayana
authors.affiliation: Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA 02115, USA.
authors.forename: Ramnath
authors.initials: R
authors.lastname: Subbaraman
authors.affiliation: McGill University & McGill International TB Centre, Dept of Epidemiology & Biostatistics, 1020 Pine Ave West, Montreal, QC H3A 1A2, Canada.
authors.forename: Madhukar
authors.initials: M
authors.lastname: Pai
mesh_terms: D000995:Antitubercular Agents / Q000627:therapeutic use*; D001431:Bacteriological Techniques; D057210:Delayed Diagnosis; D003695:Delivery of Health Care; D006801:Humans; D007194:India; D010342:Patient Acceptance of Health Care; D011237:Predictive Value of Tests; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology / Q000628:therapy*
chemical_list: D000995:Antitubercular Agents