title: Treatment delay affects clinical severity of tuberculosis: a longitudinal cohort study.
abstract: OBJECTIVE
  To describe the risk factors for treatment delay and the effect of delay on the severity of tuberculosis (TB) in a prospectively followed TB cohort at the Bandim Health Project in Guinea-Bissau.
  
  
  BACKGROUND
  Treatment delay in patients with TB is associated with increased mortality and transmission of disease. However, it is not well described whether delay influences clinical severity at diagnosis. Previously reported risk factors for treatment delay vary in different geographical and cultural settings. Such information has never been investigated in our setting. Change in delay over time is rarely reported and our prospectively followed TB cohort gives an opportunity to present such data.
  
  
  METHODS
  Patients were included at the time of diagnosis at three local TB clinics and the national TB reference hospital. Inclusion criteria were age >15 years and diagnosis of TB by either sputum examination or by the WHO clinical criteria. Patients with extrapulmonary TB were excluded.
  
  
  METHODS
  The primary outcome was treatment delay. Delay was assessed by patient questionnaires. The secondary outcome was Bandim TBscore as a measure of TB morbidity and all-cause mortality.
  
  
  RESULTS
  A total of 1424 persons were diagnosed with TB in the study area between 2003 and 2010. We included 973 patients with TB in the study. The median treatment delay was 12.1 weeks. Risk factors for delay were low educational level, HIV-1+HIV-2 dual infection and negative sputum smear. TB treatment delay decreased by 10.3% (7.9-12.6%) per year during the study period. Delay was significantly associated with clinical severity at presentation with 20.8% severe TB cases in the low delay quartile compared with 33.9% if delay was over the median of 12.1 weeks.
  
  
  CONCLUSIONS
  Long treatment delay was associated with more severe clinical presentation. Treatment delay in TB cases is decreasing in Guinea-Bissau.
authors.affiliation: Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau Department of Infectious Diseases, Aarhus University Hospital, Denmark.
authors.forename: J
authors.initials: J
authors.lastname: Virenfeldt
authors.affiliation: Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau Department of Infectious Diseases, Aarhus University Hospital, Denmark.
authors.forename: F
authors.initials: F
authors.lastname: Rudolf
authors.affiliation: Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.
authors.forename: C
authors.initials: C
authors.lastname: Camara
authors.affiliation: Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.
authors.forename: A
authors.initials: A
authors.lastname: Furtado
authors.affiliation: Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.
authors.forename: V
authors.initials: V
authors.lastname: Gomes
authors.affiliation: Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau Danish Epidemiology Science Center, Statens Serum Institut, Copenhagen, Denmark.
authors.forename: P
authors.initials: P
authors.lastname: Aaby
authors.affiliation: Department of Infectious Diseases, Aarhus University Hospital, Denmark.
authors.forename: E
authors.initials: E
authors.lastname: Petersen
authors.affiliation: Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau GloHAU, Center for Global Health, School of Public Health, Aarhus University, Denmark.
authors.forename: C
authors.initials: C
authors.lastname: Wejse
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D005260:Female; D006169:Guinea-Bissau; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy*; D055815:Young Adult