Diagnostic delay and associated factors among patients with pulmonary tuberculosis in Dar es Salaam, Tanzania.
BACKGROUND
Tanzania is among the 30 countries with the highest tuberculosis (TB) burdens. Because TB has a long infectious period, early diagnosis is not only important for reducing transmission, but also for improving treatment outcomes. We assessed diagnostic delay and associated factors among infectious TB patients.


METHODS
We interviewed new smear-positive adult pulmonary TB patients enrolled in an ongoing TB cohort study in Dar es Salaam, Tanzania, between November 2013 and June 2015. TB patients were interviewed to collect information on socio-demographics, socio-economic status, health-seeking behaviour, and residential geocodes. We categorized diagnostic delay into ≤ 3 or > 3 weeks. We used logistic regression models to identify risk factors for diagnostic delay, presented as crude (OR) and adjusted Odds Ratios (aOR). We also assessed association between geographical distance (incremental increase of 500 meters between household and the nearest pharmacy) with binary outcomes.


RESULTS
We analysed 513 patients with a median age of 34 years (interquartile range 27-41); 353 (69%) were men. Overall, 444 (87%) reported seeking care from health care providers prior to TB diagnosis, of whom 211 (48%) sought care > 2 times. Only six (1%) visited traditional healers before TB diagnosis. Diagnostic delay was positively associated with absence of chest pain (aOR = 7.97, 95% confidence intervals [CI]: 3.15-20.19; P < 0.001), and presence of hemoptysis (aOR = 25.37, 95% CI: 11.15-57.74; P < 0.001) and negatively associated with use of medication prior to TB diagnosis (aOR = 0.31, 95% CI: 0.14-0.71; P = 0.01). Age, sex, HIV status, education level, household income, and visiting health care facilities (HCFs) were not associated with diagnostic delay. Patients living far from pharmacies were less likely to visit a HCF (incremental increase of distance versus visit to any facility: OR = 0.51, 95% CI: 0.28-0.96; P = 0.037).


CONCLUSIONS
TB diagnostic delay was common in Dar es Salaam, and was more likely among patients without prior use of medication and presenting with hemoptysis. Geographical distance to HCFs may have an impact on health-seeking behaviour. Increasing community awareness of TB signs and symptoms could further reduce diagnostic delays and interrupt TB transmission.
Ifakara Health Institute, Bagamoyo Research and Training Centre (BRTC), P O Box 74, Bagamoyo, Tanzania. ksaid@ihi.or.tz.|Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland. ksaid@ihi.or.tz.|University of Basel, Petersplatz 1, 4003, Basel, Switzerland. ksaid@ihi.or.tz.
Khadija
K
Said
Ifakara Health Institute, Bagamoyo Research and Training Centre (BRTC), P O Box 74, Bagamoyo, Tanzania.|Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland.|University of Basel, Petersplatz 1, 4003, Basel, Switzerland.
Jerry
J
Hella
Ifakara Health Institute, Bagamoyo Research and Training Centre (BRTC), P O Box 74, Bagamoyo, Tanzania.|Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland.|University of Basel, Petersplatz 1, 4003, Basel, Switzerland.
Grace
G
Mhalu
National Tuberculosis and Leprosy Programme, Dar es Salaam, Tanzania.
Mary
M
Chiryankubi
National Tuberculosis and Leprosy Programme, Dar es Salaam, Tanzania.
Edward
E
Masika
Ifakara Health Institute, Bagamoyo Research and Training Centre (BRTC), P O Box 74, Bagamoyo, Tanzania.
Thomas
T
Maroa
Ifakara Health Institute, Bagamoyo Research and Training Centre (BRTC), P O Box 74, Bagamoyo, Tanzania.|Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland.|University of Basel, Petersplatz 1, 4003, Basel, Switzerland.
Francis
F
Mhimbira
National Tuberculosis and Leprosy Programme, Dar es Salaam, Tanzania.
Neema
N
Kapalata
Ifakara Health Institute, Bagamoyo Research and Training Centre (BRTC), P O Box 74, Bagamoyo, Tanzania. lukas.fenner@unibas.ch.|Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland. lukas.fenner@unibas.ch.|University of Basel, Petersplatz 1, 4003, Basel, Switzerland. lukas.fenner@unibas.ch.|Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland. lukas.fenner@unibas.ch.
Lukas
L
Fenner
D000293:Adolescent; D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities / Q000600:supply & distribution; D015331:Cohort Studies; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D042241:Early Diagnosis; D005260:Female; D062305:Geographic Mapping; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012923:Social Class; D013636:Tanzania; D016896:Treatment Outcome; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D055815:Young Adult
Diagnostic delay; Geographic information system; Health-seeking; Pharmacy; Tanzania; Transmission; Tuberculosis