Diagnostic Delay of Tuberculosis in Qatar: Results of an Exploratory Study
Authors: Garcell Humberto Guanche , Zenón Victor Emiliano Ramirez , Cruz Zailys Gomez , Serrano Ramon Nonato Alfonso 
Published: July 2019

BackgroundAccording to the World Health Organization Report on Tuberculosis in 2013, it is estimated that 9 million people developed tuberculosis and 1.5 died of the disease. In Qatar, the incidence of tuberculosis is the highest in the Gulf countries but this mainly depends on migrant laborers from countries with high incidence, especially Nepal, India, and the Philippines. It is important to consider that only India contributes with the 25% of the global burden of tuberculosis. Among the strategies for the prevention and control of tuberculosis are included measures to promote the early diagnosis and the compliance with treatment. The delay in the diagnosis has a critical role in the control of tuberculosis and it constitutes a threat for the community and it worsens the prognosis for the patient's improvement in the clinical status. In a literature review of 52 studies, Sreeramareddy CT et al reported that (median or mean) total delay, patient delay, healthcare system delay for diagnosis of tuberculosis were ranging from 25 to 185 days, 4.9 to 16.2 days and 2 to 8.9 days respectively. The overall average patient delay was similar to health system delay (31.03 versus 27.2 days). According to a multinational study about diagnostic delay carried out in the Eastern Mediterranean Region (EMR) in 2003–2004 the mean duration of delay between the onsets of symptoms until treatment with anti-tuberculosis drugs ranged from one month and a half to 4 months in the different countries. The mean delay was 46 days in Iraq, 57 in Egypt, 59.2 in Yemen, 79.5 in Somalia, 80.4 in the Syrian Arab Republic, 100 in Pakistan, and 127 in the Islamic Republic of Iran. This report comments that the infection control programs are able to detect an average of one third of smear-positive tuberculosis cases, while the rest continue to transmit infection in the community until treated, whether adequate or inadequate by other health sectors. Recently published papers report total diagnosis delay of 60 days (Porto Alegre and Yemen, 2013), and 36 days (Guimaraes, 2015), patient delay of 15 days (Brazil, 2013 - Porto Alegre, 2013) and system delay of 15 days (Croatia, 2013) and 18 days (Porto Alegre, 2013). No previous reports have been published about the topic in Qatar. Based on the previous information and on the national goal for prevention and control of communicable diseases we considered necessary to conduct an epidemiological research to describe the diagnostic delay in tuberculosis, as an initial step for a population-based study.Objective– To identify the diagnostic delay in patients with tuberculosis and to describe the patient and healthcare system components.– To test the method of collection of information for the design of a population-based study.MethodsAn exploratory study was carried out in 49 newly diagnosed tuberculosis patients admitted to a hospital facility during the period of May-October, 2015 Criteria for inclusion:– Patient who accepts to answer the questions during a regular clinical interview.– Patient with a clinical status who allows the interview, regardless of the type of tuberculosis (pulmonary or extra pulmonary) Criteria for exclusion– Unstable clinical status that interferes with a proper communication– Language barrier that could not be overcome due to unavailability of interpreter for any specific language.Procedure During the admission period, and during the regular clinical evaluation, the patients answered the study questions. The interview was conducted by a nurse, using an interpreter if considered necessary. It was collected information about the first time the patient arrived in Qatar and the date of onset of symptoms related with tuberculosis. If the patient visited an outpatient or emergency department of another healthcare facility during the symptomatic period and before the admission, it was defined the date and the type of facility (primary level facility, hospital facility) and if the treatment recommended included antibiotics. The date of diagnosis was considered to be the date of the collection of the confirmatory laboratory test (acid fast bacilli or GeneXpert PCR positive for mycobacterium tuberculosis complex in clinical samples).Definitions– Patient delay was considered as the time between symptoms onset and first contact with the healthcare system, regardless the category or level of care provided by the facility (primary healthcare facility, hospital).– System delay was considered as the time between the first contact with the healthcare system and the diagnosis.AnalysisData were entered in JMP 10.0 (SAS Institute, http://www.jmp.com). Descriptive statistical methods were used. Median and percentile distribution was calculated for patient and healthcare system delay, and boxplot graph was obtained. The interquartile range [IQR] was calculated (Q3 – Q1).ResultsThe patients have lived in Qatar a mean time of 5.5 years, with a maximum of 32 years. All patients were confirmed with pulmonary or pleural tuberculosis by means of a smear positive for acid fast bacilli, PCR positive for mycobacterium tuberculosis complex in clinical samples (sputum, pleural fluid, biopsy samples). The median total delay was 30 days (IQR 23.5 days, maximum 365 days), the patient delay was 21 days (IQR 22 days, maximum 362 days), and the system delay was 3 days (IQR 8 days, maximum 60 days). 26 patients out of 42 who visited another facility before admission (61.9%) were attended in a primary healthcare facility and 16 patients (38.1%) in a hospital facility. The 92% of these patients received antibiotic treatment for the management of the respiratory symptoms and were discharged from these ambulatory contacts. After that, due to no improvement of their clinical status they were admitted to hospital and the diagnosis of tuberculosis was confirmed. The above-mentioned results highlight the contribution of the patient component in the diagnosis delay in tuberculosis, which constitutes a significant risk for community transmission. Consequently, this finding should guide the actions for the prevention and control of tuberculosis. It is important to stand out the strengths of the tuberculosis program in Qatar, including the availability of the latest technology for its diagnosis (Gene Xpert PCR, Quantiferon TB Gold, PCR for rifampicin resistance), which is performed in a central laboratory at a national level, and a devoted Tuberculosis clinic for diagnosis and follow up with devoted staff with expertise on this field. In addition, the national law supports the free of charge healthcare services for tuberculosis patients, including the admission in hospital, anti tuberculosis treatment and follow-up.ConclusionOur findings provide insights about the delay of tuberculosis diagnosis and the need to identify strategies for its reduction, especially the patient component.RecommendationsTo conduct a population-based or cohort study to identify the risk factors and determinants for delay in the diagnosis of tuberculosis, including detailed information about the health-seeking behavior of patients with suspected tuberculosis.