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Clinical Research
© Med Sci Monit, 2004; 10(2): CR62-67
PMID: 14737045
CR62
Factors affecting delays in diagnosis and treatment
of pulmonary tuberculosis in a tertiary care hospital
in Istanbul, Turkey
Döndü Güneylioglubdefg, Adnan Yilmazabcdefg, Sevinc¸ Bilginbdf,
Ümmühan Bayrambf, Esen Akkayaace
Department of Pulmonology, SSK Süreyyapas¸a Center for Chest Diseases and Thoracic Surgery, Istanbul-Turkey
Source of support: none.
Summary
Background: To investigate delays in the diagnosis and treatment of inpatients with smear-positive pul-
monary tuberculosis and to identify factors affecting these delays.
Materials/Methods: 204 hospitalized patients with smear-positive pulmonary tuberculosis were identified. The
clinical files of the patients were analyzed and questionnaires were created.
Results: Mean application interval was 31.4 days, mean referral interval was 22.1 days, mean diagnosis
interval was 3.3 days, and mean initiation of treatment interval was 1.4 days. Patient delay was
present in 34.8 percent of the patients. The application interval was shorter for patients hav-
ing an index case for tuberculosis (p=0.039) and for those with good economic status
(p<0.005). 167 patients (81.9%) had institutional delay. The referral interval was longer for
female patients than for male patients (p=0.015). The most common causes of institutional
delays were a low index of suspicion for tuberculosis, health care system delays, and underuti-
lized chest X-ray examinations. One hundred and three patients (50.5%) had delays in diag-
nosis and 51 patients (25.0%) had delays in treatment. The most frequent reason for diagnos-
tic delay was health care system delays (35.9%).
Conclusions: There were several delays in the diagnosis of tuberculosis patients. For an effective tuberculo-
sis control, efforts should be made to reduce these delays. Physicians and the public should be

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Med Sci Monit, 2004; 10(2): CR62-67 Güneylioglu D et al – Delays in pulmonary tuberculosis diagnosis and treatment
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BACKGROUND
Prior to the twentieth century, tuberculosis was one of
the major causes of death in both developed and devel-
oping countries [1]. During the twentieth century it con-
tinued to be a major public health problem worldwide.
In 1993, the World Health Organization (WHO)
declared a state of global emergency for tuberculosis due
to the steady increase of the disease worldwide [2]. It is
estimated that by the year 2005 12 million cases of tuber-
culosis will be identified in the world annually, a 58%
increase from the 7.5 million estimated for 1990 [3]. It
was reported that 19% to 43% of the world’s population
was infected with Mycobacterium tuberculosis [4]. One of
the main objectives in any tuberculosis control program
is to reduce tuberculosis transmission in the community
through early detection of tuberculosis cases and prompt
implementation of a full course of therapy [5]. This is
especially important in the case of untreated smear-posi-
tive patients, who are the main sources of infection in a
community [5,6]. Delays in the diagnosis and start of
effective treatment of tuberculosis patients result in a
prolonged period of infectivity in the community and
health care workers [7–9]. These delays have been noted
in both high- and low-prevalence countries [6,7,10–16].
Turkey has an estimated incidence of tuberculosis of 30

of first doctor visit, (11) date of admission to hospital,
(12) date of diagnosis, and (13) date of treatment initia-
tion. The presence of cough, fever, night sweats,
hemoptysis, weight loss, anorexia, fatigue, and dyspnea
were the criteria for the onset date of symptoms.
Patients were classified as ‘urban’ if they lived in a city
or metropolis and ‘rural’ if they lived in the towns and
villages surrounding these. The patients were catego-
rized into three groups with respect to their economic
status. When monthly income was below $200 (US), the
patient’s economic status was regarded as poor.
Monthly income was between $200 and $550 for
patients with moderate economic status. Patients with
good economic status had monthly incomes over $550.
The following time intervals and delays were deter-
mined for each patient: The patient’s application interval
was defined as the time interval between the onset of
symptoms and the first doctor visit. Intervals that
exceeded 30 days were considered indicative of a patient
delay [12]. The referral interval was defined as the time
from the first doctor visit to admission [17]. With regard
to our health care system, intervals that exceeded two
days were considered indicative of an institutional delay
[14]. The diagnosis interval was regarded as the time from
admission to a positive acid-fast smear. Intervals that
exceeded one day were considered indicative of a
delayed diagnosis [14,18]. The treatment interval was the
time from diagnosis to initiation of treatment. Intervals
that exceeded one day were considered indicative of a
delayed treatment [14,18]. Clinic delay was defined as the

133 patients (65.2%) and longer than 30 days in 71
patients (34.8%). According to these results, 34.8% of
the patients had patient delays.
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Med Sci Monit, 2004; 10(2): CR62-67Clinical Research
Table 2 gives a sub-analysis of application interval and
patient delays with respect to several factors. Age, sex,
area of residence, and education level had no effect on
the application interval. Significantly shorter mean appli-
cation intervals were noted in patients having an index
case for tuberculosis (p=0.04) and patients who had good
economic status (p=0.03). The rate of cases having
patient delay was lower among patients with hemoptysis
than patients with other first symptoms (p=0.04).
Factors associated with the referral interval are summa-
rized in Table 3. The referral interval was shorter than
three days in 37 patients (18.1%). This interval was
between 3 and 10 days in 64 patients (31.4%) and was
longer than 10 days in 103 patients (50.5%). One hun-
dred and sixty-seven (81.9%) patients had institutional
delay. Sub-analysis identified 200 reasons for institu-
tional delay in these patients. While age, education
level, residence area, and economic status had no effect
on the referral interval, this interval was significantly
shorter in male patients (p=0.015). Similarly, the rate of
cases having institutional delay was significantly lower
among male patients (p=0.003). Patients referred by a
chest specialist had a significantly shorter referral inter-
val than those referred by the other physicians
(p=0.043), with a subsequent lower rate of institutional

tiation of treatment with respect to days is shown in
Table 5. The mean (95%, CI) interval was 26.7 days
(22.5 to 30.8 days) and median interval was 15 days.
There were doctor delays in 178 of 204 patients
(87.2%). The mean interval (95%, CI) from onset of
symptoms to initiation of treatment was 64.1 days (55.2
to 73.1 days). This interval suggested total delay.
DISCUSSION
We analyzed delays in the diagnosis and treatment of
inpatients with smear-positive pulmonary tuberculosis
and factors affecting these delays. The present study
indicated that there were several delays between the
onset of symptoms and initiation of treatment in our
patients. These delays included patient delay, institu-
tional delay, diagnostic delay, and delay in the treat-
ment. Both patient and institutional delays result in
increased infection risk for the population. Diagnostic
and treatment delays result in increased infection risk
for medical personnel [14]. An untreated smear-positive
patient may infect on average more than 10 contacts
onset of first visit to admission to diagnosis initiation of
symptoms physician hospital treatment
patient’s delay institutional diagnostic delay delayed treatment
delay

application interval referral interval diagnosis interval treatment interval
doctor’s delay
Clinic delay
Figure 1. Components of the
time from onset of

for patients with pulmonary tuberculosis are more com-
mon in developing countries [10,12,14]. A has previous
report suggested that delays associated with pulmonary
tuberculosis were common in Turkey [14]. Delays have
also been reported in developed countries [7,11,13].
In our study, the median application interval was found
to be 17.5 days. Seventy-one patients (34.8%) had
patient delay. While many reports present a shorter
median application interval than ours [21,22], longer
median application intervals were noted in two previous
studies [10,12]. This interval was between 0.3 weeks and
120 days in these reports [12,22]. A previous report
indicated that 28.4 percent of the patients had patient
delay and that the median application interval was 17.5
days [14]. The rate of patient delay was slightly higher
in the present study than in our previous report.
Similar median application intervals were determined
in these series.
This study showed that the rates of doctor delay were
higher than those of patient delay. We noted that one
hundred and seventy-eight patients (87.2%) had doctor
delay and that the median doctor delay was 15 days. A
previous report indicated that the rate of doctor delay
was 88.2% and that the median doctor delay was 9 days
[14]. Liam et al. reported that median doctor delay was
7 weeks [21]. Doctor delay included institutional delay,
diagnostic delay and delayed treatment [14]. The rates
of delay were 81.9% for institutional delay, 50.5% for
diagnostic delay, and 25% for delayed treatment in the
present study. These results indicate that the rate of

Mean (SD) Median 95% CI Yes No p
Sex
Male
Female
Age
<45
≥45
Residence
Urban
Rural
Index case
Yes
No
Education
No education
Primary
Secondary
University
Economic status
Poor
Moderate
Good
First symptom
Cough
Hemoptysis
Other
35.2 (42.9)*
25.7 (31.4)*
29.5 (38.3)*
34.5 (39.8)*

*
2 (5.6)
##,
*
49 (37.1)
###,&
8 (20.0)
###,&&
14 (43.8)
&,&&
77 (63.1)
56 (68.3)
85 (67.5)
48 (61.5)
100 (66.2)
33 (62.3)
49 (75.4)
84 (60.5)
16 (69.6)
71 (60.2)
41 (73.2)
5 (71.4)
9 (17.0)
90 (68.3)
34 (94.4)
83 (62.9)
32 (80.0)
18 (56.2)
18.0
15.0

6.7–12.9
25.6–38.6
12.8–40.4
19.8–46.2
*
,
**p>0.05
*
,
**p>0.05
*
,
**p>0.05
**p=0.039
*
,
*** p>0.05
#
p<0.005
##
p<0.005
*p=0.026
###
p=0.055
&
p>0.05
&&
p=0.04
Table 2. A sub-analysis of patient delay.
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and diagnostic delays. Poor economic status was an
important reason of patient delay in our series.
CONCLUSIONS
In conclusion, the present study suggests that our
patients with smear-positive pulmonary tuberculosis had
several delays from the onset of symptoms to initiation of
treatment. Because untreated smear-positive patients are
the main sources of infection, delays in the diagnosis and
treatment of these patients increase the risk of disease
transmission in the community. These delays are also
associated with a prolonged period of infectivity for
medical personnel. According to our data, doctor delay
was more significant than patient delay, and institutional
delay was the most important component of doctor
delay. The low index of tuberculosis, underutilized chest
Days
n%n%
Diagnosis interval Diagnosis interval
0–1
2–10
>10
101
93
10
153
50
1
49.5
45.6
4.9

Urban
Rural
Education
No education
Primary
Secondary
University
Economic status
Poor
Moderate
Good
First visit
Chest specialist
Practitioner
Other
19.1 (28.7)*
26.6 (30.8)*
20.5 (26.9)*
24.8 (33.1)*
21.2 (27.8)*
22.6 (30.5)*
29.6 (37.2)**
21.3 (30.5)**
19.8 (21.9**
14.1 (21.3)**
25.1 (34.6)*
21.5 (27.8)*
20.3 (28.3)*
11.4 (20.6)**
23.1 (26.8)**

12 (31.6)
9 (16.1)
1 6 (14.5)
7.5
14.5
11.0
11.0
11.0
11.0
19.0
8.0
11.0
4.0
15.0
10.0
11.0
6.0
14.0
14.0
14.0–24.2
19.8–33.4
15.8–25.1
17.4–32.3
13.4–29.0
17.7–27.1
13.5–45.7
15.5–27.1
13.9–25.6
5.5–33.8
15.5–34.6

oratory delays should be minimized. These efforts can
reduce delays in pulmonary tuberculosis treatment. We
conclude that delays are important reasons for the
increased period of infectivity, and that decreasing these
delays will help tuberculosis control.
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