Long Delays and Missed Opportunities in Diagnosing Smear-Positive Pulmonary Tuberculosis in Kampala, Uganda: A Cross-Sectional Study

BACKGROUND: Early detection and treatment of tuberculosis cases are the hallmark of successful tuberculosis control. We conducted a cross-sectional study at public primary health facilities in Kampala city, Uganda to quantify diagnostic delay among pulmonary tuberculosis (PTB) patients, assess associated factors, and describe trajectories of patients' health care seeking. METHODOLOGY/PRINCIPAL FINDINGS: Semi-structured interviews with new smear-positive PTB patients (≥ 15 years) registered for treatment. Between April 2007 and April 2008, 253 patients were studied. The median total delay was 8 weeks (IQR 4-12), median patient delay was 4 weeks (inter-quartile range [IQR] 1-8) and median health service delay was 4 weeks (IQR 2-8). Long total delay (>14 weeks) was observed for 61/253 (24.1%) of patients, long health service delay (>6 weeks) for 71/242 (29.3%) and long patient delay (>8 weeks) for 47/242 (19.4%). Patients who knew that TB was curable were less likely to have long total delay (adjusted Odds Ratio [aOR] 0.28; 95%CI 0.11-0.73) and long patient delay (aOR 0.36; 95%CI 0.13-0.97). Being female (aOR 1.98; 95%CI 1.06-3.71), staying for more than 5 years at current residence (aOR 2.24 95%CI 1.18-4.27) and having been tested for HIV before (aOR 3.72; 95%CI 1.42-9.75) was associated with long health service delay. Health service delay contributed 50% of the total delay. Ninety-one percent (231) of patients had visited one or more health care providers before they were diagnosed, for an average (median) of 4 visits (range 1-30). All but four patients had systemic symptoms by the time the diagnosis of TB was made. CONCLUSIONS/SIGNIFICANCE: Diagnostic delay among tuberculosis patients in Kampala is common and long. This reflects patients waiting too long before seeking care and health services waiting until systemic symptoms are present before examining sputum smears; this results in missed opportunities for diagnosis

Low HIV testing rates among tuberculosis patients in Kampala, Uganda

<p>Abstract</p> <p>Background</p> <p>HIV testing among tuberculosis patients is critical in improving morbidity and mortality as those found to be HIV positive will be offered a continuum of care including ART if indicated. We conducted a cross-sectional study in three Kampala City primary care clinics: to assess the level of HIV test uptake among newly diagnosed pulmonary tuberculosis (PTB) patients; to assess patient and health worker factors associated with HIV test uptake; and to determine factors associated with HIV test uptake at the primary care clinics</p> <p>Methods</p> <p>Adult patients who had been diagnosed with smear-positive PTB at a primary care clinic or at the referral hospital and who were being treated at any of the three clinics were interviewed. Associations between having taken the test as the main outcome and explanatory variables were assessed by multivariate logistic regression.</p> <p>Results</p> <p>Between April and October 2007, 112 adults were included in the study. An HIV test had been offered to 74 (66%). Of the 112 patients, 61 (82%) had accepted the test; 45 (74%) had eventually been tested; and 32 (29%) had received their test results.</p> <p>Patients who were <25 yeas old, female or unemployed, or had reported no previous HIV testing, were more likely to have been tested. The strongest predictor of having been tested was if patients had been diagnosed at the referral hospital compared to the city clinic (adjusted OR 24.2; 95% CI 6.7-87.7; p < 0.001). This primarily reflected an "opt-out" (uptake 94%) versus an "opt-in" (uptake 53%) testing policy.</p> <p>Conclusions</p> <p>The overall HIV test uptake was surprisingly low at 40%. The HIV test uptake was significantly higher among TB patients who were identified at hospital, among females and in the unemployed.</p

Patients' trajectories through the health system.

<p>Legend: The figure shows the health service delay of the patients from the last step of provider before the patient is finally diagnosed with TB. Length of the arrow is equivalent to the length of the delay drawn on scale. Other arrows are not drawn to scale. They just indicate the direction of patient's movement in search of the health care. The width of the arrow represents the number of patients who go from one point to the next. The number in the circles are the total number of patients that start from that point together with those that go through that care provider. In the hospital 2 patients did not experience health service delay. Nine patients did not experience health service delay at the KCC clinics. KCC = Kampala City Council.</p

Socio-demographic, clinical and diagnostic characteristics of 403 smear-positive pulmonary tuberculosis patients registered for treatment at three Kampala City Clinics, Uganda 2007-8.

<p>Socio-demographic, clinical and diagnostic characteristics of 403 smear-positive pulmonary tuberculosis patients registered for treatment at three Kampala City Clinics, Uganda 2007-8.</p

Diagnostic trajectories of tuberculosis patients registered for treatment at three Kampala City clinics, Uganda 2007-8.

<p><b>Legend</b></p><p>Health service delay: from the last provider in the trajectory to start of tuberculosis treatment.</p><p>*For those patients finally diagnosed at the city clinics kwallis p-value = 0.088 while those finally diagnosed at hospital kwallis p-value = 1.000.</p><p>**For those patients finally diagnosed at the city clinics kwallis p-value = 0.009 while those finally hospital kwallis p-value = 0.029.</p><p>Other smaller routes are not shown. Comparisons are only made between the shown groups.</p

Long total delay and predictor variables of 253 smear-positive pulmonary tuberculosis patients registered for treatment at three Kampala City clinics, Uganda 2007-8.

<p><b>Legend</b></p><p>* =  Data available for only 239;</p><p>KCC  =  Kampala City Council;</p><p>OR =  Odds ratio;</p><p>aOR =  adjusted odds ratio;</p><p>CI =  Confidence interval;</p><p>TB =  tuberculosis.</p