Roberts David J, Mannes Trish, Verlander Neville Q, Anderson Charlotte
Field Epidemiology Training Programme, Public Health England Colindale, London, UK.
European Programme for Interventional Epidemiology Training (EPIET), European Centers for Disease Control, Stockholm, Sweden.
ERJ Open Res. 2020 Mar 16;6(1). doi: 10.1183/23120541.00161-2019. eCollection 2020 Jan.
Delays in treatment initiation for tuberculosis (TB) may lead to worse clinical outcomes and increased transmission. We aimed to determine factors associated with treatment delays, to guide public health action.
We extracted data on clinical characteristics and documented potential barriers to treatment from all pulmonary TB cases with clinical case review data from 2011 to 2015 and linked these to TB surveillance data. We described the distribution of delays from symptom onset to first presentation ("presentation delay") and from presentation to treatment ("healthcare delay"). We calculated time ratios (TRs) to determine the association between sociodemographic and clinical factors and delay outcomes.
Median presentation delay was 30 days (interquartile range (IQR) 11-72 days). Language barriers were associated with 40% longer presentation delay (TR 1.40, 1.01-1.94). Median healthcare delay was 40 days (IQR 13-89 days), and mostly consisted of the time taken before deciding to refer to TB specialists (median 26 days, IQR 4-73 days). Shorter healthcare delay was associated with positive sputum smear (TR 0.58, 0.47-0.70), UK residency <2 years (TR 0.47, 0.32-0.67), male sex (TR 0.74, 0.60-0.91) and secondary care referral (TR 0.63, 0.51-0.78).
Our findings support continued initiatives to enable access to care for migrant populations to minimise presentation delay. Multifaceted approaches to increase clinician awareness of TB clinical presentations, to implement systems enabling early case recognition, to maximise the yield from sputum smear investigations and to ensure rapid diagnosis of smear negative cases are required to achieve further TB control.
结核病（TB）治疗起始延迟可能导致更差的临床结局并增加传播。我们旨在确定与治疗延迟相关的因素，以指导公共卫生行动。
我们从2011年至2015年所有具有临床病例审查数据的肺结核病例中提取了临床特征数据，并记录了潜在的治疗障碍，并将这些与结核病监测数据相关联。我们描述了从症状出现到首次就诊（“就诊延迟”）以及从就诊到治疗（“医疗延迟”）的延迟分布情况。我们计算了时间比（TRs），以确定社会人口统计学和临床因素与延迟结局之间的关联。
就诊延迟的中位数为30天（四分位间距（IQR）为11 - 72天）。语言障碍与就诊延迟延长40%相关（TR为1.40，1.01 - 1.94）。医疗延迟的中位数为40天（IQR为13 - 89天），主要包括决定转诊至结核病专科医生之前所花费的时间（中位数为26天，IQR为4 - 73天）。较短的医疗延迟与痰涂片阳性（TR为0.58，0.47 - 0.70）、在英国居住<2年（TR为0.47，0.32 - 0.67）、男性（TR为0.74，0.60 - 0.91）以及二级医疗转诊（TR为0.63，0.51 - 0.78）相关。
我们的研究结果支持继续采取举措，使流动人口能够获得医疗服务，以尽量减少就诊延迟。需要采取多方面的方法来提高临床医生对结核病临床表现的认识，实施能够早期识别病例的系统，最大限度地提高痰涂片检查的阳性率，并确保对涂片阴性病例进行快速诊断，以实现进一步的结核病控制。
