Before the discovery of anti tuberculosis drugs, tuberculosis treatment consisted of attempts to strengthen the patients resistance to the disease .The 'sanatorium movement' was originated in England. Due to the absence of chemotherapy, patients were recommended a balanced diet, fresh air and regular exercise [1].

WHO has estimated 10.0 million cases of TB in worldwide. Most of TB cases in 2018 were in the WHO regions of South-East Asia (44%), Africa (24%), followed by the Western Pacific (18%), with smaller percentages in the Eastern Mediterranean (8%), the Americas (3%) and Europe (3%) [3].

Currently, most of the WHO regions and many high TB burden countries are not on track to reach the 2020 milestones of the end (TB) strategy 2014 [1].

Drug-resistant TB continues to be a public health threat. Globally, 3.4% of new TB cases and 18% of previously treated cases had MDR (TB) [3]. The epidemic of TB has been growing by emergence of MDR and extensively drug resistant (XDR) TB strains, especially in Central Asia [2]. Uzbekistan is one of the four Central Asian states among the 27 identified by the (WHO) with the highest burden of MDR (TB) [3].

To improve the treatment outcome of tuberculosis patients and subsequently reducing the number of deaths, there is urgent need to determine various reasons of delays in health seeking care by the patients and delay in diagnosis at level of health care providers. Findings of some studies conducted in India and abroad are mentioned.

Literature Review

Kudakwashe C et al. conducted a study in Zimbabwe, on Tuberculosis treatment delays and associated factors within the Zimbabwe national tuberculosis programme.

In this study, 383 patients were recruited. Two hundred eleven (55%) were male with an overall median age of 34 years (IQR, 28-43). There was a median of 28 days (IQR, 21-63) for patient delays and 2 days (IQR, 1-5) for health system delays with 184 (48%) and 118 (31%) TB patients experiencing health system delays more than 30 days and more than 4 days respectively. It also elucidated that starting TB treatment at rural primary healthcare versus district/mission facilities and taking self-medication with p value of <0.01 were associated with encountering patient delays [4].

A cross-sectional study was conducted in 10 public and 10 private DOTS providing health facilities from April 3, 2012, to June 7, 2012 by Henok Asefa et al. This study was conducted to study factors associated with treatment delay among pulmonary tuberculosis patients in public and private health facilities in Addis Ababa, Ethiopia. In this study, it was revealed that median durations of a patient, healthcare system, and total treatment delays were 17.9, and 35 days respectively. Overall179 (42.1%), 233 (54.8%), and 262 (61.6%) of patients experienced patient delay, healthcare system delay, and total treatment delay, respectively. Distance more than2.5 km from TB treatment health facility, and the presence of TB-associated stigma associated with patient delay, whereas, being unemployed, patients with the hemoptysis symptom indicated lowerodds of health system delay [5].

        Usman Ali et al. conducted a study at a hospital in Rawalpindi in Pakistan, on delay in diagnosis of Pulmonary Tuberculosis and to study the factors related to patients and health care system. In this study, out of total 199 subjects, 41.1% were males and 58.9% were females. Patients delay and healthcare delay was assessed. Mean total delay was 114.48 days whereas median total delay was 53.5 days. Mean patient delay was 33.25 days and mean health care delay was 81.23 days. On multivariate analysis, unemployment was related to significant patients delay in diagnosis whereas less no. of encounters with healthcare facility, smear negative TB and patientsself realization about delayed diagnosis was related to healthcare delay [6].       

 A Cross-sectional study from South India which was conducted by Arun N. Bhatt et al. in Tamil Nadu regarding delays in tuberculosis control. The results of this study revealed that median interval was 15 days (IQR 7 to 30 days) for healthcare seeking and 4 days (IQR 3 to 8 days) for treatment initiation. Prevalence of delay was 51.3% for healthcare seeking and 26.9% for treatment initiation. Lower educational status with p-value <0.015 and rural residence (adjusted OR- 3.748, p-value 0.013) were significantly associated with delay in healthcare seeking. Extra-pulmonary tuberculosis (adjusted OR- 5.620, p-value: 0.013) was significantly associated with delay in treatment initiation [7].

A similar study was conducted by Purty et al. regarding patient and health system delay among new pulmonary tuberculosis patients diagnosed at medical college hospitals in Puducherry, India. In this study, a total of 138 new sputum smear positive TB patients were included. The mean age of participants was 41.8 years ± 17.3 years (range 15-87 years). Majority (67.4%) of the patients were male. The median patient delay, health system delay and total delay was 36 days, 28.5 days and 81 days respectively. The place of residence (OR = 0.39, 95% CI = 0.18-0.87) and family size (OR = 0.45, 95% CI = 0.21-0.97) were found as the determinants of various delays for TB patients [8].

In a study done in Darjeeling district of West Bengal in 2017 by Nirmalya Roy, et al. to estimate the prevalence and to know determinants of delay in diagnosis of pulmonary tuberculosis. They found that health system delay, patient delay and total diagnostic delay were 27 days, 20.1 days, and 20.6 days respectively. The mean of delays were 23.64, 5.71, and 29.46 days, and median delays were 25, 5, and 32 days respectively. The risk factors associated with patient delay were female gender, rural residence, illiteracy, smoking, alcohol consumption, taking two or more alternate treatments. The Risk factors associated with health system delays were female sex, rural residence, time to reach health facility, time spent per visit; and for total diagnostic delay were female sex, alcoholism, and seeking more than two alternate treatments [9].

An institutional, r­etrospective, observational study was carried out from January to June 2017 by Jayasri H.Gali et al. in the Department of Pulmonary Medicine of a Medical College Hospital,Hyderabad. This study was done to study that delay in diagnosis is a hurdle in the eradication of tuberculosis. In this study 263 patients were included, 34 (20.86%) were diagnosed at the first visit. The delay in seeking medical care was ranged from 0 to 25 days. A total of 110 (67%) patients were initiated treatment for TB on the same day or the day after diagnosis, less than 1 month in 33 (20.25%) and 1–3 months in 83 (51%). In this study it was revealed that delay from patient and health services (both combined) ranged from half a month to 48 months. The delay in diagnosis was in range of 0–24 days, whereas treatment delay (n = 162) was 2.19±3.89S.D days. Gender was a statistically significant risk factor in patients delay in receiving the treatment/medical. The delay for diagnosis of pulmonary and extra pulmonary TB was 48±24 and 240 ±386 days, respectively [10].

A study on delay in diagnosis and treatment among TB patients registered under RNTCP Mandi, Himachal Pradesh was conducted by Rajesh Thakur et al. The results of this study showed that median patient, health system and total delays were 15, 13 and 36 days respectively. In this it was revealed that significant factors associated with total delay included patients’ knowledge about TB, seeking care from non-specialized individuals as the first action, consulting more than 2 health facilities before diagnosis and consulting private health facilities. Patients with low family income and those who had high expenditure on consultations before initial diagnosis were associated with patient and health system delay respectively [11].

A systematic review was done by Yang et al. by using 12 electronic databases on barriers and delays in tuberculosis diagnosis and treatment services. In this research, out of 13,448 articles, 137 were included in this review. The assessed articles includes individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial 64% versus 36%, physical 100% versus 0%, social stigma 85% versus 15%, literacy 67% versus 33%, provider/system-level 100% versus 0% and longer delays (presentation to diagnosis 45% versus 0%) than men [12].