INT J TUBERC LUNG DIS 9(9):992–998

© 2005 The Union

Patient and health care system delays in pulmonary tuberculosis

diagnosis in a low-incidence state

J. E. Golub,*†‡ S. Bur,† W. A. Cronin,† S. Gange,‡ N. Baruch,† G. W. Comstock,‡ R. E. Chaisson*‡

* School of Medicine, Johns Hopkins University, Baltimore, † Maryland Department of Health and Mental Hygiene,
Baltimore, ‡ Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA

SUMMARY

S E T T I N G : Tuberculosis (TB) patients reported to the
Maryland Department of Health and Mental Hygiene
from 1 June 2000 to 30 November 2001.
O B J E C T I V E : To determine the extent of delayed diagno-
sis of TB and to assess patient and provider factors as-
sociated with delays.
D E S I G N : A prospective cohort study.
R E S U L T S : Median patient, health care and total delays
were 32, 26 and 89 days, respectively, for 158 patients.
Non-white (relative hazard [RH] 0.62; 95%CI 0.39–
0.98) and less educated (RH 0.43; 95%CI 0.26–0.72)
patients had longer patient delays. English-speaking
patients (RH 0.40; 95%CI 0.24–0.68) had increased
health care delays, as did patients who received a diag-
nosis of a respiratory illness and non-TB antibiotics (RH
0.69; 95%CI 0.49–0.96) prior to a TB diagnosis. Pa-
tients first presenting to a private physician (51 days)
rather than a hospital emergency room (18 days; RH
1.87; 95%CI 1.05–3.33) or public health clinic (10 days;
RH 1.79; 95%CI 1.21–2.63) had longer health care
delays. When a TB diagnostic tool (chest radiograph or
AFB culture) was utilized, a more rapid diagnosis of
TB was made.
C O N C L U S I O N : Education of the patient population
about TB symptoms might reduce delays. Increased phy-
sician awareness of the current epidemiology of TB and
better use of available diagnostic tools will reduce delays
and may reduce TB transmission.
K E Y W O R D S : tuberculosis; epidemiology; delayed diag-
nosis

PROMPT DIAGNOSIS of tuberculosis (TB) is para-
mount in controlling and reducing the transmission
of Mycobacterium tuberculosis.1 After a resurgence
of TB between 1984 and 1992, TB rates in the United
States have decreased dramatically to a low of just 5.2
patients per 100 000 population in 2002.2 As TB
declines as a major health threat, awareness of the
disease by both physicians and the general public
may fall, leading to prolonged delays in diagnosis and
treatment.
A number of factors have been found to be associ-
ated with delays in diagnosis in hospitals3–7 or over-
seas settings,8–18 but little research has been done at
the community level in the US.19 Population-based as-
sessment of delays in TB diagnosis may provide in-
sight into the impact of this phenomenon at a popu-
lation level. Outbreaks of TB in Maryland20,21 and
other sites in the US6,22,23 suggest that reducing delays
in diagnosis should be an important factor in reduc-
ing TB transmission. The current diagnostic algo-
rithm for TB in the US briefly states that a patient
with a productive cough .3 weeks should be investi-
gated through chest radiography and bacteriological
examination.24 The current study was done to deter-
mine the extent of delayed diagnosis of TB in the US,
and to assess patient and provider factors associated
with longer delays.
METHODS
We conducted a prospective cohort study of TB pa-
tients in Maryland. Patients who were reported to the
Maryland Department of Health and Mental Hy-
giene (DHMH) with a verified diagnosis of pulmo-
nary TB (PTB)24 and a positive culture for M. tuber-
culosis between 1 June 2000 and 30 November 2001
were included. Materials for cultures were obtained
from sputum and induced sputum.
A questionnaire ascertained the date of onset for
cough, chest pain, fatigue, fever, night sweats, chills,
anorexia, weight loss and other symptoms. Interview-
ers recorded the month and year of symptom onset
and the duration of each symptom (days, weeks,
months). If a participant did not have accurate recall
of symptom onset, dates of significant events (e.g.,
holidays, birthdays) were offered in an attempt to

Correspondence to: Dr Jonathan Golub, School of Medicine, Johns Hopkins University, 1820 Lancaster St, Suite 300, Bal-
timore, MD 21231, USA. Tel: (11) 443-287-2969. Fax: (11) 443-287-7955. e-mail: jgolub@jhmi.edu
Article submitted 27 October 2004. Final version accepted 17 February 2005.

improve recall. Patients were asked which factors de-
layed their decision to seek care for their symptoms.
The principal investigator (JEG) conducted 80% of
the interviews and trained nurses performed the re-
mainder. When necessary, translated forms in Span-
ish, French and Amharic were used by bilingual
interviewers.
Medical records were reviewed and information
related to an eventual TB diagnosis was recorded (e.g.,
symptoms, diagnostic data, laboratory tests, radiog-
raphy). Chest radiography (CXR) data were derived
from radiography reports, and not from the original
radiographs. These data were compared to inter-
views to create a conservative timeline of events lead-
ing to a TB diagnosis. When symptom duration differed
between a hospital record and an interview response,
the date yielding the shorter symptom duration was
used. All records were reviewed by the principal
investigator.
The study was approved by the institutional re-
view boards of the Maryland DHMH, Johns Hopkins
Medical Institutions and the Baltimore City Health
Department, and all patients provided written informed
consent.
Study outcomes
‘Patient delay’ was defined as the number of days
from first TB symptoms to first health care visit for
those symptoms. ‘Health care delay’ was defined as
the number of days from the first consultation with a
medical provider to the initiation of treatment for TB.
‘Total delay’ was defined as the number of days from
first TB symptoms to initiation of treatment for TB
(and equal to the sum of patient delay and diagnostic
delay). Although date of diagnosis was not always the
same as the date that TB treatment was initiated, we
used treatment initiation as our endpoint.
Statistical methods
All analyses were conducted using the Stata® statisti-
cal package, Version 7 (Stata Corp, College Station,
TX, 2001). Median delays associated with all covari-
ates were calculated. The Kruskal-Wallis test was
used to compare between-group distribution of de-
lays. The covariates were divided into three subgroups:
demographics/risk factors (e.g., age, race/ethnicity,
substance abuse, country of origin), clinical factors
(e.g., symptoms) and diagnostic factors (e.g., site of
first visit, diagnostic tests).
Cox proportional hazards models for each sub-
group were constructed separately for each type of
delay outcome (patient, diagnosis, and total) using
variables found to be important in univariate analysis
(P < 0.10). Cox regression results are presented as a
relative hazard (RH) corresponding to the instanta-
neous risk associated with being diagnosed at a given
time. Thus, an RH .1 indicates a faster diagnosis
compared to the referent for each comparison group,
Delayed diagnosis of tuberculosis 993
while an RH ,1 indicates a longer diagnosis delay.
Data were truncated at 265 days for patient delay and
210 days for health care delay to account for outlying
patients with significantly greater delays.
RESULTS
Study participants and characteristics
From 1 June 2000 to 30 November 2001, 256 pa-
tients with PTB and a positive M. tuberculosis culture
were reported in Maryland. Thirty-two patients were
excluded prior to interview for the following reasons:
age ,5 years (8), transferred from out of state (4), ref-
ugees diagnosed before entering the US (6), diagnosed
in prison (3), previous TB (5), identified through contact
investigations (3), detected through school screening
(1), contradictory answers during interview (1), and
one because diagnosis occurred directly after recov-
ery from a coma. Of the remaining 224 PTB patients,
158 (71%) were interviewed. Of the 66 who were not
interviewed, 42 were lost to follow-up, 8 were too ill
to be interviewed and had no family members to serve
as proxies, 10 were reported at death, 4 left the coun-
try before being interviewed and 2 had language bar-
riers. Our intention was to interview the families of
patients reported at death; however, no family mem-
bers offered consent. Those who were not inter-
viewed were older (median 56 years vs. 39 years, P ,
0.01) and less likely to be sputum smear-positive
for acid-fast bacilli (AFB) (53% vs. 67%; P 5
0.03). There were no statistically significant differ-
ences by sex, race/ethnicity, country of origin or lan-
guage between those interviewed and those who
were not.
The median interval from the start of TB medica-
tions to interview was 15 days; 65% were interviewed
within 21 days. Interviewed patients were dispersed
geographically throughout Maryland proportionate to
local TB case rates. Demographic and clinical charac-
teristics for all patients are summarized in Tables 1
and 2, stratified by type of delay. At least one respira-
tory symptom (cough, shortness of breath and/or chest
pain) was reported by 146 (92%) patients. Twenty-
five patients (15%) reported 1–3 symptoms, 51 (32%)
4–6 symptoms and 77 (48%) more than 7 symptoms.
Five patients reported no TB symptoms at their first
health care visit; all five were diagnosed after an ab-
normal CXR taken for another reason.
Patient delay
Median patient delays are presented in Tables 1–3.
The median patient delay for all patients reporting
symptoms (n 5 153) was 32 days (range 0–539 days).
Among those reporting respiratory symptoms only,
the median delay was still 32 days. Eight per cent of
patients sought care for their symptoms within 7 days
of onset, 45% within 30 days, and 24% waited more
than 90 days before seeking medical care (Figure, A).
994 The International Journal of Tuberculosis and Lung Disease

Table 1 Median patient and health care delays (days): Table 3 Median patient delays (days): barriers to care
demographic factors
Patient delay
Patient delay Health care delay
Barrier to care n* (%) Median
Covariate n (%) Median n (%) Median
Knows where to go for symptoms
All cases 153* 32 158 26 Yes 107 (79) 30
Sex No 28 (21) 86†
Male 91 (59) 32 95 (60) 29 Knowledge of TB symptoms
Female 62 (41) 33 63 (40) 21 Yes 108 (84) 31
Age, years No 21 (16) 37
,50 110 (72) 33 112 (71) 21 Treatment prior to health care visit
>50 43 (28) 32 46 (29) 40† Self-treated 48 (36) 31
Race Did not self-treat 84 (64) 34
White (reference) 20 (13) 16 22 (14) 39 Language
Black 80 (52) 38† 81 (51) 27 English-speaking 118 (77) 30
Asian 29 (19) 32† 31 (20) 28 Non-English-speaking 35 (23) 52‡
Hispanic 24 (16) 50† 24 (15) 8‡ Fear of immigration authorities (among
Place of birth foreign-born)
Foreign-born 86 (56) 34 88 (56) 21 Yes 10 (14) 57
US-born 67 (44) 31 70 (44) 36 No 62 (86) 41
Language Housing
English-speaking 118 (77) 30 122 (77) 34‡ Homeless 7 (5) 63
Non-English-speaking 35 (23) 52† 36 (23) 13 Not homeless 146 (95) 32
Marital status§ Insurance
Single 68 (44) 32 70 (44) 20 Insured 86 (61) 33
Married 67 (44) 30 69 (44) 29 Non-insured 54 (39) 31
Substance use¶ Cost for health care services is
Substance use 47 (31) 31 50 (32) 28 A concern 54 (41) 39
No substance use 106 (69) 38 108 (68) 25 Not a concern 77 (59) 30
Education, years
* Five patients did not report any symptoms.
† P , 0.05. ,12 75 (77) 50†
‡ P , 0.01. >12 22 (23) 19
§ Data unknown for 19 patients.
¶ Included alcohol and injecting drug use. * Some categories do not add up to 153 due to unknown data.
† P , 0.01.
‡ P , 0.05.

TB 5 tuberculosis.

Table 2 Median patient and health care delays (days):

clinical factors

Patient delay Health care delay Among patients who reported that they waited too
long to seek care, the most common reasons were not
Covariate n (%) Median n (%) Median
having insurance (29%) and not thinking their symp-
All cases 153* 32 158 26 toms were serious (35%). Potential barriers to care
HIV-infected leading to increased patient delays are presented in
Yes 21 (14) 60 21 (13) 26
No 114 (75) 32 116 (73) 25 Table 3.
Unknown 18 (12) 18 21 (13) 29 In multivariate analysis, non-white patients (RH
Other chronic illness 0.62; 95% confidence interval [CI] 0.39–0.98), pa-
Yes 57 (38) 30 60 (48) 41 tients with less than 12 years of education (RH 0.43;
No 96 (63) 39 98 (62) 21
95%CI 0.26–0.72), patients with no respiratory symp-
Asthma
Yes 15 (10) 19 15 (10) 71† toms (RH 0.29; 95%CI 0.11–0.71) and patients with
No 138 (90) 36 137 (90) 24 no asthma (RH 0.51; 95%CI 0.30–0.89) had longer
Respiratory symptoms patient delays. The following variables were included
Yes 146 (95) 32 146 (92) 23 in the model, but were not found to be associated with
No 7 (5) 121† 12 (8) 46
increased delays: English speaking, human immuno-
Cough
Yes 134 (88) 32 134 (85) 21 deficiency virus (HIV) infection, and other illness.
No 19 (12) 60† 24 (15) 60†
Symptoms Health care delay
1–14 days NA NA 33 (21) 46 Median health care delays are presented in Tables 1, 2
15–29 days NA NA 36 (23) 28
30–59 days NA NA 29 (18) 22† and 4. The median health care delay was 26 days
>60 days NA NA 55 (35) 17‡ (range 0–519 days). Of the 158 TB patients, 38
No symptoms NA NA 5 (3) 71 (24%) were diagnosed within 1 week of their first
* Five patients did not report any symptoms. visit to a health care facility, 86 (54%) within 30
† P , 0.05.
‡ P , 0.01.
days, and 42 (27%) remained undiagnosed 60 days
HIV 5 human immunodeficiency virus; NA 5not applicable. after the initial health care visit (Figure, B). Among
 Delayed diagnosis of tuberculosis 995

Table 4 Median health care system delays: diagnostic factors

Health care delay

Covariate n (%) Median
All cases 158 26
First health care visit to a
Private physician 73 (46) 51*
Hospital 69 (44) 18
Public health clinic 16 (10) 10
Insurance
Insured 86 (54) 41
Not insured 54 (34) 18
Unknown 18 (11) 9
TST at first visit
Yes 70 (44) 20
No 88 (56) 31
AFB culture at first visit
Yes 67 (42) 6
No 91 (58) 56*
CXR at first visit
Yes 105 (66) 15
No† 52 (34) 69*
TB ‘test’ at first visit‡
Yes 109 (69) 15
No 49 (31) 67*
On first CXR
TB mentioned§ 50 (48) 8
No TB mentioned 55 (52) 20¶
CXR with cavitation at first visit§
Figure Kaplan-Meier curve for patient delay. A. Proportion Yes 36 (34) 6
not yet seeking care. B. Proportion undiagnosed. No 69 (66) 17*
Infiltrate on CXR§
With infiltrate and no cavity 73 (72) 22
With no infiltrate and no cavity 29 (28) 38
patients with sputum smear positive for AFB, 25% Sputum smear for AFB
Positive 91 (58) 18
remained undiagnosed after 30 days. Forty patients Negative 67 (42) 37¶
(25%) were diagnosed after one health care visit, 61 Respiratory illness
(39%) after two visits, and 57 (36%) after three or Yes 85 (54) 39¶
more visits. The median number of visits before treat- No 73 (46) 16
ment initiation was 2.6. Health care delays were Antibiotics prescribed
Yes 85 (54) 39¶
longer in rural counties, but this was not significant. No 73 (46) 15
An inverse relationship was seen between duration
of cough and health care delay. Among those patients * P , 0.05.
† First CXR unknown for one patient.
who had been coughing .2 weeks, median health ‡ TB ‘test’ is at least one of TST, AFB culture or CXR.
§ Of 105 patients with CXR at first visit.
care delay was 18 days compared to 48 days for those ¶ P , 0.01.
with <2 weeks of cough (P , 0.01). TST 5 tuberculin skin test; AFB 5 acid-fast bacilli; CXR chest X-ray; TB 5
In multivariate models examining the demographic tuberculosis.

group of characteristics, longer health care delays were

marginally associated with age .50 years (RH 0.67;
95%CI 0.44–1.03) and strongly associated with
speaking English (RH 0.40; 95%CI 0.24–0.68). Sex,
race, country of origin, substance use, drug use and
alcohol use did not influence health care delay.
Among the clinical factors, multivariate models
found that patients presenting with cough (RH 2.05;
95%CI 1.20–2.50) and those with increasing patient
delays (RH 1.28; 95%CI 1.09–1.49) had shorter health
care delays. Patients with a history of asthma (RH
0.51; 95%CI 0.27–0.97) had longer health care delays,
but HIV infection status was not associated with health
care delay.
Among the diagnostic factors, multivariate analy-
sis revealed that patients who initially sought care at
a hospital emergency department (18 days; RH 1.87;
95%CI 1.05–3.33) or a public health clinic (10 days;
RH 1.79; 95%CI 1.21–2.63) were diagnosed consid-
erably faster than those who went first to a private
physician (51 days). Positive AFB sputum smear re-
sults were found to be associated with a shorter health
care delay (RH 1.69; 95%CI 1.15–2.48). Patients who
had a tuberculin skin test (RH 1.62; 95%CI 1.16–
2.24), a sputum specimen (RH 5.42; 95%CI 3.37–
8.71) or a CXR (RH 2.13; 95%CI 1.36–3.34) at the
first visit had considerably reduced health care delay.
When the CXR report at the initial visit mentioned
TB in the differential diagnosis, health care delay was
shorter (8 days) than when TB was not mentioned (20
days) (RH 1.60; 95%CI 1.07–2.39). Patients whose
996 The International Journal of Tuberculosis and Lung Disease
initial CXR showed cavitation (6 days) had shorter
health care delays than those without cavitation (17
days), but this association was not significant in
multivariate models (RH 1.37; 95%CI 0.88–2.11).
Patients who received antibiotics for an initial diag-
nosis other than TB had longer health care delays (39
vs. 15 days; RH 0.69; 95%CI 0.49–0.96). Finally,
patients with insurance had longer health care delays
(RH 0.70; 95%CI 0.48–1.03).
DISCUSSION
This prospective study of 158 PTB patients in Mary-
land found that the median total delay from onset of
symptoms to TB treatment was 3 months. Median
patient delay was 32 days and median health care
delay was 26 days. The major predictors of patient
delay in this study were non-white race and educa-
tion ,12 years. Factors associated with health care
delays were age .50 years,8 speaking English, and
initially presenting to a private physician.3,6,25 Other
factors leading to longer health care delays were
not receiving a CXR, not providing a sputum spec-
imen or not receiving a tuberculin skin test6,19,26 at
the initial health care visit and being diagnosed
with another respiratory illness or receiving non-
TB antibiotic therapy.27
Cough was the most common symptom, present
among 85% of all patients, and was strongly associ-
ated with shorter health care delays.19,28 Moreover, the
longer the cough had been present the more quickly
the patient was diagnosed after seeking care. No symp-
tom or combination of symptoms other than cough was
identified as a predictor of a faster diagnosis.
TB among foreign-born persons in the US and
Maryland continues to represent an increasing pro-
portion of all patients (Maryland DHMH, unpub-
lished data, 2002).29 Non-English-speaking patients
were found to have increased patient delay in New
York City (NYC)19 and Los Angeles.30 In our study,
more non-English-speaking patients delayed seeking
care compared to those who spoke English, but this
finding was not statistically significant in the final
models. However, several non-English-speaking im-
migrants who had considerably longer patient delays
cited fear of being reported to immigration authori-
ties as their main reason for avoiding seeking care.30
Foreign-born patients in Maryland need to be made
aware that accessing health services for TB at public
health clinics will not put them at risk of deportation
and that these services are free. Moreover, education
of at-risk populations regarding the symptoms of TB
and the importance of seeking care for their illness
will likely lead to reduced patient delays. However, it
is important to note that care of conditions other than
TB may not be assured because a lot of patients lack
insurance. Many individuals have pulmonary symp-
toms consistent with TB but in fact have other condi-
tions, and lack of access to diagnostic and clinical ser-
vices remains a critical challenge in the US, where
health care is not guaranteed by the state.
Non-English-speaking patients were diagnosed con-
siderably more quickly than English-speaking pa-
tients once they did get health care. These patients
were also more likely to receive a CXR at their first
health care visit and to provide a sputum specimen.
However, a patient’s country of origin did not make a
difference in delay once we controlled for other fac-
tors in the final model. Thus, while suspicions among
Maryland physicians appear heightened when a pa-
tient does not speak English, this does not apply to
foreign-born persons who are able to converse in En-
glish. The highest rates of TB in Maryland in 2001 were
among the foreign-born (35/100 000 vs. 2/100 000 for
US born), and clinicians need to maintain a high index
of suspicion for TB in foreign-born persons regardless
of their language skills (Maryland DHMH, unpub-
lished data, 2002).
The study population included all PTB patients di-
agnosed during a defined time period in a defined geo-
graphic area. Other than a study conducted in 1994
among 184 patients in NYC,19 most previous studies
in the US have been hospital-based.31–33 The preva-
lence and epidemiology of TB in NYC is quite differ-
ent from that of Maryland, and NYC physicians are
likely to have more experience diagnosing TB. This
latter point may explain the slightly longer health care
delays found in Maryland (26 days) compared to
NYC (15 days).
The community-based sample allowed us to com-
pare delays for patients initially seeking care at hospi-
tal emergency rooms and public health clinics and
from primary care physicians. This distinction was
extremely important, as we found that the greatest
delays were occurring among patients who first con-
tacted private primary care physicians. Patients first
contacting the emergency department or public clin-
ics were more likely to undergo CXR and sputum ex-
amination at that visit, suggesting either that physi-
cians at the emergency departments and clinics had a
higher suspicion for TB or that there was better access
to these diagnostic tools. The underutilization of these
diagnostic procedures may lead to longer delays, espe-
cially among non emergency department physicians.6
Conversely, patients who first present to emergency
rooms may be more symptomatic and may possess
more classic risk factors for TB (e.g., foreign-born,
HIV) and therefore receive a more directed diagnostic
work-up.
Finally, we had intended to include patients who
died as a result of TB. However, families of deceased
TB patients were not willing to participate. These pa-
tients often represent the most prolonged delays.28,34,35
Exclusion of these patients most likely reduced the de-
lays reported here.

CONCLUSIONS
Identifying potentially infectious patients as early as
possible in their illness has long been accepted as an
epidemiologically sound method of limiting TB trans-
mission.36,37 Despite this, 45% of all TB patients in
Maryland remained undiagnosed 30 days after first
contacting a physician, including 25% of patients
with positive sputum smears for AFB. Sixteen per
cent remained undiagnosed 90 days after their first
health care visit. These 158 patients visited a health
care provider an average of 2.6 times before being di-
agnosed with TB, and of 398 health care visits made
by symptomatic patients in this cohort, only 40% re-
sulted in a TB diagnosis. Thus, there is considerable
room for diagnostic improvement.
Maryland can be described as a microcosm of the
US with regard to its demographic composition. We
therefore believe that this study may be generalizable
to other areas with a declining TB burden. TB inci-
dent rates in Maryland have been declining since
1991, and only 306 cases were reported in 2002
(DHMH, unpublished data) resulting in considerable
reduction in clinical experience with TB. Informing
physicians of the current epidemiology and clinical
presentation of TB in the US and locally, and empha-
sizing the importance of the relatively inexpensive
tools available to help diagnose TB more quickly, may
lead to enhanced knowledge of the disease as well as
reduce diagnostic delays.
Acknowledgements
We would like to thank all of the patients who gave their time for
interviews and permission for medical record reviews. We would
also like to thank the staff at the Maryland DHMH and all the
local health departments for their time with this project.
The project was supported by the Centers for Disease Control
Tuberculosis Elimination and Laboratory Cooperative Agreement
Number U52/CCU300500 and NIH Grant AI01637.
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outbreak in a rural Missouri high school. Pediatrics 2004; 113:
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24 American Thoracic Society. Diagnostic standards/classification
of TB in adults and children. Am J Respir Crit Care Med 2000;
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28 Bobrowitz I D. Active tuberculosis undiagnosed until autopsy.
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29 Centers for Disease Control and Prevention. Reported tuber-
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ment of Health and Human Services, CDC, September 2004.
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CONTEXTE : Les patients tuberculeux déclarés au Dépar-
tement de la Santé et de l’Hygiène Mentale du Maryland
entre le 1er juin 2000 et le 30 novembre 2001.
O B J E C T I F : Déterminer l’étendue du délai de diagnostic
de la tuberculose (TB) et évaluer les facteurs associés à
ces délais chez les patients et les pourvoyeurs de soins.
S C H É M A : Etude prospective de cohorte.
R É S U L T A T S : Les délais médians du patient, du système
de santé ainsi que les délais totaux ont été respective-
ment de 32, 26 et 89 jours chez 158 patients. Les délais-
patient prolongés se rencontrent chez les patients non-
blancs (risque relatif [RH] 0,62; IC95% 0,39–0,98) et
chez les patients à degré d’éducation moindre (RH 0,43 ;
IC95% 0,26–0,72). Les patients de langue anglaise ont
un délai du service de santé accru (RH 0,40 ; IC95%
0,24–0,68), tout comme les patients chez qui le diagnos-
tic de maladie respiratoire a été porté et des antibi-
MARCO DE REFERENCIA : Los pacientes con tuberculo-
sis (TB) notificados al Departamento de Salud e Higiene
Mental del estado de Maryland entre el 1ro de junio de
2000 y el 30 de noviembre de 2001.
O B J E T I V O : Determinar la proporción de diagnósticos
tardíos de TB y evaluar los factores asociados que de-
penden del paciente y del proveedor de atención de salud.
M É T O D O : Estudio prospectivo de cohortes.
R E S U L T A D O S : Para 158 pacientes, la mediana del re-
traso dependiente del paciente fue 32,26 días y depen-
diente del proveedor 89 días. Los mayores retrasos se ob-
servaron en pacientes de etnias diferentes a la blanca
(riesgo instantáneo proporcional [RH] 0,62 ; IC95%
0,39–0,98) y en pacientes con menor nivel de educación
(RH 0,43 ; IC95% 0,26–0,72). Los pacientes anglopar-
lantes sufrieron un retraso institucional más prolongado
(RH 0,40 ; IC95% 0,24–0,68), al igual que los pacientes
en quienes se diagnosticó la TB después de un diagnós-
tico de enfermedad respiratoria y un tratamiento con
culosis isolation and suspicion among persons hospitalized
with HIV-related pneumonia. Chest 1999; 117: 110–116.
34 Edlin G P. Active tuberculosis unrecognised until necropsy.
Lancet 1978; 1 (8065): 650–652.
35 Kramer F, Modilevsky T, Waliany A R, Leedom J M, Barnes
P F. Delayed diagnosis of tuberculosis in patients with human
immunodeficiency virus infection. Am J Med 1990; 89: 451–
456.
36 Dubos R, Dubos J. The white plague: tuberculosis, man and
society. 3rd ed. New Brunswick, NJ: Rutgers University Press,
1987.
37 Frost W H. How much control of tuberculosis? Am J Publ
Health 1937; 27: 759–766.
RÉSUMÉ
otiques non-tuberculeux ont été administrés avant le di-
agnostic de TB (RH 0,69 ; IC95% 0,49–0,96). Les délais
du système de santé sont plus longs chez les patients se
présentant d’abord chez un médecin privé (51 jours), par
rapport à une salle d’urgence hospitalière (18 jours ; RH
1,87 ; IC95% 1,05–3,33) ou une polyclinique de santé
publique (10 jours ; RH 1,79 ; IC95% 1,21–2,63). Lor-
sque l’on a utilisé un outil de diagnostic de la TB (cliché
thoracique ou culture des bacilles acido-résistants), le di-
agnostic de TB a été porté plus rapidement.
C O N C L U S I O N S : L’éducation de la population de pa-
tients concernant les symptômes de la TB pourrait ré-
duire les délais. Une meilleure prise de conscience des
médecins au sujet de l’épidémiologie actuelle de la TB
ainsi qu’une utilisation meilleure des outils de diagnostic
disponibles réduiront les délais et pourraient diminuer la
transmission de la TB.
RESUMEN
antibióticos diferentes a los antituberculosos (RH 0,69 ;
IC95% 0,49–0,96). Los pacientes que acudieron inicial-
mente a un médico particular tuvieron un mayor retraso
dependiente del médico (51 días), comparados con
quienes acudieron a un servicio hospitalario de urgencias
(18 días ; RH 1,87 ; IC95% 1,05–3,33) o a un dispensa-
rio público (10 días ; RH 1,79 ; IC95% 1,21–2,63).
Cuando se utilizó una herramienta para el diagnóstico
de la TB (radiografía de tórax o cultivo para bacilos
ácido-alcohol resistentes) el diagnóstico de TB fue más
rápido.
C O N C L U S I Ó N : La educación de la población de pa-
cientes acerca de los síntomas de la TB podría reducir
los retrasos en el diagnóstico. Una toma de conciencia de
la epidemiología actual de la TB por parte del cuerpo
médico y un mejor uso de las herramientas diagnósticas
disponibles acortará el retraso del diagnóstico y podría
reducir la transmisión de la TB.