Delay in the Diagnosis of Turkish Servicemen with Pulmonary Tuberculosis

Military Medicine, Mar 2005 by Okutan, Oguzhan, Kartaloglu, Zafer, Cerrahoglu, Kamil, Ilvan, Ahmet, Et al

Objective: This study was designed to assess the time between the first appearance of symptoms and the start of treatment among Turkish servicemen with tuberculosis (TB). Methods: Ninety-seven patients with pulmonary TB were enrolled in the study. We surveyed their complaints and education levels, the opportunity to visit a health care facility, and the time elapsed until diagnosis and treatment. Results: Of the study group, 62 (63.7%) reported that they had visited an infirmary as soon as their complaints appeared. The median total delay in diagnosis was 21 days for all cases. Patient delay decreased among patients with hemoptysis (2.1 vs. 6.4 days, p = 0.013) and increased with night sweats (7.3 vs. 3.1 days, p = 0.042). Total delay was not correlated with any symptom. Conclusion: We suggest that delays in diagnosis and treatment among Turkish soldiers with pulmonary TB arise from some factors related to both patients and health care facilities, and these factors should be taken into account by military health services.

Introduction

A characteristic of tuberculosis (TB) is that the disease progresses insidiously until the symptoms appear. During this period, patients usually are not aware of the disease. Meanwhile, they may spread the disease because of the reproduction characteristics of TB bacilli. Patients with pulmonary TB may infect two or three individuals in developed countries and three to five individuals in developing countries before a diagnosis is made.1 Delays in diagnosis and treatment become much more important in public places such as school dormitories, prisons, and military units. Also, delayed diagnosis of active TB is an important problem in many general hospitals in industrialized countries, because it may cause significant morbidity and death.2

Delays of more than 2 months have been shown to spread the disease to domestic contacts.3 It has been reported that age, gender, and some symptoms of TB may influence delays in diagnosis.4 In open-ended interviews, subjects attributed their typical symptoms (e.g., chronic cough and weight loss) to mild conditions not requiring the care of a physician.5 The aim of this study was to determine the delay between the first symptom and the diagnosis of pulmonary TB and the onset of treatment, as well as factors affecting this delay, in Turkish military units.

Methods

The general practitioner of a military unit provides first-step health service to the members of the Turkish Armed Forces (TAF). When a consultation with a specialist is required, the patient is referred to a local hospital. If TB is suspected at the local hospital, then the patient is referred to the Camlica Chest Disease Hospital of Gülhane Military Medical Academy, which is a specialty hospital. The treatment of patients with TB is conducted in this hospital.

Ninety-seven patients with pulmonary TB who were admitted to Gülhane Military Medical Academy Camlica Chest Diseases Hospital between June 1999 and October 1999 were enrolled in the study. This group represented all soldiers diagnosed with TB during this period in our center. All patients underwent history, physical examination, hemogram, posteroanterior and lateral chest X-rays, sputum smear for acid-fast bacilli (AFB), and Mycobacterium tuberculosis culture. None of the patients had a previous TB diagnosis. The history of pulmonary TB was surveyed with 17 questions. A questionnaire consisting of 17 questions regarding patients' complaints, education levels, and opportunity to visit a doctor and factors affecting the time interval until the diagnosis was used. The questionnaire attempted to detect factors affecting the delay in TB diagnosis.

The time that elapsed between the beginning of a patient's complaints and his or her reporting to a doctor was called the patient delay. The period of time between the first medical visit and admission of the patient to a local hospital with the possibility of pulmonary TB was considered the doctor delay. The period of time between admission of the patient and making the diagnosis with a positive sputum smear for AFB was considered the hospital delay. The sum of all of these delays was called the total delay.

The data were analyzed as mean ± SD. For statistical analyses, we used Pearson's correlation test to assess the relationship between the level of education and visiting a doctor. Analysis of variance (with post hoc Bonferroni test) was used to assess the relationship between the education levels and delays. The χ^sup 2^ test was used to investigate the relationship between symptoms and nontuberculous treatment. Student's t test was used to analyze the relationship between symptoms and delays.

Results

The median patient age was 21 years (range, 20-29 years) and the median period of military duty was 9 months (range, 1-18 months). Fifty patients (51.5%) were active smokers, whereas 47 were nonsmokers. Of the patients, 7 (7.2%) were uneducated, 42 (43.2%) were primary school graduates, 16 (16.5%) were intermediate school graduates, 28 (28.9%) were high school graduates, and 4 (4.1%) were university graduates.