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Vol. 57. Issue 6.
Pages 440-442 (June 2021)
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Vol. 57. Issue 6.
Pages 440-442 (June 2021)
Scientific Letter
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Study of the Diagnostic Delay of Tuberculosis in Spain
Estudio del retraso diagnóstico de la tuberculosis en España
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Asunción Seminarioa,b, Luis Anibarroc,b, Josefina Sabriád,b, Marta María García-Clementee,b, Adrián Sánchez-Montalvánf,b, Juan Francisco Medinag,b, Isabel Mirh,b, Antón Penasi,b, José Antonio Camineroj,b,s, Guillermo José Pérezj,b, Nieves Altetk,b, Ángel Domínguezl,b, María Ángeles Jiménez-Fuentesf,b, Sarái Quirósm,l, Eva María Taberneron,b, María Luiza De Souza-Galvãof,b, Antonia Sáezo, Joan Artur Caylàb,p, José María García-Garcíab,q, Teresa Rodrigob,p,r,
Corresponding author
pii_tb_teresa_rodrigo@separ.es

Corresponding author.
, Working Group of the Integrated Tuberculosis Research Program (PII-TB) of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)
a Hospital Universitari Joan XXIII, Institut Català de la Salut (ICS), Tarragona, Spain
b Fundación Respira, Programa Integrado de Investigación en Tuberculosis (PII-TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
c Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
d Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain
e Hospital Universitario Central de Asturias, Oviedo, Spain
f Hospital Universitario Vall d’Hebrón, Institut Català de la Salut (ICS), Barcelona, Spain
g Hospital Universitario Virgen del Rocío, Sevilla, Spain
h Hospital Son Llàtzer, Palma de Mallorca, Spain
i Hospital Universitario Lucus Augusti, Lugo, Spain
j Hospital General Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
k Unidad de Prevención y Control de la Tuberculosis, Barcelona, Spain
l Hospital Virgen Macarena, Sevilla, Spain
m Complejo Hospitalario La Paz-Cantoblanco-Carlos III, Madrid, Spain
n Hospital de Cruces, Barakaldo, Vizcaya, Spain
o Estadística, Axioma Comunicaciones, Sevilla, Spain
p Fundación Unidad de Investigación en Tuberculosis (fuiTB), Barcelona, Spain
q Hospital San Agustín de Avilés, Asturias, Spain
r Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
s International Union Against Tuberculosis and Lung Disease (UICTER), París, France
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Table 1. Factors associated with diagnostic delay in all study cases. Univariate and multivariate analysis of the study variables.
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To the Editor,

Tuberculosis (TB) control is based on early case detection, initiation and completion of treatment, effective contact tracing, and the appropriate diagnosis and treatment of tuberculous infection in people at risk of developing disease.1 The longer a patient with pulmonary TB remains undiagnosed or untreated, the greater the chances of disease transmission and epidemic outbreaks.2,3

The main objectives of this study were to analyze the diagnostic delay of TB in Spain, to determine the associated factors, and to determine to what extent delays are attributable to the patient and to the health system.An observational, prospective, multicenter study was conducted in Spain in patients diagnosed with TB during the period 2015–2017 and listed in the registry of the Integrated Tuberculosis Research Program (PII-TB) of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). “Delay attributable to the patient” (DP) was defined as the time from the onset of symptoms to the request for health care by the patient; “delay attributable to the health system” (DS) was the time from the request for assistance to the start of treatment; and “overall diagnostic delay” (OD) was calculated as DP plus DS.4 The median diagnostic delay was calculated for each group. Variables associated in the univariate analysis with p<0.15 were included in a multivariate model, and adjusted odds ratios (OR) and their 95% confidence intervals (CI) were calculated, p<0.05 being considered significant.

Overall, 657 cases were analyzed (52% bacilliferous). Median OD for all cases was 62 days and 61 days for bacilliferous cases. DP was 29 days and DS was 11 days. The OD was attributed to the patient in 82.6% cases and to the system in 17.4%. Factors associated with diagnostic delay, defined as greater than the median delay relative to the study variables, are described in Table 1.

Table 1.

Factors associated with diagnostic delay in all study cases. Univariate and multivariate analysis of the study variables.

Variables  Total delayUnivariate analysisMultivariate analysis
  ≤62 days  >62 days  OR (95% CI)  p value  OR (95% CI)  p value 
  n=338 (51.4%)  n=319 (48.6%)         
Country of origin
Others  98 (29.0%)  124 (38.9%)  1,557 (1,125–2,156)  0.008  1,638 (1,114–2,409)  0.012 
Native  240 (71.0%)  195 (61.1%)  Ref.    Ref.   
Drugs
No  305 (90.2%)  304 (95.3%)  Ref.    Ref.   
Yes  29 (8.6%)  12 (3.8%)  0.415 (0.208–0.829)  0.013  0.461 (0.217–0.979)  0.044 
ND  4 (1.2%)  3 (0.9%)  0.752 (0.167–3.390)       
Place seen
Hospital emergency department  206 (60.9%)  122 (38.2%)  Ref.    Ref.   
Primary care  63 (18.6%)  95 (29.8%)  2,546 (1,725–3,758)  <0.001  2,325 (1,539–3,512)  <0.001 
Area specialist  39 (11.5%)  65 (20.4%)  2,814 (1,784–4,439)  <0.001  2,132 (1,295–3,509)  0.003 
Others  23 (6.8%)  28 (8.8%)  2,056 (1,133–3,728)  0.018     
ND  7 (2.1%)  9 (2.8%)  2,171 (0.789–5,977)  0.134     
HIV
No  294 (87.0%)  297 (93.1%)  2,441 (1,222–4,876)  0.011  2,773 (1,288–5,969)  0.009 
Yes  15 (4.4%)  10 (3.1%)  1,611 (0.566–4,583)  0.371     
ND  29 (8.6%)  12 (3.8%)  Ref.    Ref.   
Diagnostic sample type
Sputum  241 (71.3%)  197 (61.8%)  1,539 (1,110–2,132)  0.010     
BAS/BAL  72 (21.3%)  77 (24.1%)  1,176 (0.816–1,694)  0.219     
Exudate  51 (15.1%)  19 (6.0%)  2,806 (1,617–4,868)  <0.001  2,074 (1,134–3,795)  0.018 
Gastric aspirate  3 (0.9%)  4 (1.3%)  1,418 (0.315–6,386)  0.468     
Tissue biopsies  32 (9.5%)  72 (22.6%)  2,787 (1,779–4,367)  <0.001  2,447 (1,475–4,060)  0.001 
Others  36 (10.7%)  28 (8.8%)  0.807 (0.480-1,357)  0.249     
Site
Pulmonary  258 (76.3%)  242 (75.9%)  0.975 (0.681–1,395)  0.480     
Pleural  75 (22.2%)  20 (6.3%)  4,263 (2,534–7,173)  <0.001  3,667 (2,116–6,353)  0.001 
Disseminated  18 (5.3%)  20 (6.3%)  1,189 (0.617–2,292)  0.363     
Extra-pulmonary only  22 (6.5%)  64 (20.1%)  3,605 (2,161–6,014)  <0.001     

The greater delay observed among foreign patients is probably due to a reluctance to consult the health system because of language barriers, or cultural, social or legal factors5; similar results were obtained in Italy and Portugal.6,7

The increased delay in the outpatient system compared to the emergency department may be due to the decreased incidence of TB in recent years,8 because physicians may be less likely to consider this diagnosis. It may also reflect better access to emergency departments.

Drug use appears as a factor associated with less delay, as there may be higher diagnostic suspicion in this group.9

Our results were similar to others published not only in Spain,10,11 but also in neighboring countries.12,13 The greater delay when exudates and biopsies are used for diagnosis, as in pleural tuberculosis, is noteworthy. These times to diagnosis must be reduced by implementing new diagnostic techniques.14,15

We conclude that the diagnostic delay of TB in Spain is still prolonged, while the greater part of the delay is attributable to the patient. Interventions to correct this situation must be based on disseminating knowledge about the disease, both among the general population and among health professionals, and improving access to health services.

Funding

This study was funded with a Research Grant from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)134/2014.

Conflict of interests

The authors state that they have no conflict of interests.

Acknowledgements

The authors are particularly grateful for the effort and time of all researchers who collaborated in the PIITB Research Group.

Appendix A
Annex. PIITB Research Group:

A. Bustamante (Hospital Sierrallana, Torrelavega); E. Carrió (Centro Asistencial Dr. Emili Mira I López, Santa Coloma de Gramanet); X. Casas (Serveis Clínics, Barcelona); A. Cecilio (Hospital Universitario Lozano Blesa, Zaragoza); L. Domínguez (Hospital Universitario de Ceuta, Ceuta); M. Domínguez (Hospital del Mar, Barcelona); S. Dorronsoro (Hospital de Zumárraga, Zumárraga); J. Esteban (Hospital de Cruces, Barakaldo); M. García (Hospital de Cabueñes, Gijón); F.J. Garros (Hospital Santa Marina, Bilbao); P. Gijón (Hospital General Universitario Gregorio Marañón, Madrid); Y. González (Serveis Clínics, Barcelona); J.A. Gullón (Hospital San Agustín, Avilés); I. Jiménez (Complejo Hospitalario de Navarra – B, Pamplona); M. Jiménez (Hospital Universitario de Donostia, Donostia); I. López (Hospital Universitario de Cruces, Barakaldo); M. Lumbierres (Serveis Clínics TDO, Lérida); M. Marín (Hospital General de Castellón, Castellón); J.P. Millet (Serveis Clínics, Barcelona); I. Molina (Serveis Clínics, Barcelona); J. Ortiz (Hospital El Bierzo, Ponferrada); E. Pérez (Hospital SAS de Jérez, Jérez de la Frontera); V. Pomar (Hospital de la Santa Creu i Sant Pau, Barcelona); R. Rabuñal (Hospital Lucus Augusti, Lugo); J. Rodríguez (Hospital San Agustín, Avilés); M.J. Ruiz (Hospital General Universitario Gregorio Marañón, Madrid); F. Sánchez (Hospital del Mar, Barcelona); I. Santamaría (Hospital Txagorritxu, Vitoria); M. Santín (Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat); F. Sanz (Hospital General Universitario de Valencia, Valencia); A. Soriano (Hospital Vall D’Hebrón, Barcelona); I. Suárez (Hospital Universitario de Canarias, La Laguna); J. Ugedo (Complejo Hospitalario San Millán-San Pedro, Logroño); J.L. Vidal (Complejo Hospitalario La Paz-Cantoblanco-Carlos III, Madrid).

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Please cite this article as: Seminario A, Anibarro L, Sabriá J, García-Clemente MM, Sánchez-Montalván A, Medina JF, et al. Estudio del retraso diagnóstico de la tuberculosis en España. Arch Bronconeumol. 2021;57:440–442.

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