Health system delay and risk factors in pulmonary tuberculosis diagnosis before and during the COVID-19 epidemic: a multi-center survey in China.

Background: Understanding health system delay (HSD) in pulmonary tuberculosis (PTB) diagnosis aids in tailoring interventions for case detection and curbing transmission. However, recent nationwide studies on HSD in PTB diagnosis have been scarce. This study assesses HSD and its risk factors in China, taking into account the impact of the COVID-19 epidemic.

Methods: Patients diagnosed with PTB between 2019 and 2022 were selected using a multistage stratified clustering method. A semi-structured questionnaire was employed to assess HSD, which was defined as the interval between the patient's initial visit to a health facility and the definitive PTB diagnosis. The HSD was then compared between 2019 (before the epidemic) and 2020-2022 (during the epidemic). Factors associated with long health system delay (LHSD, defined as HSD > 14 days) were examined using both univariate and multivariate analyses with chi-square tests and binary logistic regression, respectively.

Results: In total, 958 patients with PTB were analyzed: 478 before and 480 during the epidemic. The HSD was 14 (interquartile range, 7-30) days for all patients, and the HSD before and during the epidemic also shared this value. A total of 199 patients (20.8%) had LHSD. LHSD was more prevalent in patients presenting solely with cough and expectoration (Odds ratio [OR]: 1.482, 95% confidence interval [CI]: 1.015-2.162) and those visiting ≥2 health facilities before definitive diagnosis (2 health facilities: OR = 2.469, 95%CI: 1.239-4.920; ≥3 health facilities: OR = 8.306, 95%CI: 4.032-17.111). Additionally, patients with negative bacteriological results were independently associated with higher LHSD risk (OR = 1.485, 95%CI: 1.060-2.080).

Conclusion: In China, HSD in PTB diagnosis remains relatively low and is primarily mediated by factors associated with health providers. No significant impact on HSD from the COVID-19 epidemic has been found. Implementing targeted training programs to enhance health providers' awareness of chronic respiratory symptoms and maintain vigilance for PTB; strengthening presumptive PTB identification capabilities at grassroots health facilities, and promoting the use of (MTB) bacteriological technologies are recommended to shorten the HSD.