Preplanned Studies: Patient, Diagnosis, and Treatment Delays Among Tuberculosis Patients Before and During COVID-19 Epidemic — China, 2018–2022

A total of 3,270,346 TB patients were included in the final analysis, representing 99.6% of reported TB cases between January 1, 2018, and December 31, 2022. Sociodemographic, clinical, and management characteristics of the patients are presented in Table 1.

The median and IQR of total delay and its components among TB patients notified between January 1, 2018, and December 31, 2022 was 29 (12–59) days, with patient delay constituting the largest component at 20 (6–46) days. Median (IQR) diagnosis and treatment delays were 1 (0–8) days and 0 (0–0) days, respectively. Male and female TB patients exhibited similar delays. Patients aged 65 and older experienced longer delays than younger age groups. Among various occupations, agricultural workers such as farmers, herdsmen, and fishermen experienced the longest total (30, 13–62) and patient delays (22, 7–50), while students had the shortest (20, 9–41 and 14, 4–32, respectively). Ethnic minorities experienced higher total (31, 13–64) and patient delays (25, 8–53) compared to the Han population (28, 12–58 and 19, 6–45). Migrants from other PLADs had the shortest patient delay (14, 3–37) but the longest diagnosis delay (3, 0–12) compared to local residents and migrants within PLAD. Longer total delays were observed among TB patients detected through passive case-finding (29, 12–60), those who were retreated (31, 13–73), bacteriologically positive (30, 12–63), with radiological TB lesions (29, 13–60), rifampin-resistant (31, 11–70), with comorbidities (32, 14–67), and HIV-positive (33, 15–66) patients, with similar patient delays. Patients with only pulmonary lesions experienced shorter delays compared to those with both pulmonary and extrapulmonary lesions, though patients with only extrapulmonary lesions had the shortest delays.

Trends in diagnosis, treatment, and patient delays have not changed within a 5-year period. Patient delay showed a moderate decrease from 22 (7–48) days in 2018 to 18 (6–43) days in 2021, before increasing slightly to 20 (6–47) days in 2022. These trends were observed in most subgroups, with migrants and individuals identified through active TB screening experiencing a decline over the 5-year period from 2018 to 2022. Conversely, patient delay among those without bacteriological or radiological results exhibited minimal decline and even increased in some years (Table 2).

The distribution of patient delay varied across 32 PLADs, ranging from 5 (0–28) days in Beijing to 31 (10–72) days in Chongqing. Overall, patient delay was shorter in eastern regions (27, 11–55) compared to western (30, 13–64) and central regions (29, 13–56), with significant differences (DSCF values =112.0, 59.2; P<0.001). Central regions also had fewer patient delays than western regions (DSCF value =56.5; P<0.001). However, among eastern regions, Hainan had the longest patient delay (30, 8–60), while within western regions, Xinjiang Corps exhibited the shortest patient delay (10, 3–31) (Figure 1).

Figure 1. 

Patient delays among tuberculosis patients across 32 PLADs in China, 2018–2022.

Abbreviation: PLADs=provincial-level administrative divisions; XPCC=Xinjiang Production and Construction Corps.

The overall delay experienced by TB patients during the COVID-19 pandemic has slightly decreased compared to pre-pandemic levels. The patient delay was the primary factor contributing to the total delay. TB patients who were agricultural workers, from minority populations, identified through active screening, and those with comorbidities or who were HIV positive experienced relatively longer patient delays compared to other subgroups. Additionally, patient delay was shorter in the eastern regions of the study area compared to the western and central regions.

A previous study conducted in 2021 (6) demonstrated that COVID-19 can influence the behavior of TB patients seeking medical care. Over twenty percent of patients might postpone seeking medical care due to transportation restrictions, disruptions in TB services, and personal reasons. However, the current study did not find any significant increase in delays after 2019. Given that TB is a respiratory disease with symptoms similar to those of COVID-19, the heightened attention paid by patients, communities, and healthcare facilities could be the primary reason for the absence of additional delays. Another contributing factor is China’s strict NPIs strategy during the pandemic period, which caused COVID-19 not to reach true nationwide transmission until the end of 2022. Its impact can vary across time and region according to COVID-19 epidemic and different public health responses. Ningxia has reported a longer patient delay during early 2020 compared to pre-pandemic period (7). On the contrary, pulmonary TB patients in Tianjin experienced a shorter patient delay during almost the same period (8). Nevertheless, the continuous low level of diagnosis and treatment delays can also be evidence for generally non-serious interruption of TB service during COVID-19 epidemic.

Compared to other occupations, agricultural workers often experience poorer health equity. Their remote living conditions and relatively lower income make it more challenging for them to access healthcare facilities when TB symptoms arise. However, the shorter patient delay observed among students may suggest that TB education and control efforts in schools have been effective in recent years. Migrant TB patients have also had less patient delay than local residents in this analysis. Generally, migrant population was considered as one of three major challenges in TB control. Stigma, poor accessibility to health service and many other factors may influence their health-seeking behavior (9). The National TB Program (NTP) started focusing on this vulnerable population since the early 21st century. Many active screening and health promotion activities have been implemented and a specific guideline for cross-regional management of TB patients (10) was launched in 2009. The patient delays were much shorter in eastern regions especially in the biggest cities. It is not surprising that Beijing, Shanghai, and Tianjin had shorter patient delays than most other regions since they have the richest medical resources and people living in these regions may have higher health knowledge. Besides changing individuals’ personal perspectives through health education, active case-finding is the most useful method to reduce patient delay (11). Results from this study further confirmed its effectiveness. However, the proportion of patients detected through active screening still accounted for a minority in all patients. NTP should consider promoting the strategy in larger coverage.

The present study has certain limitations. First, we were unable to quantify the correlation between the COVID-19 pandemic and changes in delays. Furthermore, it is important to note that the number of TB notifications declined by more than a quarter from 2018 to 2021 (1), which could suggest that patients seeking treatment at health facilities exhibited more severe symptoms. In addition, as our study is a retrospective analysis utilizing surveillance data, we could not determine the existence of undetected patients or the impact of these undetected patients on average delays. Lastly, our dataset did not include various social and environmental factors, such as health service accessibility and income, which may have affected the results. Future research should be conducted to identify potential risk factors, especially in different settings, to provide a more comprehensive understanding of the situation.

There is no evidence indicating that delays for TB patients worsened during the COVID-19 pandemic in China. However, the observed increase in patient delays in 2022 warrants attention for ongoing TB control efforts. Health education and active screening should be enhanced and expanded among high-risk populations and in regions experiencing prolonged patient delays.

This work was supported by the Epidemic of Tuberculosis Recurrence and Types of Recent Recurrence in Western China (JY22-3-11), Chinese Center for Disease Control and Prevention.