Delay of TB patients in diagnosis in a conflict setting of Mogadishu, Somalia - a cross-sectional study

BBackground. The TB case detection rate in Somalia is 42%, which is much lower than the WHO target of detecting 70% of new TB cases. Understanding the factors contributing to the delay of TB patients in the diagnosis, and reducing the time between the onset of TB symptoms to diagnosis, is a prerequisite to increase the case detection rate and to ultimately bring the TB epidemic in Somalia under control. The aim of this study is to examine the duration of delay, and factors associated with the delay among patients in TB management centers in Mogadishu, Somalia. Methods. An institution-based, cross-sectional study was conducted in TB management clinics providing directly observed treatments (DOTS) programs in Mogadishu. A total of 276 patients were interviewed using a structured questionnaire from June-October 2018. We analyzed data using descriptive statistics and different logistic regression models. Results. Approximately 78% of study participants were male. Nearly a third (36.5%) came from a household of nine individuals or more, while 73% were unemployed. The median patient and provider delays were 50 days and one day, respectively. The median total delay was 55 days, with an inter-quartile range of 119 days. Patients who had a poor knowledge of the symptoms of TB had 3.16 times higher odds of delay over 50 days than their counterparts. Furthermore, a poor knowledge of the symptoms of TB (aOR 4.22, CI 2.13-8.40), not making ones own decisions in seeking TB treatment (aOR 2.43, CI 1.22-4.86) and a poor understanding of the fact that TB can be treated with biomedical treatment, as opposed to traditional treatment (aOR 2.07, CI 1.02-4.16), were predictors of a patient delay over 120 days. Conclusions. The duration in the delay of TB patients under diagnosis in Mogadishu is one of the highest reported in developing countries, exceeding two years in some patients. Training local community health workers to detect suspected TB cases, and referring the cases of prolonged cough over three weeks for TB care centers for diagnosis, is imperative to help break the transmission and reduce the infectious pool in the population of Mogadishu. This may not only increase the community awareness of TB disease, but it may also facilitate the early referral of TB patients to diagnostic and treatment care centers.