Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 148 No. 3536 (2018)

Health-seeking behaviour and treatment delay in patients with pulmonary tuberculosis in Switzerland: some slip through the net

  • Christian Auer
  • Sabine Kiefer
  • Meike Zuske
  • Christian Schindler
  • Kaspar Wyss
  • Johannes Blum
  • Xavier Bosch-Capblanch
  • Ursula Widmer
  • Sonia Sauthier
  • Jean-Paul Janssens
  • Katharina Bossard
  • Christophe Chatonnet
  • Jesica Mazza-Stalder
  • Bea Zacek
  • Jean-Pierre Zellweger
  • Ekkehardt Altpeter
  • Mirjam Mäusezahl
Cite this as:
Swiss Med Wkly. 2018;148:w14659



To assess the health-seeking behaviour, the patient delay (onset of symptoms to first consultation) and the health system delay (first consultation to start of tuberculosis treatment) among patients with pulmonary tuberculosis (TB) diagnosed in Switzerland, and to assess the predictors of the various types of delay.


A survey among pulmonary TB patients was carried out in six cantons, covering 42% of all pulmonary adult TB cases notified in Switzerland. Data were collected by collaborators of the cantonal lung associations in charge of the follow-up of TB patients to investigate treatment seeking behaviour and to establish various delays and its predictors. Predictors of percentiles of delay (median and 75th percentile) were assessed using quantile regression.


Among 252 eligible patients, 162 patients could be interviewed. Of these, 20.4% were born in Switzerland. Cough as a symptom was mentioned by 76% of the interviewed patients. Almost half of the 162 patients (46%) consulted first a general practitioner in an ambulatory care setting and 26% approached a hospital first. The median delay between symptom onset and first healthcare contact (patient delay) was 5.2 weeks, which is slightly longer than findings in other low prevalence countries. The interquartile range was 1.6 to 14.2 weeks. The median delay between first consultation in Switzerland and the start of TB treatment (health system delay) was 2 weeks. The interquartile range was 0.6 to 7.1 weeks.

There were no clear predictors of patient delay. The main predictors of a longer median health system delay were the presence of fever (1.6 weeks, 95% confidence interval [CI] 0.5 to 2.6 weeks), having visited first a general practitioner or a paediatrician (1 week, 95% CI 0.1 to 1.9 weeks) and having seen three or four doctors before beginning TB treatment (2.9 weeks, 95% CI 0.7 to 5.1 weeks). A clear predictor of a shorter median health system delay was having undergone an X-ray at the first consultation (−2.9 weeks, 95% CI −4.8 to −0.9 weeks). Marginally significant for shorter delay was male sex (−2.6 weeks, 95% CI −5.4 to 0.1 weeks).


No predictor of patient delay was found among the variables collected. For one fourth of the patients, the health system delay was longer than 7 weeks. General practitioners are commonly approached first, and they have to consider TB, also for patients not considered at high-risk for TB.


  1. Brändli O. Tuberkulose aktuell. Swiss Med Forum. 2013;13(25):493–8. doi:
  2. Figures received from the Federal Office of Public Health in March 2017.
  3., accessed on 29 March 2017.
  4. Pezotti P, Pozzato S, Ferroni E, Mazzocato V, Altieri AM, Gualano G, et al. Delay in diagnosis of pulmonary tuberculosis: a survey in the Lazio region, Italy. Epidemiology Biostatistics and Public Health. 2015;12(1):e94941.
  5. Tattevin P, Che D, Fraisse P, Gatey C, Guichard C, Antoine D, et al. Factors associated with patient and health care system delay in the diagnosis of tuberculosis in France. Int J Tuberc Lung Dis. 2012;16(4):510–5. doi:.
  6. Díez M, Bleda MJ, Alcaide J, Caloto T, Castells C, Cardenal JI, et al.; Multicentre Project for Tuberculosis Research Study Group. Determinants of patient delay among tuberculosis cases in Spain. Eur J Public Health. 2004;14(2):151–5. doi:.
  7. Sultan H, Haroon S, Syed N. Delay and completion of tuberculosis treatment: a cross-sectional study in the West Midlands, UK. J Public Health (Oxf). 2013;35(1):12–20. Published online June 21, 2012. doi:.
  8. Saldana L, Abid M, McCarthy N, Hunter N, Inglis R, Anders K. Factors affecting delay in initiation of treatment of tuberculosis in the Thames Valley, UK. Public Health. 2013;127(2):171–7. Published online January 11, 2013. doi:.
  9. Farah MG, Rygh JH, Steen TW, Selmer R, Heldal E, Bjune G. Patient and health care system delays in the start of tuberculosis treatment in Norway. BMC Infect Dis. 2006;6(1):33. Published online February 24, 2006. doi:.
  10. Kiefer S, Auer C, Altpeter E, Zellweger J-P, Blum J, Wyss K. Tuberkulose in der Schweiz: das Wichtigste in Kürze. Swiss Med Forum. 2016;6:613–6.
  11. Figure received from the Federal Office of Public Health in April 2017.
  12. Ibrahim WH, Alousi FH, Al-Khal A, Bener A, AlSalman A, Aamer A, et al. Diagnostic Delay among Adults with Pulmonary Tuberculosis in a High Gross Domestic Product Per Capita Country: Reasons and Magnitude of the Problem. Int J Prev Med. 2016;7(1):116. Published online October 26, 2016. doi:.
  13. Lewis KE, Stephens C, Shahidi MM, Packe G. Delay in starting treatment for tuberculosis in east London. Commun Dis Public Health. 2003;6(2):133–8.
  14. Altet Gómez MN, Alcaide Megías J, Canela Soler J, Milá Augé C, Jiménez Fuentes MA, de Souza Galvao ML, et al. [Pulmonary symptomatic tuberculosis’ diagnostic delay study]. Arch Bronconeumol. 2003;39(4):146–52. Article in Spanish.
  15. Storla DG, Yimer S, Bjune GA. A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health. 2008;8(1):15. doi:.
  16. Kherad O, Herrmann FR, Zellweger JP, Rochat T, Janssens JP. Clinical presentation, demographics and outcome of tuberculosis (TB) in a low incidence area: a 4-year study in Geneva, Switzerland. BMC Infect Dis. 2009;9(1):217. doi:.
  17. Cai J, Wang X, Ma A, Wang Q, Han X, Li Y. Factors associated with patient and provider delays for tuberculosis diagnosis and treatment in Asia: a systematic review and meta-analysis. PLoS One. 2015;10(3):e0120088. doi:.
  18. Bogale S, Diro E, Shiferaw AM, Yenit MK. Factors associated with the length of delay with tuberculosis diagnosis and treatment among adult tuberculosis patients attending at public health facilities in Gondar town, Northwest, Ethiopia. BMC Infect Dis. 2017;17(1):145. doi:.
  19. Samal J. Health Seeking Behaviour among Tuberculosis Patients in India: A Systematic Review. J Clin Diagn Res. 2016;10(10):LE01–06. Published online October 1, 2016.
  20. Chung KF, Pavord ID. Prevalence, pathogenesis, and causes of chronic cough. Lancet. 2008;371(9621):1364–74. doi:.
  21. Helbling P, Zellweger JP, Altpeter E, Boubaker K. [Epidemiogy and treatment of tuberculosis in Switzerland]. Rev Med Suisse. 2006;2(82):2276–8, 2280–1. Article in French.
  22. World Health Organization. Systematic screening for active tuberculosis: principles and recommendations. Geneva: World Health Organization; 2013. Report No.: WHO/HTM/TB/2013.04.
  23. Altpeter E, Schoch O, Helbling P. Tuberkulose in der Schweiz: selten, und manchmal kompliziert. Swiss Med Forum. 2015;15(41):925–30.
  24. Martinez L, Xu L, Chen C, Sekandi JN, Zhu Y, Zhang C, et al. Delays and Pathways to Final Tuberculosis Diagnosis in Patients from a Referral Hospital in Urban China. Am J Trop Med Hyg. 2017;96(5):1060–5. Published online February 13, 2017. doi:.
  25. Gagliotti C, Resi D, Moro ML. Delay in the treatment of pulmonary TB in a changing demographic scenario. Int J Tuberc Lung Dis. 2006;10(3):305–9.
  26. Dara M, Sulis G, Centis R, D’Ambrosio L, de Vries G, Douglas P, et al. Cross-border collaboration for improved tuberculosis prevention and care: policies, tools and experiences. Int J Tuberc Lung Dis. 2017;21(7):727–36. doi:.
  27. Dara M, de Colombani P, Petrova-Benedict R, Centis R, Zellweger JP, Sandgren A, et al.; Wolfheze Transborder Migration Task Force. Minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement. Eur Respir J. 2012;40(5):1081–90. Published online May 31, 2012. doi:.
  28. Heuvelings CC, de Vries SG, Greve PF, Visser BJ, Bélard S, Janssen S, et al. Effectiveness of interventions for diagnosis and treatment of tuberculosis in hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review. Lancet Infect Dis. 2017;17(5):e144–58. Published online March 11, 2017. doi:.

Most read articles by the same author(s)

1 2 3 > >>