84% case detection , 87% treatment success rate and reversing tb incidence rate by 2015 are the main goals of world health organization ( who ) and stop tb partnership to control tb . delay in diagnosis of tb is a major defect in tb program and it can lead to several complications , mortality , and tb contamination in the community . it may be related to patient ( patient delay ) or the health system ( system delay ) . hence , the tb patients are evaluated and reported by some health care sources , identifying the diagnosis delay in these sources is important to planning effective national tb program ( ntp ) . also , some variable such as age , sex , residency , nationality and hiv may be related to the diagnosis delay . evaluation of determinants of delay must be studied and addressed to improve the effectiveness of the ntps . also , conducting this study is important for planning public - private mix ( ppm ) program . this program advised by who to improve the collaboration of public and private sectors in the ntp . the aim of this study was evaluation of diagnosis delay in smear positive tuberculosis patients in islamic republic of iran 2009 - 2010 in this cross sectional study , all smear positive tb registered patients from 20 march 2009 to 20 march 2010 ( one hijri year ) in iran were assessed . smear positive tb cases were defined according to who and iran 's national tb guideline . diagnosis delay ( both delays caused by patient and physician ) is defined as the time interval between the first presentations of tb symptoms such as cough>2 - 3 weeks , fever , loss weight , sputum , night sweating to the diagnosis of tb . the patients were reported from public health outpatient system ( pho ) , public hospitals ( phs ) , private outpatient system ( po ) , private hospitals ( ph ) , social security fund ( hospitals or clinics that are belong to social security fund organizations ) and other sources ( charity and army forced clinic or hospitals ) . sputum smear positivity grade by direct microscopic examination were graded as 1 - 9 bacilli , 1 + , 2 + and 3 + . tb patients data were entered in tb register software via double - entry . after a review , the final data were prepared for analysis using spss16 software . quantitative data were evaluated using kolmogorow - smironov statistical test and also via graphical test to assure their normal distribution . relationship between diagnostic delay group ( > median and < = median ) and dichotomous variables was evaluated by chi - square test and odds ratio ( 95% confidence intervals ) was calculated . logistic regression analysis was used to examine the adjusted odds ratio by spss software 16 ( chicago , usa ) . the mean age of 5702 tb patients was 47.8 ( sd : 21.6 ) years . 2855 ( 50.1% ) were female , 852 ( 14.9% ) were non - iranian , 183 ( 3.2% ) were prisoner , and 107 ( 1.9% ) were hiv positive . diagnosis delay was longer in female than male ( p=0.004 ) , non - iranian than iranian ( p<0.001 ) , urban than rural ( p<0.001 ) , non - prisoner than prisoner ( p<0.001 ) [ table 1 ] . comparison of median diagnosis delay according to some variables in multivariate analysis , non - iranian , urban , non- prisoner and patients older than 50 years had chance 1.367 , 1.335 , 2.126 and 1.22 times more likely that their delay in tb diagnosis be longer than>59 days , respectively [ table 2 ] . relation of different variables with diagnosis delay ( cut - off point , median = 59 days ) median diagnosis delay in patients who chose the po system ( private clinics ) to be visited were higher than pho ( p<0.001 ) . comparison of median diagnosis delay ( day ) in registered tuberculosis patients from different source of reporting one hundred ninety three ( 3.4% ) were 1 - 9 bacilli , 2053 ( 36% ) were 1 + , 1324 ( 23.2% ) were 2 + and 2132 ( 37.4% ) were 3 + in sputum smear examination . diagnosis delay was longer in non - iranian , urban , non- prisoner and older than 50 years patients . study in iran , 2003 the median of diagnosis delay was reported as 89 days which is fortunately reduced now . a reduction of one month in diagnosis delay is considered as a great success in iran ntp . however , diagnosis delay in our country is higher than other countries . in other studies , the median of diagnosis delay was about 50 days in vietnam , 56 days in ghana , and 6 days in new york . generally , the median of delay in diagnosis of smear positive patients varies from 2 days to 4 months in different countries . . total delay in diagnosis in public sector and private sector are respectively 47.6 and 60.3 days in egypt , 99.02 and 110.8 days in pakistan , 79.7 and 84.1 days in somali , 67 and 86 days in syria , and 5.05 and 63.1 days in yemen ; in all countries except somalia and syria , delay in private sector is significantly higher than public sector which is the same as our study . it is suggested to implement tb control and reporting system in private sectors in iran and design and perform a public - private mix program . the minimum delay was seen in prisons ; it is a sign of early tb case finding in iran prisons . median diagnosis of tb in hiv positive did not have different with hiv negative in our study . however , we expected the hiv positives were diagnosed in early stage of tb because of active follow - up of these patients . in diez et al . study hiv positive diagnosed faster than hiv negative patients . however , diagnosis of tb in hiv patients is difficult but it is likely that tb diagnosis in hiv patients not appropriate in iran . characteristics such as lack of specific symptoms ( hemoptesia ) , unemployed , smokers , females , older age , attending private sector as first provider attended , not prescription of cxr , living in suburban or rural area and low literacy were related with more diagnosis delay . some of these factors related to presence of co - morbidity , health seeking behaviors , society culture and health care providers practice and attitude . family physician system has been implemented in rural area in iran and it may lead to decrease tb diagnosis delay in rural area . also , according to the results , it is likely that private care system not familiar with ntp or complicated patients are referred to private system . therefore , education and cooperation of private system through public - private mix model is an important key in successful ntp . first , we just considered the characteristics that recorded in tb register software so we could not evaluate some related characteristics . second , there may have been some recall bias from patients regarding the onset of symptoms . non - iranian , urban , non - prisoner and old patients are in risk of diagnosis delay of tb . cooperation of private system through public - private mix model is an important key in successful ntp .
background : early diagnosis of tuberculosis ( tb ) is a major key for effective tb program . 
 evaluation of delay in diagnosis of smear positive tb is needed to evaluation of tb program situation in each country . 
 the aim of this study was to evaluate of diagnosis delay in smear positive tuberculosis patients in islamic republic of iran.materials and methods : in this cross sectional study , all smear positive tb registered patients from 20 march 2009 to 20 march 2010 in iran were assessed . 
 diagnosis delay is defined as the time interval between the first presentations of tb symptoms to the tb confirmation . 
 mann - whitney test , chi - square and logistic regression was used to analysis.results:diagnosis delay was 58 days in female and 53 days in male ( p=0.004 ) , 61 days in non - iranian and 54 days in iranian ( p<0.001 ) , 59 days in urban and 50 days in rural ( p<0.001 ) , 57 days in non - prisoner and 37 days in prisoner ( p<0.001 ) , 61 days in patients who chose private outpatients system and 52 days in patients who chose public health outpatients system ( p<0.001 ) . 
 193 ( 9.4% ) had 1 - 9 bacilli and 2132 ( 37.4% ) were 3 + in sputum smear examination.conclusion:non-iranian , urban , non - prisoner , old patients and the patients who chose private system are in risk of delay diagnosis of tb . 
 cooperation of private system through public - private mix model is an important key in successful national tb program ( ntp ) .