Tuberculosis (TB) in the refugee camps in Ethiopia: trends of case notification, profile, and treatment outcomes, 2014 to 2017

Prevalence and factors associated with TB among presumptive TB patients in war-affected areas of North Wollo, Ethiopia

Background

TB is a leading infectious disease globally, with war and displacement significantly increasing its burden. In Ethiopia, ongoing conflict and displacement have worsened health conditions, yet data on TB prevalence and resistance remain scarce. This study aimed to determine the prevalence of TB, rifampicin-resistant TB (RR-TB), and associated factors among presumptive TB patients in hospitals during the ongoing crisis.

Methods

A cross-sectional study was conducted with 273 presumptive TB participants, recruited via convenience sampling. Data on socio-demographic and behavioural factors were collected through interviews using a pre-tested structured questionnaire. Sputum samples were examined using the Xpert MTB/RIF molecular assay. Binary logistic regression was used to analyse the association between independent variables and TB. Variables with a P value  ≤0.25 in the univariate analysis were included in the multivariable regression to identify independent predictors, with a P value ≤0.05 considered statistically significant.

Results

Among the 273 study participants, 47 were confirmed to have Mycobacterium tuberculosis, resulting in a prevalence of 17.2%. Of the 47 patients diagnosed with M. tuberculosis, 17 (36.2%) were found to have rifampicin-resistant strains. Previous contact with displaced persons [adjusted odds ratio (AOR): 4.237; 95% CI: 1.67-10.762; P value: 0.002), contact with TB-infected individuals (AOR: 5.644; 95% CI: 2.46-12.96; P value: <0.01) and being HIV positive (AOR: 3.074; 95% CI: 1.26-7.50; P value: 0.014) were the significant predictors for TB.

Conclusions

Our study revealed a troubling prevalence of RR-TB, underscoring the adverse effects of war and displacement on healthcare services. Significant associations with predictors like HIV infection and close contact with TB-infected individuals necessitate targeted interventions.

Barriers and facilitators of tuberculosis treatment among immigrants: an integrative review

BACKGROUND AND OBJECTIVES

Migration, as an important social determinant in the field of health, plays a crucial role in the non-eradication of tuberculosis worldwide. Therefore, it is essential to identify the factors related to tuberculosis treatment in immigrants to effectively combat this disease. However no comprehensive study has focused on this issue. Therefore, this study was conducted using an ecological approach to identify the barriers and facilitators of tuberculosis treatment in immigrants.

METHODS

This qualitative study utilized an integrative literature review. Studies were searched without time restrictions in database such as MEDLINE, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBAS, as well as internal databases like Scientific Information Database and Magiran. The findings of 100 studies that met the inclusion criteria were analyzed using the conventional content analysis method based on the ecological approach.

RESULTS

In general, the aforementioned codes were placed into four main categories, including individual factors (i.e., biological factors, psychological factors, behavioral factors, patient knowledge, factors related to tuberculosis, and economic factors), interpersonal factors (i.e., communication with the treatment team and family-related factors), factors related to health service provider centers (i.e., medical facilities), and extra-organizational factors (i.e., social factors and health policies).

CONCLUSION

The findings of the present study show that treating tuberculosis in immigrants is a complex phenomenon influenced by several factors. Therefore policymakers and healthcare providers should take a more comprehensive look at the factors affecting treatment in this group of patients to plan and implement more effective interventions.

Prevalence of pulmonary tuberculosis among key and vulnerable populations in hotspot settings of Ethiopia. A systematic review and meta-analysis

BACKGROUND

Despite the decline in tuberculosis (TB) incidence across many regions worldwide, including Ethiopia, the disease remains highly concentrated among vulnerable or socially marginalized populations and in high-risk settings. This systematic review and meta-analysis aims to estimate the pooled prevalence of pulmonary tuberculosis (PTB) among key and vulnerable populations (KVPs) residing in hotspot settings in Ethiopia.

METHODS

Potential papers were searched systematically in PubMed, Scopus, ScienceDirect databases, Google Scholar search engine, and institutional electronic repositories/registrars. A total of 34 potential articles that provide necessary information on the prevalence of PTB were reviewed and data were analyzed to determine the pooled prevalence of PTB among KVPs. The relevant data were recorded and analyzed using STATA 17.0. Cohen's kappa was computed to determine the agreement between reviewers, the Inverse of variance (I2) to evaluate heterogeneity across studies, and Egger's test to identify publication bias. A random effect model was used to determine the pooled prevalence of PTB, subgroup analysis was computed by types of hotspot settings and year of publication.

RESULTS

This meta-analysis demonstrates that the pooled prevalence of PTB among populations residing in hotspot settings in Ethiopia was 11.7% (95% confidence interval (95CI): 7.97-15.43) with an I2 of 99.91% and a p< 0.001. Furthermore, the subgroup analysis unveiled the pooled prevalence of PTB among KVPs residing in different hotspot settings as follows: Prison inmates 8.8% (95CI: 5.00-12.55%), University students 23.1% (95CI: 15.81-30.37%), Refugees 28.4% (95CI: -1.27-58.15%), Homeless peoples 5.8% (95CI: -0.67-12.35%), Healthcare settings 11.1% (95CI: 0.58-21.63%), Spiritual holy water sites attendees 12.3% (95CI: -6.26-30.80%), and other high-risk settings 4.3% (95CI: 0.47-8.09%). Besides, the subgroup analysis revealed that the pooled prevalence of PTB post-2015 was 10.79% (95CI: 5.94-15.64%), whereas it stood at 14.04% (95CI: 10.27-17.82%) before 2015.

CONCLUSION

The prevalence of PTB among KVPs residing in the hotspot settings in Ethiopia remains significant, with a weighted pooled prevalence of 11.7%. Thus, the national TB control programs should give due attention and appropriate control measures should be instituted that include regular systematic TB screening, compulsory TB testing for presumptive TB cases among KVPs, and tightened infection control at hotspot settings.

Trend of pulmonary tuberculosis and rifampicin-resistance among tuberculosis presumptive patients in Central Tigray, Ethiopia; 2018 -2023: a six-year retrospective study

BACKGROUND

Tuberculosis (TB) is a major public health concern in the developing countries. Moreover, the emergence of multidrug-resistant tuberculosis is challenging. However, there are no organized data on the trends of pulmonary tuberculosis and rifampicin-resistant Mycobacterium tuberculosis in the study area.

METHODS

A retrospective cross-sectional study was conducted to fill the information gap in Central Tigray at St. Mary General Hospital between 2018 and 2023. Data were collected from the GeneXpert™ tuberculosis registration logbooks using standard checklists and analyzed using Statistical Package for Social Science version 22. After performing logistic regression, a p-value < 0.05 with a corresponding 95% confidence interval was considered statistically significant. Moreover, chi square test for trend was performed to assess the percentage of annual detection of pulmonary tuberculosis and rifampicin-resistant Mycobacterium tuberculosis during the study years.

RESULT

Presumptive pulmonary tuberculosis patients with complete data (n = 3696) were included in the study. The overall prevalence of pulmonary tuberculosis was 11.7%, of which 8.1% were resistant to rifampicin. The study revealed that the incidence of pulmonary tuberculosis has been increasing, mainly in the recent four years. Likewise, an increase in rifampicin-resistant Mycobacterium tuberculosis was observed with considerable fluctuations. Age, human immunodeficiency virus infection, and presumptive rifampicin-resistant Mycobacterium tuberculosis infection were significantly associated with the presence of pulmonary tuberculosis. Moreover, pulmonary tuberculosis was more prevalent among participants in the productive-age group.

CONCLUSION

Although there have been fluctuations, an increasing of pulmonary tuberculosis and rifampicin-resistant Mycobacterium tuberculosis has been observed in recent years. Hence, prevention and treatment strategies for tuberculosis should be strengthened to alleviate the burden of pulmonary tuberculosis and rifampicin-resistant Mycobacterium tuberculosis in the study area.

Evaluation of treatment outcomes among adult patients diagnosed with tuberculosis in Ghana: A 10 year retrospective review

Objectives

The study determined tuberculosis (TB) treatment outcomes in Southern Ghana from 2012 to 2021.

Methods

A retrospective analysis of service data on TB cases was conducted. Treatment success was defined as TB cure or completion of treatment course, whereas unsuccessful outcomes was defined as death, failure of treatment and lost to follow up. Bivariate and multivariate logistic regression was used to determine factors associated with treatment outcomes.

Results

A total of 4106 adult TB cases were reported with a median age of 41 (interquartile range 32-52) years. Of these, 93.1% (n = 3823) were newly diagnosed. The treatment success rate declined from 71.0% in 2012 to 55.7% in 2021 (ktau-b = -0.56, P = 0.0318). Clinically diagnosed TB and extra-pulmonary TB had 7.0% (adjusted prevalence ratio [aPR]: 0.93, 95% confidence interval [CI]: 0.88-1.00) and 24.0% (aPR: 0.76, 95% CI: 0.69-0.84) respectively, less successful treatment outcome compared to pulmonary TB patients. HIV negative status was associated with 22% higher successful treatment outcome compared with being HIV positive (aPR: 1.22, 95% CI: 1.12-1.33).

Conclusion

Tuberculosis treatment success rate declined over the period. There is a need for the TB Control Programme to review the national and sub-national TB data to ascertain poor performing TB treatment sites to identify and address context specific challenges with treatment interventions and system inadequacies to improve treatment success rates.

Scoping Review of Health Economics Research on Refugee Health in Sub-Saharan Africa

OBJECTIVES

Most refugees and internally displaced people (IDP) stay in low- and middle-income settings. A substantial proportion are hosted by countries in sub-Saharan African (SSA), which puts significant pressure on limited government healthcare budgets. As health economics may guide more optimal healthcare decision making, we scope the health economics literature on forcibly displaced populations in SSA to identify the nature and range of health economics evidence.

METHODS

We conducted a scoping review of peer-reviewed and gray literature in English published from 2000 to 2021. Our search terms comprised a combination of keywords related to refugees, SSA, and health economics. We followed a stepwise methodology consisting of the identification and selection of studies, extraction and charting of data.

RESULTS

We identified 29 health economics studies on refugees and IDPs in SSA covering different providers, interventions, and delivery platforms. Twenty-one articles studied the determinants of health, followed by 5 on the supply of healthcare and 2 concerned with economic evaluation and the demand for healthcare, respectively. We found an equal division of articles focusing on refugees and IDPs, as well as by settlement type. Mental health was the most frequently studied health area and Uganda was the most studied destination country.

CONCLUSIONS

The health economics literature on refugees in SSA remains limited. Our scoping review encourages future research to study a larger variety of healthcare systems and health economic topics such as economic evaluations, health financing and whole health systems to support resource allocation decisions and sustainable long-term solutions.

Genomic transmission clusters and circulating lineages of Mycobacterium tuberculosis among refugees residing in refugee camps in Ethiopia

BACKGROUND

Understanding the transmission dynamics of Mycobacterium tuberculosis (Mtb) could benefit the design of tuberculosis (TB) prevention and control strategies for refugee populations. Whole Genome Sequencing (WGS) has not yet been used to document the Mtb transmission dynamics among refugees in Ethiopia. We applied WGS to accurately identify transmission clusters and Mtb lineages among TB cases in refugee camps in Ethiopia.

METHOD AND DESIGN

We conducted a cross-sectional study of 610 refugees in refugee camps in Ethiopia presenting with symptoms of TB. WGS data of 67 isolates was analyzed using the Maximum Accessible Genome for Mtb Analysis (MAGMA) pipeline; iTol and FigTree were used to visualize phylogenetic trees, lineages, and the presence of transmission clusters.

RESULTS

Mtb culture-positive refugees originated from South Sudan (52/67, 77.6%), Somalia (9/67, 13.4%). Eritrea (4/67, 6%), and Sudan (2/67, 3%). The majority (52, 77.6%) of the isolates belonged to Mtb lineage (L) 3, and one L9 was identified from a Somalian refugee. The vast majority (82%) of the isolates were pan-susceptible Mtb, and none were multi-drug-resistant (MDR)-TB. Based on the 5-single nucleotide polymorphisms cutoff, we identified eight potential transmission clusters containing 23.9% of the isolates. Contact investigation confirmed epidemiological links with either family or social interaction within the refugee camps or with neighboring refugee camps.

CONCLUSION

Four lineages (L1, L3, L4, and L9) were identified, with the majority of strains being L3, reflecting the Mtb L3 dominance in South Sudan, where the majority of refugees originated from. Recent transmission among refugees was relatively low (24%), likely due to the short study period. The improved understanding of the Mtb transmission dynamics using WGS in refugee camps could assist in designing effective TB control programs for refugees.

Impact of the use of GeneXpert on TB diagnosis and anti-TB treatment outcome at health facilities in Addis Ababa, Ethiopia in the post-millennium development years

BACKGROUND

GeneXpert is an effective and rapid molecular system used for tuberculosis (TB) diagnosis. It is expected to improve the detection rate and treatment outcomes needed to meet the sustainable development goals (SDG) and End TB strategy targets set for 2030. This study aimed to evaluate the impact of GeneXpert on diagnosis and anti-TB treatment outcomes in the post-millennium development goals (MDGs) in the capital city of Ethiopia. Hence, the global priority indicator based on the End TB Strategy for TB treatment success rate was met early in 2018 in Addis Ababa, Ethiopia, which was anticipated to be met by 2025.

METHODS

A retrospective health facilities-based study was conducted in Addis Ababa, Ethiopia. Records of all TB cases diagnosed and treated in selected health facilities from January 1st, 2015 to December 31st, 2018 were reviewed and included in the study. Data analysis of descriptive and inferential statistics was conducted using SPSS version 20.

RESULTS

The reviewed records have shown that a total of 45,158 presumptive pulmonary TB (PTB) cases had accessed TB diagnosis services. Of which, 28.9% (13072/45158) were tested by AFB microscopy and 71.1% (32086/45158) were tested by GeneXpert. During the study period, the coverage of Xpert MTB/RIF testing increased to 94.9% in 2018 compared to 1.6% in 2015. The number of presumptive PTB cases tested with the GeneXpert system showed a significant increase compared to smear microscopy. The odds of positivity were detected in males compared to females. The odds of detecting TB cases were much higher among study participants aged 15-44 years compared to younger than 15 years. Treatment success rate showed a relative improvement each year between 2015 and 2018 with a mean of 92.6%. Reduced odds of treatment successes were observed in age categories older than 35 years, and in TB/HIV co-infected patients. Increased odds of treatment successes were reported in the years between 2016 and 2018 compared to 2015.

CONCLUSION

Scaling up the Xpert MTB/RIF assay as a point-of-care test for presumptive TB cases in resource-limited settings would have a significant impact to meet the SDG and End TB strategy both in TB detection and treatment success rates.

Prevalence of tuberculosis and associated factors among presumptive TB refugees residing in refugee camps in Ethiopia

BACKGROUND

Tuberculosis (TB) causes significant morbidity and mortality in refugee populations. Although Ethiopia is the third largest refugee-hosting country in Africa, there is limited published data on the prevalence and associated factors of TB in refugees. The objective of this study was to estimate the prevalence of bacteriologically confirmed pulmonary TB (PTB) and explore associated factors in presumptive TB refugees residing in refugee camps in Ethiopia.

METHODS

A facility-based cross-sectional study was conducted between February and August 2021 in refugee camps in Ethiopia. Data were collected consecutively from 610 presumptive TB refugees who attended for TB diagnosis in selected refugee camp clinics in Ethiopia. A pre-tested questionnaire was used to collect data, and sputum samples were collected from eligible study participants. The Xpert Mycobacterium tuberculosis (MTB)/Rifampicin (RIF) assay was performed on direct spot sputum samples, whereas morning sputum samples were processed and inoculated for bacteriological culture using Mycobacterium Growth Indicator Tube (MGIT) and Lowsteen Jensen (LJ) methods. The statistical software package (STATA version 14) was used for statistical analysis. A logistic regression model was used for the evaluation of the association between bacteriologically confirmed TB cases and the associated factors. Descriptive statistics were used for the expression of the results, and statistical significance was assumed at p < 0.05.

RESULTS

Out of 610 study participants, more than half were female (54.9%), and the mean age was 37.9 years (SD, 16.64). The prevalence of bacteriologically confirmed PTB cases among refugees residing in refugee camps in Ethiopia was 13.3% (95% CI, 10.7-16.2%) using the Xpert MTB/RIF assay and/or culture. MTB was detected in 12.8% (95% CI, 10.2-15.7%) of the individuals using the Xpert MTB/RIF assay, while culture positivity was observed in 11.6% (95% CI, 9.2-14.5%). The multivariable logistic regression model showed South Sudan origins (adjusted odds ratio, AOR = 7.74; 95% CI, 3.05-19.64), age group, 19-38 years old (AOR = 5.66; 95% CI, 1.86-17.28), and male sex (AOR = 2.69; 95% CI, 1.58-4.56) were significantly associated with the bacteriologically confirmed TB among refugees residing in refugee camps in Ethiopia.

CONCLUSION

The prevalence of bacteriologically confirmed PTB among presumptive TB refugees residing in refugee camps in Ethiopia was high. The national TB program should strengthen TB prevention and control activities in the refugee camps of Ethiopia. Moreover, an active TB survey program should be implemented in refugee camps in Ethiopia.

The effect of internal displacement due to armed conflict on tuberculosis treatment outcomes in northwest Syria, 2019-2020

Background

Northwest Syria accounts for over 4 million people of whom more than half are internally displaced persons (IDPs). More than 1 million IDPs reside in camps and many more live in settings which are overcrowded and poorly ventilated. Suboptimal social living conditions leave these populations susceptible to tuberculosis (TB) morbidity and mortality. This study aimed to assess the effect of internal displacement due to armed conflict on the risk of unsuccessful treatment outcomes among TB patients in northwest Syria.

Methods

All patients registered to start TB treatment at three centres in northwest Syria between the 1st June 2019 to the 31st December 2020 were included. Unsuccessful TB treatment outcome was defined as a composite outcome combining the WHO TB treatment outcomes of treatment failure, loss to follow-up, and death. We assessed the association between internal displacement and unsuccessful TB treatment outcomes using multivariable logistic regression. We also explored the risk of an unsuccessful treatment outcome by internal displacement setting (camp, village or city).

Results

Of the total 737 registered patients included in the analysis, 400 (54%) were documented as internally displaced. The median age of IDPs was 30 (IQR: 21.5-48) and the median age of residents was 34 (IQR:22-50). A significantly higher percentage of those who were IDPs had an unsuccessful treatment outcome compared to residents (40% vs 18%, p<0.001). After adjustment for confounders, the relative risk of having unsuccessful TB treatment was two-fold higher in internally displaced TB patients compared to residents (95% CI: 1.5-2.6). IDPs living in villages had a 30% lower risk of an unsuccessful treatment outcome compared to IDPs living in camps (RR 95% CI: 0.50-0.91), and IDPs living in cities had a 13% lower risk of an unsuccessful treatment outcome (RR 95% CI: 0.57-1.18).

Conclusion

This is one of few studies which aims to quantify the effect of internal displacement on TB treatment outcomes during times of conflict. Our findings starkly highlight how social determinants contribute to poor TB outcomes and act as a starting point for much needed research on how best to manage TB in humanitarian crisis settings.

Risk-adjusted active tuberculosis case finding strategy in central Ethiopia

•

Active tuberculosis case finding in communities improves early case detection

•

Optimal use of limited human and financial resources for case finding is uncertain

•

Our study explored a risk-adjusted approach to improve case detection in Ethiopia

•

We demonstrated an increased case detection rate compared with the standard approach

Background

The World Health Organization recommends active case finding for tuberculosis (TB). Our study evaluated the targeted screening of household contacts (HHCs) of patients with contagious pulmonary tuberculosis (PTB) in Central Ethiopia.

Methods

The HHCs of patients with microbiologically confirmed PTB were screened for TB symptoms and risk factors for TB transmission. Symptomatic HHCs were subjected to secondary investigation. Antimicrobial resistance was investigated among study participants.

Results

Overall, 112 index patients with TB were included, and 289 HHCs from 89 households were screened. Multidrug-resistant-TB was detected in 2.7% (n=3) of index patients. The routine public health system process did not identify any TB suspects among HHCs. In total, 23.9% (n=69) of HHCs reported ≥1 TB symptom and PTB was confirmed in 2.1% (n=6). Reporting >1 TB symptom (relative risk [RR] 29.4, 95% CI 3.5−245.5, P<0.001) and night sweats (RR 27.1, 95% CI 3.2−226.6, P<0.001) were associated with the greatest relative risk. Regular alcohol consumption was identified as an individual risk factor for TB among HHCs (P=0.022).

Conclusion

The MDR-TB rate among our patients was higher than recently reported for Ethiopia. Enhanced contact tracing using a risk-adjusted approach seems feasible and increases the case detection rate among HHCs of confirmed TB cases.

Updates in Pediatric Tuberculosis in International Settings

Childhood tuberculosis (TB) has been underreported and underrepresented in TB statistics across the globe. Contributing factors include health system barriers, diagnostic barriers, and community barriers leading to an underdetected epidemic of childhood tuberculosis. Despite considerable progress in childhood TB management, there is a concerning gap in policy and practice in high-burden countries leading to missed opportunities for active case detection, early diagnosis and treatment of TB exposure, and infection and disease in children regardless of human immunodeficiency virus status. Bridging this gap requires multisectoral coordination and political commitment along with an eye to research and innovation with potential to scale.

Active case finding of pulmonary TB in a European refugee camp: lessons learnt from Oinofyta hosting site in Greece

OBJECTIVES

To report on an active case finding (ACF) intervention that took place in the migrant camp of Oinofyta, Greece, upon suspicion of active TB transmission.

METHODS

Upon diagnosis of 3 TB cases among camp residents, an ACF intervention among contacts was implemented. All camp residents were offered two-step screening, that is tuberculin skin testing (TST) followed by chest X-ray in case of positive TST (defined as ≥5 mm).

RESULTS

336 of 379 (89%) camp residents underwent TST testing, of whom 110 (33%) exhibited a positive skin reaction. The rate of positive TST results was particularly high in the elderly and significantly higher in adults than in children. Differences by sex or nationality were not observed. Of the 110 cases with positive TST, only 75 underwent chest X-ray, resulting in the detection of one pulmonary TB case in an adult woman.

CONCLUSIONS

In the given intervention context, two-step ACF proved to be operationally cumbersome, with many residents lost to follow-up and a high Number Needed to Screen. Simpler ACF designs should be pilot-tested in similar settings in the future, and blanket screening of all camp residents should be reconsidered. Conclusions drawn by these exercises should pave the way for adopting a comprehensive, context-specific and evidence-based national strategy on TB in migrants.