Tuberculosis in Ethiopia

A study in Ethiopia examined the immunological, hematological, and biochemical changes in newly diagnosed tuberculosis (TB) patients at Dessie Comprehensive Specialized Hospital. The hematological findings demonstrated a notable increase in white blood cell (WBC) count, neutrophils, lymphocytes, and platelets, all indicative of an active inflammatory response to TB infection. However, TB patients exhibited significantly reduced red blood cell (RBC) count, hemoglobin levels, and hematocrit, contributing to a high prevalence of anemia. The majority of anemia cases were normocytic and microcytic, suggesting underlying chronic disease or nutritional deficiencies. These findings highlight the profound impact of TB on blood parameters, necessitating close monitoring for potential complications such as anemia and abnormal immune responses.[3]

Beyond hematological changes, TB was also associated with significant biochemical alterations, reflecting the systemic burden of the disease. Increased levels of alanine aminotransferase (ALT) and total bilirubin suggested potential liver involvement, possibly due to TB itself or as a result of concurrent conditions. Elevated glucose levels indicated possible metabolic disturbances, whereas reduced total protein, alkaline phosphatase, and cholesterol levels pointed to malnutrition or compromised liver function. These biochemical disruptions emphasize the importance of a holistic approach in TB management, addressing not only the infection but also its systemic effects on metabolism and organ function.[3]

In terms of immune function, CD4 counts were lower in pulmonary TB patients compared to those with extrapulmonary TB, although the difference was not statistically significant. This finding suggests that, in the absence of HIV, TB may not cause profound immune suppression, even though it triggers a heightened inflammatory response. The systemic immune-inflammation index (SII) was significantly elevated in male TB patients, reinforcing the role of inflammation in disease progression. These findings underscore the necessity of integrating immune and inflammatory markers into TB patient care, ensuring timely interventions to manage both the infection and its broader physiological consequences.[3]

In Addis Ababa, Ethiopia, a study was conducted across 10 subcities to investigate the relationship between diabetes and latent tuberculosis infection (LTBI) among household contacts (HHCs) of newly diagnosed pulmonary TB cases. These HHCs were identified through public health surveillance and were required to have valid IGRA results and HbA1c measurements. The study established strict inclusion criteria, excluding individuals under 15 years old, those with low hemoglobin levels, active TB, a history of TB, pregnancy, or immunosuppressive therapy. By carefully selecting participants, the researchers ensured a focused analysis of LTBI risk factors in a high-burden setting.[1]

The study classified participants’ diabetes status based on HbA1c levels, distinguishing between euglycemia, prediabetes, and diabetes, while also considering self-reported diabetes history. Among the 597 included participants, 5.2% had diabetes, and 15% were classified as prediabetic. A key finding was the significantly higher body mass index (BMI) among those with diabetes (26.1 kg/m²) and prediabetes (23.3 kg/m²) compared to euglycemics (20.5 kg/m²). Notably, LTBI was highly prevalent, affecting 71% of the participants, with an even greater prevalence (86.7%) among those with diabetes. This stark contrast highlighted the potential role of metabolic disorders in increasing susceptibility to TB infection in high-risk communities.[1]

The study further revealed an age-dependent association between diabetes and LTBI. While the overall prevalence difference between diabetics and euglycemics was 17.7%, the disparity was most pronounced in individuals aged 40 years and older, where diabetes was linked to a 16.7% higher LTBI prevalence and an adjusted odds ratio of 3.68. In contrast, among those younger than 40, the association was weaker, with a prevalence difference of only 2.8% and an odds ratio of 1.15. These findings suggest that diabetes may exert a stronger influence on LTBI risk in older populations, underscoring the need for targeted TB prevention strategies among older adults with metabolic disorders.[1]

A prospective cohort study conducted in Addis Ababa, Ethiopia, from August 2020 to November 2021, examined the impact of diabetes mellitus (DM) on tuberculosis (TB) treatment outcomes. Among the 267 participants, 8.9% were identified with diabetes at baseline, while 10.5% had prediabetes. As the study progressed, two additional cases of diabetes were diagnosed, one of which had initially been classified as prediabetes. Participants with prediabetes who did not develop diabetes were categorized as TB patients without diabetes during the treatment phase, allowing for a clearer comparison of outcomes across metabolic health statuses.[2]

The study revealed that 94.0% of participants successfully completed TB treatment, with 35.2% classified as cured and 58.8% achieving treatment completion. However, 16 individuals experienced poor TB outcomes, including deaths, treatment failure, loss to follow-up, and transfers out. Notably, participants with diabetes, including those diagnosed during treatment, had a significantly higher rate of adverse outcomes, with 26.9% facing complications. Diabetes was implicated in multiple negative outcomes, including two deaths, three cases of transfer out, one case of loss to follow-up, and the only recorded instance of treatment failure, emphasizing the challenges posed by this comorbidity.[2]

Further analysis demonstrated that diabetes substantially increased the risk of poor TB outcomes, with an adjusted odds ratio of 14.8 compared to TB patients without diabetes. Additional risk factors for poor outcomes included smear-positive pulmonary TB, extrapulmonary TB, and a history of other non-communicable diseases, highlighting the multifactorial nature of TB treatment challenges. These findings underscore the critical need for integrated care strategies that address both TB and metabolic disorders, ensuring that patients with diabetes receive specialized interventions to improve treatment success and reduce mortality risks.[2]

References: 

1. Smith, A. G. C., Kempker, R. R., Wassie, L., Bobosha, K., Nizam, A., Gandhi, N. R., Auld, S. C., Magee, M. J., Blumberg, H. M., & Tuberculosis Research Unit: Role of Antigen Specific Responses in the Control of TB (TBRU-ASTRa) Study Group. (2022). The impact of diabetes and prediabetes on prevalence of Mycobacterium tuberculosis infection among household contacts of active tuberculosis cases in Ethiopia. Open Forum Infectious Diseases, 9(7), ofac323.

2. Adane, H.T., Howe, R.C., Wassie, L. and Magee, M.J., 2023. Diabetes mellitus is associated with an increased risk of unsuccessful treatment outcomes among drug-susceptible tuberculosis patients in Ethiopia: A prospective health facility-based study. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 31, p.100368.

3. Gebreweld, A., Fiseha, T., Kebede, E., Tamir, Z., Gebremariam, B., Miruts, F. and Haileslasie, H., 2024. Immuno-Hematological and Biochemical Changes in Patients with Tuberculosis in Dessie Comprehensive Specialized Hospital, Dessie, Ethiopia. Journal of Blood Medicine, pp.147-155.