War and its implications for the tuberculosis program in the Amhara Region

Abstract

Background: War is one of the most significant factors exacerbating tuberculosis (TB) epidemics, increasing both morbidity and mortality rates. Direct attacks on healthcare facilities and medics, displacement of millions of people, and challenges with access to and delivery of medicines disrupt patients' treatment. This study aimed to assess war and its implications for the TB control program in the Amhara region.

Methods: Retrospective data archived in the regional Health Management Information System (HMIS) database were extracted to understand the regional TB program in the prewar period and forecast the impact of war on the TB control program. Four years of secondary archived data (July 2019 to December 2022) were used to forecast TB incidence and treatment outcomes in war-affected zones in 2022. To validate the model, the results were compared with actual observed TB incidence data. Line graphs and bar charts were used to compare the incidence of TB across age and sex categories.

Results: The TB incidence rate in North Wollo, Waghimira, and North Gondar (war-affected zones) was 198.7, 169.7, and 142 per 100,000, respectively. Among females, the proportion of extrapulmonary TB (EPTB), clinically confirmed TB cases, and pulmonary TB cases were 49.3%, 26.6%, and 24.0%, respectively. In the region, 204 drug-resistant TB cases were notified. TB patients, including those with multidrug-resistant TB (MDR-TB), were left without care and were forced to flee to internally displaced persons (IDP) centers. Of the 116 drug-susceptible TB patients identified during the war, 85 (73.3%) were from IDP sites. According to the six months HMIS report, Zones had zero TB case notification. The TB control program was interrupted for nine months in war-affected zones and severely attenuated in other zones.

Conclusion: The incidence of TB in war-affected areas was high. Severe types of TB and under-diagnosed cases were more prevalent, which could lead to high TB transmission, reactivation, and drug resistance development in both war-affected and non-affected zones. Therefore, strengthening active and passive case finding, restoring diagnostic capacity, providing Bacillus Calmette-Guérin (BCG) vaccination, conducting rigorous TB screening and surveillance, and managing TB, including severe forms such as MDR-TB and Extensively drug-resistant tuberculosis (XDR-TB), are crucial measures to enhance the regional TB control program.