Pre-XDR-TB affects 3% and XDR-TB 1% of MDR-TB patients in EthiopiaDrug-Resistant TB Strains Affect 4% of Ethiopian MDR-TB Patients

BACKGROUND: The burden of pre-extensively drug-resistant tuberculosis (Pre-XDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) cases in Ethiopia has become one of the most challenging problems for monitoring the treatment of patients with multidrug-resistant tuberculosis (MDR-TB). This study aimed to provide a valuable evidence synthesis on the pooled prevalence of Pre-XDR and XDR-TB among MDR-TB patients in Ethiopia. METHODOLOGY: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data from relevant articles were analyzed using STATA version 17.0. The pooled estimate of the effect size was computed using a restricted maximum likelihood random-effects model, considering a 95% confidence interval, and a forest plot was used to visualize the proportion of Pre-XDR and XDR-TB. Because the Pre-XDR and XDR-TB cases are rare, the Freeman-Tukey double arcsine transformation was applied to estimate the pooled proportions. The I2 statistic and Galbraith plot confirmed heterogeneity. A univariate meta-regression, sensitivity, and subgroup analyses were conducted to identify the source of heterogeneity. Egger's test and funnel plot were used to check publication bias. RESULTS: Eight studies comprising 1,518 MDR-TB patients, with 656 new and 862 previously treated cases, were included. Among those, 52 Pre-XDR and 13 XDR-TB cases were identified. According to the Freeman-Tukey transformation, the overall pooled prevalence of Pre-XDR-TB was 3% (95% CI: 2%-5%, I2 = 43.69%) and XDR-TB was 1% (95% CI: 0%-4%, I2 = 54.07%). In the subgroup analysis, the prevalence of Pre-XDR-TB across studies from multiple regions of Ethiopia was 7% (95% CI: 3%-13%), and in Addis Ababa, it was 3% (95% CI: 2%-4%). Single studies in the Amhara, Tigray, and Oromia regions reported Pre-XDR-TB prevalence of 6%, 5%, and 3%, respectively. The pooled prevalence of XDR-TB in Addis Ababa was 1% (95% CI: 0%-2%). A single study conducted in Oromia reported a relatively higher prevalence of XDR-TB; 10% (95% CI: 3%-26%). Regarding the study year, the XDR-TB prevalence was 3% (95% CI: 0%-11%) in 2005-2018 and 1% (95% CI: 0%-2%) in 2019-2024. A statistically significant publication bias was observed in XDR-TB prevalence (p = 0.024). CONCLUSION: There is a significant prevalence of Pre-XDR and XDR-TB cases among MDR-TB patients in Ethiopia. It highlights the need for strengthened surveillance in all regions and expanded drug susceptibility testing of local strains for better management of MDR-TB patients.