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Acid-Fast Bacilli Smear Positivity and HBV, HCV, HIV, and Syphilis Co-infections between 2016 and 2019 in Mogadishu, Somalia

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Although tuberculosis (TB) is a treatable disease, it continues to be an important health problem affecting societies worldwide. TB is one of the 10 most common causes of death worldwide today, despite the efforts of national organizations and the global struggle efforts of the World Health Organization (WHO), that have continued since its first establishment and exceeded seventy years. Somalia faces many negative factors that hinder the success of TB eradication programs, such as limitation of economic resources, lack of adequate infrastructure systems in the urban and rural regions, inadequacies in sheltering and nutrition, as well as instability, conflicts, and difficulties in accessing health care services. However, the country has been located in a rapidly developing region where socio-economic development and transformation has been experienced in many fields in recent years. This study includes the analysis of Acid Resistant Basil (ARB) smear examination results of patients admitted to a tertiary health center in the region where public health surveillance, screening programs, and treatment interventions have been disrupted for the last 30 years due to the aforementioned reasons. A total of 5,160 ARB test results of 3,909 patients admitted to the hospital with different medical reasons during the 4-year period between July 2016 and November 2019 were included in the study. The mean age was 43.3±21.8 years, with a range of <1 to 97 years and the ARB test positivity rate was found to be %5.63 (220/3,909) in the study group. The positivity rate was 6.70% (158/2,199) in males and 3.99% (62/1,490) in females (p<0.001). The group most affected by the infection (TB) were young and adult men between the ages of 10-40. HBsAg, anti-HCV and anti-HIV tests were also performed for approximately half of the patients who requested ARB test and the co-infection rates for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) were found as 9.68%, 2.46%, and 0.0%, respectively. These rates are compatible with the seroepidemiological situation of the mentioned viral infections in the region. The results also reveal the low frequency of HIV-TB co-infections in the Somali population, unlike other regions of sub-Saharan Africa. The co-infection rate for syphilis, in which fewer patients were tested, was found to be 2.27%. It was found that ARB positivity rates changed as 5.31%, 6.44%, and 5.63% between 2017-2019 and did not increase or decrease according to years; with the exception of 2016 (11.2%) when a small number of patients were admitted. Early diagnosis and early treatment of active cases are critical for the effectiveness of TB control programs. Despite certain limitations, the data presented in the study can be considered as a reference point for future studies.
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Open Access Journal [doi: 10.54584/lms.2022.20] Research Article
Acid-Fast Bacilli Smear Positivity and HBV, HCV, HIV, and Syphilis Co-infections
between 2016 and 2019 in Mogadishu, Somalia
Somali Mogadişu’da 2016 ve 2019 arasında Aside Dirençli Basil Yayma Pozitifliği
ve HBV, HCV, HIV ve Sifiliz Ko-enfeksiyonları
Kemal TEKİN1 [ ], Mohamed ABDI OSMAN2 [ ], Faduma NUR ADAN2 [ ],
Ahmed Muhammad BASHIR3 [ ], Hilmi Erdem SÜMBÜL3 [ ], Fatih ŞAHİNER4 [ ]
1Medical Microbiology Laboratory, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Türkiye.
2Department of Infectious Disease and Clinical Microbiology, Mogadishu Somalia-Turkey Recep Tayyip Erdoğan Training and
Research Hospital, University of Health Sciences, Mogadishu, Somalia.
3Department of Internal Medicine, Mogadishu Somalia-Turkey Recep Tayyip Erdoğan Training and Research Hospital,
University of Health Sciences, Mogadishu, Somalia.
4Department of Medical Microbiology, Mogadishu Somalia-Turkey Recep Tayyip Erdoğan Training and Research Hospital,
University of Health Sciences, Mogadishu, Somalia.
Article Info: Received; 19.08.2022. Accepted; 14.09.2022. Published; 29.09.2022.
Correspondence: Tekin K; MD., Medical Microbiology Laboratory, Gulhane Training and Research Hospital, University of
Health Sciences, Ankara, Türkiye. E-mail: ktekin1978@gmail.com
Cite as: Tekin K, Abdi Osman M, Nur Adan F, Bashir AM, Sümbül HE, Şahiner F. Acid-Fast Bacilli Smear Positivity and HBV,
HCV, HIV, and Syphilis Co-infections between 2015 and 2019 in Mogadishu, Somalia. Life Med Sci 2022; 1(4): 140-146.
Abstract
Although tuberculosis (TB) is a treatable disease, it continues to be an important health problem
affecting societies worldwide. TB is one of the 10 most common causes of death worldwide today, despite the
efforts of national organizations and the global struggle efforts of the World Health Organization (WHO), that
have continued since its first establishment and exceeded seventy years. Somalia faces many negative factors
that hinder the success of TB eradication programs, such as limitation of economic resources, lack of adequate
infrastructure systems in the urban and rural regions, inadequacies in sheltering and nutrition, as well as
instability, conflicts, and difficulties in accessing health care services. However, the country has been located
in a rapidly developing region where socio-economic development and transformation has been experienced
in many fields in recent years. This study includes the analysis of acid-fast bacilli (AFB) smear examination
results of patients admitted to a tertiary health center in the region where public health surveillance, screening
programs, and treatment interventions have been disrupted for the last 30 years due to the aforementioned
reasons. A total of 5,160 AFB test results of 3,909 patients admitted to the hospital with different medical
reasons during the 4-year period between July 2016 and November 2019 were included in the study. The
mean age was 43.3±21.8 years, with a range of <1 to 97 years and the AFB test positivity rate was found to
be %5.63 (220/3,909) in the study group. The positivity rate was 6.70% (158/2,199) in males and 3.99%
(62/1,490) in females (p<0.001). The group most affected by the infection (TB) were young and adult men
between the ages of 10-40. HBsAg, anti-HCV and anti-HIV tests were also performed for approximately half
of the patients who requested AFB test and the co-infection rates for hepatitis B, hepatitis C, and human
immunodeficiency virus (HIV) were found as 9.68%, 2.46%, and 0.0%, respectively. These rates are
©Copyright . Licenced by Creative Commons Attribution-NonCommercial 4.0 International ( ).
Tekin K, et al. Life Med Sci 2022; 1(4): 140-146.
141
compatible with the seroepidemiological situation of the mentioned viral infections in the region. The results
also reveal the low frequency of HIV-TB co-infections in the Somali population, unlike other regions of sub-
Saharan Africa. The co-infection rate for syphilis, in which fewer patients were tested, was found to be 2.27%.
It was found that AFB positivity rates changed as 5.31%, 6.44%, and 5.63% between 2017-2019 and did not
increase or decrease according to years; with the exception of 2016 (11.2%) when a small number of patients
were admitted. Early diagnosis and early treatment of active cases are critical for the effectiveness of TB
control programs. Despite certain limitations, the data presented in the study can be considered as a reference
point for future studies.
Keywords: Tuberculosis, AFB smear, Somalia, Hepatitis B, Hepatitis C, HIV, Syphilis.
Özet
Tüberküloz (TB) tedavi edilebilir bir hastalık olmasına rağmen nya genelinde toplumları etkileyen
önemli bir sağlık sorunu olmaya devam ediyor. Ulusal kuruluşların çabaları ve Dünya Sağlık Örgütü’nün (DSÖ)
ilk kurulduğu yıllardan itibaren devam eden ve yetmiş yılı aşan global mücadele sürecine rağmen, TB
günümüzde dünya genelinde en yaygın 10 ölüm nedeninden biridir. Somali ekonomik kaynakların kısıtlılığı,
kentsel ve kırsal lge altyapı sistemlerindeki zayıflıklar, barınma ve beslenmedeki yetersizlikler gibi TB
eradikasyon programlarının başarısı önündeki birçok olumsuz etkenin varlığı yanında istikrarsızlık, çatışmalar
ve sağlık bakım hizmetlerine ulaşımdaki güçlükler ile karşı karşıyadır. Ülke aynı zamanda son yıllarda birçok
alanda sosyoekonomik gelişmenin ve dönüşümün yaşandığı hızlı gelişmekte olan bir bölgede konumlanmıştır.
Bu çalışma, son 30 yıllık dönemde toplum sağlığı sürveyansının, tarama programlarının ve tedavi süreçlerinin
bahsedilen nedenler ile aksadığı bölgede bir üçüncü basamak sağlık merkezine başvuran hastaların aside
dirençli basil (acid-fast bacilli, AFB) yayma inceleme sonuçlarını içermektedir. Çalışmaya Temmuz 2016 -
Kasım 2019 tarihleri arasındaki 4 yıllık süreçte çeşitli tıbbi gereelerle hastaneye başvuran 3909 hastaya ait
toplam 5160 AFB test sonucu dahil edilmiştir. Ortalama yaşın 43.3±21.8 yıl (<1 ile 97 aralığında) olduğu
çalışma grubunda AFB test pozitifliği oranı %5.63 (220/3909) olarak bulundu. Pozitiflik oranı erkeklerde 6.70%
(158/2199) ve kadınlarda 3.99% (62/1490) idi (p<0.001). Enfeksiyondan (TB) en çok etkilenen grup 10-40
yaş arası genç ve erişkin erkeklerdi. AFB test istemi olan hastaların yaklaşık yarısı için HBsAg, anti-HCV ve
anti-HIV testleri de çalışılmıştı ve hepatit B, hepatit C ve insan immün yetmezlik virusu (human
immunodeficiency virus, HIV) için ko-enfeksiyon oranları sırasıyla %9.68, %2.46 ve %0.0 olarak bulundu. Bu
oranlar ilgili viral enfeksiyonların bölgedeki seroepidemiyolojik görünümleri ile uyumlu olup, bu sonuçlar ayrıca
Afrikanın diğer bölgelerinden farklı olarak Somali popülasyonunda HIV-TB ko-enfeksiyonlarının düşük sıklığını
göstermektedir. Daha az sayıda hastanın test edildiği sifiliz için ko-enfeksiyon oranı ise %2.27 olarak bulundu.
Az sayıda hastanın kabul edildiği 2016 yılı (%11.2) hariç olmak üzere, AFB pozitiflik oranlarının yıllara göre
artma veya azalma eğiliminde olmadığı ve 2017-2019 yılları arasında yıllara göre %5.31, %6.44 ve %5.63
olarak değiştiği bulundu. Aktif olguların erken tanı ve tedavisi TB kontrol programlarının etkinliği için kritik
öneme sahiptir. Bazı sınırlılıklara rağmen, çalışmada sunulan veriler daha ileri çalışmalar için bir referans
noktası olarak kabul edilebilir.
Anahtar Kelimeler: Tüberküloz, AFB yayma, Somali, Hepatit B, Hepatit C, HIV, Sifiliz.
Introduction
Tuberculosis (TB), viral hepatitis and human
immunodeficiency virus (HIV) infections are
defined as common public health problems
worldwide and TB is one of the 10 most common
causes of death worldwide [1,2]. According to the
World Health Organization (WHO) data,
tuberculosis has been the leading cause of death
in Somalia for decades (2000 and 2019) [3]. WHO
has focused on fighting against infectious
diseases, especially malaria and tuberculosis,
since its foundation (1948) [4], and today, this
struggle continues to be maintained by updating
the targets [5].
Geographical regions with medium and low
levels of social and economic development facing
deficiencies in hygiene, income, shelter, and
nutrition problems are under a more serious
burden in terms of TB cases and deaths compared
to other parts of the world [5]. Somalia has the
lowest Universal Health Coverage (UHC) index in
the world in 2019 and only 27% of the population
Tekin K, et al. Life Med Sci 2022; 1(4): 140-146.
142
had access to basic health services without
financial difficulties [3].
Despite the disruptions and difficulties
encountered in TB surveillance due to the COVID-
19 outbreak, it is estimated that approximately 10
million new TB cases (best estimate; 127 cases
per 100,000 population) and 1.5 million TB-
related deaths (1.3 million among HIV negative
people and an additional 214,000 among HIV
positive people) occurred in 2020 (WHO Global
tuberculosis report 2021) [5]. According to WHO
estimates, the TB-related death rate per 100,000
people in Somalia in 2019 was 226.2, significantly
higher than the world average [3].
According to the WHO 2021 report; in 2020,
most TB cases were in WHO's geographical
regions of Southeast Asia (43%), Africa (25%),
and the Western Pacific (18%) [5]. It is estimated
that 8.0% of all TB cases are individuals living
with HIV and HIV co-infected TB cases have the
highest rates in countries in the WHO African
Region, and in some parts of southern Africa it is
exceeds 50% [5]. In Somalia, HIV seroprevalence
is relatively low [6] and the major obstacles to TB
eradication efforts are conflict and vulnerability,
low tuberculosis detection rates, difficulties in
accessing treatment, and multi-drug resistant TB
cases [5,7]. Previous WHO report revealed that
the proportion of tuberculosis cases that are
treated %42 in 2019 Somalia [3]. In a nationwide
survey conducted in 2011, the rates of multidrug-
resistant tuberculosis in patients with new and
previously treated tuberculosis were found to be
5.2% and 40.8%, respectively [8], and these drug
resistance levels were among the highest
documented in Africa and the Middle East [8].
Microscopic examination of acid-fast bacilli
(AFB) with Ehrlich-Ziehl Neelsen (EZN) staining,
which is a fast, inexpensive, and first-line method
in the diagnosis of tuberculosis, is a widely used
screening method [9]. Due to limited laboratory
facilities and the absence of comprehensive
prevalence studies, it is currently difficult to
determine the true prevalence of TB cases in
Somalia. In this screening study, it was aimed to
reveal the basic demographic profiles and co-
infection characteristics of active TB patients in
our region (Mogadishu, Somalia) by investigating
AFB positivity rates over a four-year period. Thus,
it is aimed to raise awareness about taking
preventive measures against the spread of
tuberculosis infection throughout the society,
especially among healthcare workers.
Material and Method
The study was conducted after obtaining
approval from the institutional ethics committee
(Ethics Committee of Mogadishu Somalia-Turkey
Recep Tayyip Erdoğan Training and Research
Hospital, date: 05.12.2019, decision no: 182,
number: MSTH/2723). The study was conducted
in accordance with the principles of the
Declaration of Helsinki.
Study group and design
All patients who applied to Mogadishu Somali
Turkey Recep Tayyip Erdoğan Training and
Research Hospital with suspected complaints or
findings of TB and who tested for AFB in the
Medical Microbiology laboratory during the 4-year
period between July 2016-November 2019 were
included in the study. AFB positivity rates were
determined in different age and gender groups
and the changes of the rates according to years
by retrospectively investigating of the hospital
electronic information record system. In the next
step, HBsAg, anti-HCV, anti-HIV, and Treponema
pallidum serologic tests were retrospectively
investigated for the study group.
Microscopic evaluation
Only respiratory tract samples were included
in the study, and a small number of other clinical
materials (urine, cerebrospinal and pleural fluid
samples) were excluded. Homogenization and
decontamination processes were applied to
clinical samples by sodium hydroxide-N-acetyl-L-
cysteine (NAOH-NALC) method. All samples were
concentrated by centrifugation at 3500 rpm for 15
minutes and a smear preparation was prepared
for microscopy. Preparations evaluated as positive
by the observation of red bacilli on a blue
background. According to CDC criteria patients
samples were classified as follows; 1-9 bacilli
observation in 100 areas was determined as +, 1-
9 bacilli in 10 areas as ++, 1-9 bacilli in each area
as +++, and over 9 bacilli observed in each area
as ++++ [10]. Microscopic examination results of
Tekin K, et al. Life Med Sci 2022; 1(4): 140-146.
143
the same patient within a three-day period were
accepted as a single test request and three
examinations were reported as a single report.
Serological tests
HIV serological tests were performed using
the Architect HIV Ag/Ab Combo Reagent Kit
(Abbott Diagnostics, Wiesbaden, Germany) on the
Architect I 2000 SR (Abbott Diagnostics, Abbott
Park, IL USA) system. Samples with low-level
(<10.0 S/Co) reactivity in the detection assay
were retested using a second screening assay
(Elecsys HIV combi PT assay) on a different
system (Cobas e 411 analyzers, Roche
Diagnostics, Rotkreuz, Switzerland).
Anti-HCV and HBsAg tests were performed
using the Architect Kits (Abbott Diagnostics,
Germany) on the Architect I 2000 SR system
(Abbott Diagnostics, USA). For syphilis diagnosis,
the Architect Syphilis TP assay was used in the
same platform. In addition, a rapid
chromatographic immunoassay test (VESRapido
Immunochromographic cassette test, Vesta
Medical, Ankara, Turkey) was used for the
qualitative detection of Treponema pallidum IgG
and IgM antibodies as an alternative confirmation.
Statistical analysis
At the end of the study, frequency, mean and
standard deviation values were calculated, and
comparisons were performed using the chi-square
and/or Fisher’s exact probability test. A p value of
<0.05 was considered statistically significant (at
the 95% confidence interval). All analyses were
undertaken using SPSS v. 22.0 (IBM SPSS
Statistics Version 22.0., IBM Corp., Armonk, New
York, USA).
Results
A total of 5,160 test results from 3,909
different patients were evaluated in the present
study; 3,125 patients had a single sample, while
784 patients had multiple test requests at
different times. The mean age of the participants
was 43.3±21.8 years, with a range of <1 to 97
years. The positivity rate in the study group was
found to be %5.63 (220/3,909).
Of 220 AFB positive patients, 71.8% were
male and 28.2% were female. The rate of positive
test results was 6.70% (158/2,199) in males and
3.99% (62/1,490) in females (p=0.0003). Young
and adult men between the ages of 10 and 40
were the group most affected by the infection
(Table 1).
The distribution of smear examinations was
as follows: + 4.09% (9/220), ++ 4.55%
(10/220), +++ 68.2% (150/220), and ++++
23.2% (51/220). For 220 AFB-positive cases, the
majority of the patients had TB-compatible
findings on chest X-ray (~75%) and/or computed
tomography examinations (~25%).
Table 1. Distribution of AFB-positive patients according to years, age groups, and gender.
age groups
<1-10
11-20
21-30
31-40
41-50
51-60
61-70
≥71
Total
%*
years / results
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
n (F+M)
2016
positive
0
0
0
1
3
6
0
4
0
1
2
0
0
2
0
1
20
11.2
negative
4
6
6
17
11
14
9
8
7
7
15
11
14
9
6
14
158
2017
positive
0
1
2
9
6
12
4
7
2
3
0
3
1
6
0
3
59
4.52
negative
24
34
71
87
85
148
78
81
72
87
69
88
68
87
58
110
1,247
2018
positive
0
0
2
8
7
20
4
9
2
4
1
3
1
4
1
5
71
5.31
negative
25
49
56
89
91
176
59
94
65
98
66
94
62
99
51
93
1,267
2019
positive
0
0
2
7
4
16
3
9
2
5
6
4
3
2
4
3
70
6.44
negative
15
16
44
69
83
124
55
89
48
69
73
67
60
81
40
84
1,017
Total
3,909
positive
0
1
6
25
20
54
11
29
6
13
9
10
5
14
5
12
220
5.63
negative
68
105
177
262
270
462
201
272
192
261
223
260
204
276
155
301
3,689
%
0.00
0.94
3.28
8.71
6.90
10.5
5.19
9.63
3.03
4.74
3.88
3.70
2.39
4.83
3.13
3.83
5.63
F: Female. M: Male. AFB: Acid-fast bacilli. *Percentage of AFB-positive patients by years.
Tekin K, et al. Life Med Sci 2022; 1(4): 140-146.
144
When the retrospective data were examined,
it was found that HBsAg, anti-HCV, and anti-HIV
tests were performed for approximately half of the
patients who requested AFB test, and co-infection
rates for the related diseases were 9.68%,
2.46%, and 0.0%, respectively (Table 2). The co-
infection rate for syphilis, in which fewer patients
were tested, was found to be 2.27%. Only 18 HIV-
seropositive patients (6.69%; 18/269) were
screened for acid fast bacilli in sputum, and all had
negative AFB screening. It was found that AFB
positivity rates did not increase or decrease
according to years with the exception of 2016
(11.2%) when a small number of patients were
admitted, and positivity rates changed as 5.31%,
6.44% and 5.63% between 2017-2019.
Table 2. Acid-fast bacilli smear positivity and anti-HIV, anti-HCV, HBsAg, and syphilis seropositivity.
age groups
1-10
11-20
21-30
31-40
41-50
51-60
61-70
≥71
Total
Co-I
%*
AFB
P
N
P
N
P
N
P
N
P
N
P
N
P
N
P
N
P
N
HBV
positive
0
1
1
3
2
24
6
24
0
35
2
24
0
26
1
37
12
174
9.68
negative
0
73
21
216
35
350
17
221
11
214
7
262
11
239
10
235
112
1,810
HCV
positive
0
0
1
0
0
1
0
1
0
1
0
7
2
13
0
17
3
40
2.46
negative
0
74
20
221
36
376
23
238
10
251
9
277
9
255
12
259
119
1,951
HIV
positive
0
0
0
1
0
3
0
2
0
3
0
1
0
2
0
0
0
12
0.00
negative
0
76
12
176
39
339
19
203
9
209
10
234
8
224
11
242
108
1,703
Syp.
positive
0
0
0
0
0
1
0
4
0
5
0
6
0
11
1
19
1
46
2.27
negative
0
1
9
68
17
151
6
68
5
85
1
76
2
79
3
61
43
589
Co-I: Co-infection. HBV: Hepatitis B virus. HCV: Hepatitis C virus. HIV: Human immunodeficiency virus. Syp: Syphilis.
AFB: Acid-Fast Bacilli. *Seropositivity rate for related infection in AFB positive cases.
Discussion
Somalia is one of the countries with the most
limited data on the epidemiology of infectious
diseases. Accessible and reliable data on the
incidence, prevalence, or mortality rates for most
communicable diseases almost non-exist in the
last 30 years. One of the two main reasons for this
situation is that surveillance and public health
practices, which are largely disrupted due to the
conflict environment, another reason is economic
inadequacies and the absence of a strong health
infrastructure, especially in rural areas, and
problems in access to health care services. In a
recent study, delayed diagnosis of tuberculosis
patients in Mogadishu was reported as one of the
longest reported in developing countries, while
exceeding two years for some patients [11]. This
situation has been stated as an important public
health problem that causes the continuation of the
tuberculosis transmission cycle in the community
[11]. However, it is promising that an increasing
number of data has been added to the literature
in recent years on the prevalence of infectious
diseases in Somalia [6,1215].
TB case detection rate in Somalia is estimated
at 42%, which is much lower than the WHO target
of detecting 70% of new TB cases [11]. TB control
programs in Somalia are based on passive case
detection, in which infectious cases applying to
health institutions are only diagnosed [11]. Our
study, which includes TB screening results of a
large group of patients, includes data from nearly
4000 patients who applied to our hospital for
various reasons in a long period of 4 years. In this
study, in which the rate of patients with at least
one positive AFB result was 5.63%. Culture
confirmation was performed for a small number of
these patients, while diagnosis and typing by PCR
was performed only in national TB centers where
infected patients detected by screening tests were
referred.
Although the lack of confirmatory laboratory
diagnosis was the major limitation of the study,
the majority (91.3%) of the patients were highly
(+++ or ++++) AFB positive and TB compatible
findings were found in radiological (CXR and CT)
examinations for almost all AFB positive patients.
Another limitation of the study is the possibility
Tekin K, et al. Life Med Sci 2022; 1(4): 140-146.
145
that seropositivity is an indicator of past infection,
especially for syphilis. However, while HBsAg
positivity is most likely associated with active
infection, anti-HCV and anti-HIV positivity are also
a high probability indicator of chronic infection in
a country where treatment opportunities are
limited. Another important point is that low-
positive results for all infections were excluded in
the study and not included among co-infections.
Co-infection rates in AFB-positive patients
were 9.68%, 2.46% and 0.0% for hepatitis B
(HBV), hepatitis C (HCV), and HIV, respectively,
according to HBsAg, anti-HCV, and anti-HIV
testing results. These rates are compatible with
the seroepidemiological situation of the
mentioned viral infections in the region. In the
comprehensive studies conducted in our hospital
recently, anti-HCV and anti-HIV seropositivity
were found as 1.41% (1,447/102,601) and 0.32%
(269/82,954), respectively [6,16]. Also in another
study recently conducted in our hospital, HBsAg
seropositivity was found as 8.2% (6,893/84,505)
[17]. Our results indicate that HIV-TB co-
infections are less common in Mogadishu, one of
the most populated cities in Somalia, unlike sub-
Saharan Africa countries. Of the 1,715 patients
tested for anti-HIV serology in our study, only 12
(0.7%) were HIV positive, also all HIV positive
patients were AFB negative. In a study conducted
between 2019-2020 and including 3,061 TB
patients, 46 (1.5%) of the patients were found to
be HIV/TB co-infected [15]. In the mentioned
study, it was found that 78.2% of HIV-TB co-
infected cases were between the ages of 20-49
(p=0.00048). In another study that included 385
people under TB treatment, the HIV co-infection
rate was found to be 2.6% (10/385) [18].
In the afore-mentioned study conducted with
3,061 patients, 63% of the patients were reported
as male and 37% as female [15]. Similarly, in
another study that included 385 patients under TB
treatment, the female-male ratio was reported as
33.5/66.5 (p<0.001). While these two studies
included patients under treatment, our study
included only screening tests for suspected
patients. Nevertheless, in the present study the
gender distribution was similar to the other two
studies; AFB positivity rates were found higher in
male patients than female patients, 71.8% and
28.2% respectively. As a reflection of this
situation regarding gender distribution, according
to WHO data for 2019, TB-related deaths in
Somalia were reported to be 177.8 for women and
290.8 for men per 100,000 people [3].
In this study, it was also found that "the
group most affected by the infection" are young
and adult men between the ages of 10-40.
Similarly, a 2017 study conducted in Mogadishu
reported that three-quarters of 385 patients
under treatment were young adults (18-37 years
old) [18].
Although WHO data has reported a decrease
in TB-related deaths in Somalia from 2000 to
2019 [3], TB has ranked first among all causes of
death in the intervening 20 years. In our study,
which included data from a single center in a
relatively short period of 4 years, no remarkable
decrease was observed in positive cases.
Conclusion
Our study provides up-to-date data on the
prevalence by years and co-infection
characteristics of TB infections (in a wide age
range including children) in Somalia where there
is limited information on the epidemiology of
infectious diseases in the literature, including TB.
We think that presented data of this study
conducted in the shadow of socioeconomic
inadequacies, deficiencies in health infrastructure,
and ongoing conflicts, can be considered as a
reference point for future studies.
Conflict of interest: The authors declare that there is no conflict of interest. The authors alone are responsible
for the content and writing of the paper. Financial disclosure: There is no financial support for this study.
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Article
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Background: Low tuberculosis (TB) detection and conflict and fragility have overburdened Somalia. This study estimated economic loss associated with TB deaths among persons aged >14 years. Method: Using epidemiologic and economic data, we calculated the cost based on the framework of the World Health Organization guide of identifying the economic consequences of disease and injury. Baseline loss is the product of years of life lost, non-health expenditure, and number of deaths. Adjusting for conflict and fragility conditions and growth of non-health expenditure, we discounted the loss at 3% rate. We conducted a sensitivity analysis of epidemiologic and economic factors. Results: In 2017 values, the 9180 reported deaths result in a loss of US$ 44.77 million, a US$ 4877 per death over the discounted years. Conflict conditions would increase the loss by 5.3%, while simultaneous adjustment for conflict and attunement to growth of non-health expenditure would increase the burden by 54% to US$ 67.28 million. Male fatalities account for 59% of the burden. The baseline result is robust to input variations, although sensitivity analysis suggests conflict and fragility conditions account for greater uncertainty of the loss. Conclusion: Stakeholders in the healthcare system should minimise the sizeable economic loss by taking measures to enhance surveillance of TB and security.
Article
Background: Acquired immunodeficiency syndrome (AIDS) remains a major global public health problem. This study aimed to obtain current epidemiological data on the Human immunodeficiency virus (HIV) infections in Mogadishu, Somalia. Methods: This study included 92,270 anti-HIV test results reported for 82,954 different individuals between 2015 and 2019. HIV tests were performed using the Architect HIV Ag/Ab Combo assay and retested with the Elecsys HIV combi PT assay. Results: HIV seropositivity was found to be 0.32% (269/82,954) in all individuals over a period of four years. Anti-HIV seropositivity in the 0 - 14, 15 - 19, 15 - 24, 15 - 49, and > 15 age groups were as follows: 0.17% (11/6,441), 0.17% (12/7,131), 0.15% (35/24,132), 0.37% (212/56,895), and 0.34% (258/76,513), respectively. In HIV-infected patients, anti-HBs, HBsAg, anti-HCV, and anti-TP (syphilis) seropositivity was found to be 30.3% (56/185), 9.54% (23/241), 1.24% (3/242), and 3.45% (2/58), respectively. Conclusions: The findings from this study provide comprehensive data on the HIV epidemiology in Somalia. We believe that the results presented in this study will contribute to the risk analysis and planning of preventive policies of national and global health organizations.