Predicting Tuberculosis Incidence and Its Trend in Tigray, Ethiopia: A Reality-Counterfactual Modeling Approach

Background: The Tigray region of Ethiopia, which has been affected by civil war from 2020 to 2022, is facing an increase in tuberculosis in the damaged health system. Our study employed mathematical modeling to predict the incidence of tuberculosis and its trends during the war and in the post-conflict setting of Tigray, Northern Ethiopia.
Methods: We predicted the incidence of tuberculosis from 2020 to 2025 in Tigray using the SEIRD model in the context of the recent war and compared it with its counterfactual trend in the absence of war. The counterfactual trend was forecasted using an autoregressive integrated moving average (ARIMA) model for stationary time-series data. We performed rolling origin cross-validation for ARIMA and sensitivity analysis for the SEIRD model. The initial tuberculosis data and model parameters were obtained from the Institute for Health Metrics and Evaluation and the literature, respectively.
Results: Between 2000 and 2017, the incidence of tuberculosis in Tigray decreased at an annual rate of 3.0%. Shortly before the war, the incidence of tuberculosis in the region was 178 per 100,000 people. In a counterfactual scenario where there was no war, the incidence was projected to decrease to 144.3 in 2022 and 126.3 in 2025. However, owing to the war and siege, the SEIRD-projected incidence of tuberculosis would have increased to 965.5 (95% CI: 958.5– 972.7) in 2022 and 372.4 (95% CI: 367.7– 376.6) in 2025. Over 800 cases of tuberculosis per 100,000 people were attributed to the war in 2022. In the postwar period, the incidence is projected to decrease by 30% by 2023.
Conclusion: The Tigray War reversed a two-decade decline in tuberculosis cases, causing a five-fold increase compared to the no-war scenario. Urgent interventions are needed to support tuberculosis prevention, testing, and treatment, particularly in key and vulnerable populations.