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OPEN Prevalence and types of anemia

among people with tuberculosis
in Africa: a systematic review
and meta‑analysis
Yeshewas Abaynew 1,2*, Ahmed Ali 2, Girma Taye 2 & Melese Shenkut 3
Globally, tuberculosis (TB) and anemia are public health problems related with high morbidity and
mortality. Furthermore, anemia is frequently manifested among people with TB in Africa, prevalence
ranging from 25 to 99%. The presence of anemia is associated with an increase in individuals’
susceptibility to TB and poor treatment outcomes. Studies have reported heterogeneous estimate of
prevalence of anemia among people with TB in Africa. This review aimed to estimate the prevalence
of anemia among newly diagnosed people with TB n Africa. We searched studies in Medline/PubMed,
Cochrane library, ScienceDirect, JBI database, the Web of Science, Google Scholar, WorldCat, Open
Grey, Scopus, Agency for Healthcare Research and Quality, ProQuest, and African Journals Online that
reported the prevalence of anemia at TB diagnosis. Two reviewers performed data extraction with pre-
defined inclusion criteria. A random-effects logistic regression model was used to pool the prevalence
of anemia and levels of anemia with a 95% confidence interval (CI) in STATA version 14. Heterogeneity
and publication biases were explored. A total of 1408 studies were initially identified, and seventeen
studies with 4555 people with TB were included in the analysis. The prevalence of anemia among
people with TB in Africa was 69% (95% CI 60.57–77.51). The pooled prevalence of anemia of chronic
disease was 48% (95% CI 13.31–82.75) and normocytic normochromic anemia was 32% (95% CI 13.74–
50.94) while mild anemia was 34% (95% CI 20.44–46.86). Females were more anemic than males at TB
diagnosis in Africa (74% vs. 66%). The finding indicates that anemia is a common co-morbidity present
among people with TB, especially among females. Mild anemia and normocytic normochromic anemia
were more common at TB diagnosis. The finding indicates that anemia is a common co-morbidity
present among people with TB in Africa region. Hence, it is recommended to instigate a routine
anemia screening at TB diagnosis to improve treatment outcomes.

Tuberculosis (TB) is principally caused by the bacillus Mycobacterium tuberculosis and can manifest as either
pulmonary or extra-pulmonary T ­ B1. Globally, a total of 1.6 million deaths recorded and an estimated 10.6 mil-
lion people have developed TB in 2­ 0211.
Globally, anemia is a worldwide public health ­problem2 that affects one-quarter of the world’s population with
an estimated global prevalence of 24.8% in 2­ 0083. In 2010, Kassebaum et al.4 affirmed that 32.9% of the world
population were anemic. Globally in 2019, the prevalence of anaemia in non-pregnant women aged 15–49 years
30%, while in pregnant women aged 15–49 years it 36% (34–39)5.
Anemia is functionally defined as insufficiency of erythrocyte mass to deliver oxygen in sufficient amount to
peripheral ­tissues6. The effects of anemia is diverse among people with TB such as a risk factor for the develop-
ment of T­ B7 and is associated with TB complications including lung injury and poor prognosis such as poor
sputum conversion 2 months after TB treatment initiation and also an increased risk of ­deaths8–11.
Anemia among people with TB has been related to inflammatory mediators on e­ rythropoiesis12, iron-defi-
ciency9,12, chronic i­ nflammation13, the disease ­itself14, hemoptysis, m
­ alnutrition6, bone marrow suppression, and
­ tilization15,16. Chronic inflammation and iron deficiency are predominant contributors to the
failure of iron u
presence of anemia among people with ­TB9.

1
Department of Biostatistics and Epidemiology, College of Medicine and Health Sciences, Wollo University, Dessie,
Ethiopia. 2Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa
University, Addis Ababa, Ethiopia. 3Department of Anatomy, College of Medicine and Health Sciences, Wollo
University, Dessie, Ethiopia. *email: yag2005@yahoo.com

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Studies in Africa have reported anemia to be the most common hematological derangement among people
with TB, however, the prevalence of anemia at TB diagnosis vary widely ranging from 25 to 99%17,18. Existing
studies are heterogeneous due to variation in the sample size, methods, population characteristics, and definitions
of anemia. Available studies used different criteria to define anemia including the WHO criteria. Additionally, the
small sample size among studies might contribute to the varied estimate of prevalence of anemia. Furthermore,
the variation in prevalence of anemia among studies may be attributed to the inclusion of TB-HIV co-infected
people in some studies since HIV infected people hemoglobin levels are significantly lower than HIV-negative
­people19.
Multiple studies have also documented the types of anemia presented at TB diagnosis, but findings are
inconsistent across studies; in many studies, mild anemia has been commonly encountered at TB d ­ iagnosis18,20.
21–24
Yet, other studies have reported moderate a­ nemia . Conversely, severe anemia is relatively a rare event with
prevalence ranges between 2.5 and 32.5%17,25. This inconsistency of the prevalence of the types of anemia among
people with TB could be attributed to variations of studies in terms of the sample size and study population.
Morphologically, studies have indicated that normocytic normochromic anemia is commonly present at the
time of TB d­ iagnosis20,22. However, in some studies microcytic hypochromic anemia is profoundly encountered
at TB d­ iagnosis18,24. Moreover, macrocytic anemia is often identified in less than 10% of patients at the time
of diagnosis of ­TB18. Normocytic hypochromic picture is also reported in studies with a variable frequency,
including 32.5% in E ­ thiopia23, 47.5% in the Democratic Republic of C ­ ongo24. It is noted that the observed vari-
ation might be associated to the impact of HIV/AIDS and the differences in the cutoff values used to define the
morphological pattern of anemia.
The heterogeneity in the prevalence of anemia among people with TB at diagnosis prompted us to consider
a systematic review and meta-analysis. In addition, there is no data on the estimate of the prevalence and level
of anemia among people with TB in Africa. The review was conducted to estimate the prevalence and levels of
anemia including the morphological patterns at TB diagnosis that is needed to consider anemia co-morbidity
the management of TB.
Anemia is an important co-morbid condition among people with TB and has been associated with poor
prognosis during treatment. So, there is a need to know the characteristic of anemia as a risk factor associated
with poor complications of TB to institute an intervention to address anemia among people with TB to achieve
the END TB strategy.

Results
Description of studies. As indicated in Fig. 1, the searching in electronic databases identified 1371 studies,
and 37 studies were manually included with review of references cited in the retrieved studies. A total of 355
studies were duplicated and were removed. Moreover, 916 studies were unrelated to the purpose of the current
review and were excluded from further review process. The remaining 137 studies were selected to undergo a full
paper review (Fig. 1). Finally, the review was done on 17 studies that scored 5 and above on the Joanna Briggs
Institute (JBI) quality appraisal criteria.

Characteristics of included studies. As depicted in Table 1, a total of 11 cross-sectional studies, 5 case–

control studies, and one randomized clinical trial were included. Among studies included, one was from Demo-
cratic Republic of ­Congo24, another was from ­Egypt18, four were from ­Ethiopia17,20,23,27, one was from G ­ ambia28,
two were from M ­ alawi15,29, one was from N ­ igeria30, one was from South A
­ frica25, two were from S­ udan22,31, and
four were from T ­ anzania9,21,32,33. Regarding the sample size of included studies, 39 is the smallest number of
­participants28 and 1245 is the maximum number of ­participants21 (Table 1).

Prevalence of anemia among people with tuberculosis. Among 4555 people with TB included in
the review, 3311(73%) had anemia. A total of 17 studies were found to be eligible to calculate the overall preva-
lence of anemia among people with TB, and the pooled prevalence of anemia was 69% (95% CI 60.57–77.51;
­I2 = 98%, p = 0.000) (Fig. 2).
The pooled estimate of mild, moderate and severe anemia was 34% (95% CI 20.44–46.86; I­ 2 = 99%, p = 0.000),
29% (95% CI 15.81–43.12; ­I2 = 99%, p = 0.000) and 10% (95% CI 5.77–14.28; ­I2 = 95%, p = 0.000) respectively
(Fig. 3).
The combined prevalence of anemia in male and female patients was 67% (95% CI 42.87–90.88; ­I2 = 99%,
p = 0.000) and 74% (95% CI 51.37–97.51; I­ 2 = 99%, p = 0.000) respectively (Figs. 4 and 5).

Types of anemia presented at the time of TB diagnosis. Anemia of chronic disease was the most
common type of anemia identified in TB, 48% (95% CI 35.6–74.99; I­ 2 = 98%, p = 0.000) followed by iron defi-
ciency anemia, 11% (95% CI 2.43–19.90; ­I2 = 99%%, p = 0.000) (Fig. 6).

Morphological patterns of anemia among people with tuberculosis. Considering the morpho-
logical patterns of anemia at TB diagnosis, the pooled prevalence of normocytic normochromic blood pic-
ture was 32% (95% CI 13.74–50.94; ­I2 = 96%, p = 0.000), and microcytic hypochromic anemia was 26% (95% CI
8.20–43.53; ­I2 = 96%, p = 0.000) (Fig. 7).
Publication bias was assessed with a funnel plot and with visualization the graph of the funnel plot, there
is asymmetry which suggests the presence of publication bias (Fig. 8). Egger’s regression test (bias = − 7.65,
p = 0.014) also demonstrated the existence of publication bias. However, begg’s test (z = 1.36, p = 0.174) suggested
non-significant publication bias.

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Figure 1.  Preferred reporting items for systematic reviews and meta-analyses (PRISMA)26 flow diagram
indicating the selection of studies for the systematic review and meta-analysis.

Discussion
This current systemic review and meta-analysis showed the pooled prevalence of anemia, types of anemia, and
morphological patterns among newly diagnosed people with TB in Africa. The pooled prevalence of anemia
among people with TB was 69% in Africa which is higher than a finding of a systematic review and meta-analysis,
61.53%11. In addition, studies conducted in Korea, 37%12, Iran, 25.6%34, Russia, 36.5%10, and the Philippines,
32.4%35 reported lower prevalence of anemia. This finding is also higher that pooled prevalence of anemia among
the general ­population5,and a study finding conducted in Ethiopia, (40.9%)36. However, studies conducted in
Brazil, 89.2%37, and India, 100%38 reported significantly higher prevalence of anemia among people with TB.
The observed variation could be attributed to the differences in the cut-off values used to diagnose anemia in
the included studies. Additionally, it might be as a result of the differences in the characteristics of the study
population included in the studies. In this meta-analysis, the heterogeneity between studies was substantial and
may be attributable to variations among study population characteristics, such as sex, presence of HIV/AIDS.
The current meta-analysis shows that the prevalence of anemia of chronic disease among people with TB at
diagnosis was 48%, while iron deficiency anemia was 11%. These findings are lower than a study done in Brazil,
75.9%37, and a systematic review and meta-analysis which reported a 20% of iron deficiency anemia among
people with ­TB11.
In this review, 34% of people with TB had developed mild anemia at diagnosis. However, this rate of mild
anemia is lower than studies reported from India, 60.8%13, and Korea, 84%12. A systematic review and meta-
analysis also reported a higher prevalence of mild anemia among people with TB, 35.67%11.
The present review shows that normocytic normochromic anemia is the commonest morphological pattern
of anemia, 32%. However, other studies have found microcytic hypochromic anemia to be the profound mor-
phological pattern of anemia at TB ­diagnosis39,40.
Female population with TB had higher prevalence of anemia than male population with TB (74% vs. 67%).
This result is supported by a finding from a systematic review and meta-analysis11. This finding was also noted
in a systematic analysis of global anemia burden from 1990 to 2010, which showed that females had higher
prevalence of anemia than males especially Central Asia (43.2% vs. 22.8%) and Asia Pacific (19.4% vs. 10%)4. A
study conducted in ­India41 also indicated a more pronounce prevalence of anemia among females. The observed
high rates of anemia among female TB patients as compared to males could be attributed to the existing dif-
ferences in the physiological state of females and males which is related to the monthly loss of blood during
­menstruation42. In addition, the dietary habit of women in the region may contribute for the observed difference

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No. Authors, year, country Study design Sample size Males Types of TB Anemic patients Anemic males Anemic females Quality score
Mohammed, ­201622,
1 Case–control study 40 25 SPPTB/HIV− 34 22 12 5/10
Sudan
9
Isanaka et al., ­2012 , Randomized, placebo-
2 684 448 TB/HIV+ 438 240 198 8/13
Tanzania controlled trial
18
Abdelkareem et al., ­2015 , Cross-sectional descrip-
3 100 42 PTB/HIV− 100 7/9
Egypt tive study
Atomsa et al., ­201423, Comparative cross-sec-
4 108 45 TB 40 5/9
Ethiopia tional study
Gunda et al., ­201432, Retrospective cross-
5 701 361 PTB/HIV+ 358 7/9
Tanzania sectional study
15
van Lettow et al., ­2005 ,
6 Cross-sectional study 500 227 SPPTB/HIV+ 427 8/9
Malawi
27
Abay et al., ­2018 , Comparative Cross-
7 100 51 PTB/HIV+ 53 7/9
Ethiopia Sectional Study
31
8 Bashir et al., ­2015 , Sudan Case–control study 100 77 SPPTB/HIV− 44 5/10
Mulenga et al., ­201724,
Prospective cross-sec-
9 Democratic Republic of 200 130 SPPTB/HIV+ 139 6/9
tional study
Congo
Erhabor et al., ­202030,
10 Case–control study 80 67 SPPTB/HIV− 71 5/10
Nigeria
28
Minchella et al., ­2015 , Comparative cross-sec-
11 39 28 PTB/HIV+ 26 7/9
Gambia tional study
25
Kerkhoff et al., ­2016 , Comparative cross-sec-
12 153 53 TB/HIV+ 131 44 87 7/9
South Africa tional study
17
Kahase et al., ­2020 , Comparative cross-sec-
13 40 25 PTB/HIV− 10 8/9
Ethiopia tional study
Hella et al., ­201833,
14 Case–control study 102 78 SPPTB/HIV+ 74 9/10
Tanzania
15 Yesuf, ­201720, Ethiopia Case–control study 44 30 TB/HIV+ 30 6/10
Nagu et al., ­201421, Prospective cross-sec-
16 1245 831 SPPTB/HIV+ 1067 7/9
Tanzania tional study
29
van Lettow et al., ­2004 ,
17 Cross-sectional study 319 149 SPPTB ± HIV 270 124 146 7/9
Malawi

Table 1.  A description of studies included in the systematic review and meta-analysis, 2021.

Study %
ID ES (95% CI) Weight

Mohammed MAS (2016) 85.00 (73.93, 96.07) 5.64

Isanaka et al. (2012) 64.04 (60.44, 67.63) 6.17
Abdelkareem et al. (2015) 99.00 (97.05, 100.95) 6.22
Atomsa et al. (2014) 37.04 (27.93, 46.14) 5.82
Gunda et al. (2016) 51.07 (47.37, 54.77) 6.16
van Lettow et al. (2005) 85.40 (82.30, 88.50) 6.19
Abay et al. (2018) 53.00 (43.22, 62.78) 5.76
Bashir et al. (2015) 44.00 (34.27, 53.73) 5.76
Mulenga et al. (2017) 69.50 (63.12, 75.88) 6.02
Erhabor et al. (2020) 88.75 (81.83, 95.67) 5.99
Minchella et al. (2015) 66.67 (51.87, 81.46) 5.24
Kerkhoff et al. (2016) 85.62 (80.06, 91.18) 6.07
Kahase et al. (2020) 25.00 (11.58, 38.42) 5.39
Hella et al. (2018) 72.55 (63.89, 81.21) 5.85
Yesuf M (2017) 68.18 (54.42, 81.94) 5.35
Nagu et al. (2014) 85.70 (83.76, 87.65) 6.22
van Lettow et al. (2004) 84.64 (80.68, 88.60) 6.15
Overall (I-squared = 98.3%, p = 0.000) 69.04 (60.57, 77.51) 100.00
NOTE: Weights are from random effects analysis

0 20

Figure 2.  The pooled prevalence of anemia among people with TB.

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Study %
ID ES (95% CI) Weight

Mohammed MAS (2016) 32.50 (17.99, 47.01) 7.82

Abdelkareem et al. (2015) 51.00 (41.20, 60.80) 8.25
Atomsa et al. (2014) 0.93 (-0.88, 2.73) 8.62
Gunda et al. (2016) 28.82 (25.46, 32.17) 8.59
van Lettow et al. (2005) 59.20 (54.89, 63.51) 8.56
Abay et al. (2018) 22.00 (13.88, 30.12) 8.37
Mulenga et al. (2017) 65.00 (58.39, 71.61) 8.46
Kerkhoff et al. (2016) 15.03 (9.37, 20.70) 8.50
Kahase et al. (2020) 15.00 (3.93, 26.07) 8.15
Hella et al. (2018) 38.24 (28.80, 47.67) 8.27
Yesuf M (2017) 47.73 (32.97, 62.49) 7.80
Nagu et al. (2014) 29.72 (27.18, 32.26) 8.61
Overall (I-squared = 99.0%, p = 0.000) 33.65 (20.44, 46.86) 100.00

NOTE: Weights are from random effects analysis

0 15 30

Figure 3.  The pooled prevalence of mild anemia in patients with TB.

Study %

ID ES (95% CI) Weight

Mohammed MAS (2016) 88.00 (75.26, 100.74) 19.36

Isanaka et al. (2012) 53.57 (48.95, 58.19) 20.32

Kerkhoff et al. (2016) 83.02 (72.91, 93.13) 19.76

Lee et al. (2006) 28.18 (24.12, 32.24) 20.35

van Lettow et al. (2004) 83.22 (77.22, 89.22) 20.21

Overall (I-squared = 98.7%, p = 0.000) 66.88 (42.87, 90.88) 100.00

NOTE: Weights are from random effects analysis

0 50

Figure 4.  The pooled prevalence of anemia among male TB patients.

of the prevalence anemia among sex. This difference can be attributed to the variation of health seeking behaviour
among males and females.
It is noted that the prevalence of anemia varies in the primary studies and the variation of the population
included in these studies in terms of sample size, TB type, and co-morbidity presented and the definition of
anemia significantly affected the prevalence of anemia among included studies and the observed heterogeneity
showed in the pooled analysis of the studies was attributed with aforementioned reasons. Moreover, it should
be noted that the observed inconsistences in the magnitude of the anemia in people with TB varies according
to social, economic, lifestyle, cultures, presence of infectious diseases and health-seeking behaviors in different
geographical areas. A previous study also reported a variation in growth of population, geographic area can

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Study %

ID ES (95% CI) Weight

Mohammed MAS (2016) 80.00 (59.76, 100.24) 17.90

Isanaka et al. (2012) 83.90 (79.21, 88.59) 20.58

Kerkhoff et al. (2016) 87.00 (80.41, 93.59) 20.41

Lee et al. (2006) 36.27 (31.61, 40.94) 20.58

van Lettow et al. (2004) 85.88 (80.65, 91.12) 20.54

Overall (I-squared = 98.6%, p = 0.000) 74.44 (51.37, 97.51) 100.00

NOTE: Weights are from random effects analysis

0 50

Figure 5.  The pooled prevalence of anemia among female population with TB patients.

Study %

ID ES (95% CI) Weight

Bashir et al. (2015) 15.00 (8.00, 22.00) 25.27

Minchella et al. (2015) 35.90 (20.84, 50.95) 24.37

Kerkhoff et al. (2016) 81.05 (74.84, 87.26) 25.33

Hella et al. (2018) 59.79 (50.04, 69.55) 25.03

Overall (I-squared = 98.5%, p = 0.000) 48.03 (13.31, 82.75) 100.00

NOTE: Weights are from random effects analysis

0 30

Figure 6.  The pooled prevalence of anemia of chronic disease at the time of TB diagnosis.

attributed for some increment in the prevalence of anemia among people with ­TB4. Additionally, a study done
in ­India41 revealed a high prevalence of anemia in people with low socioeconomic status, and low body weight.
Understanding of the high prevalence of anemia among people with TB from this meta-analysis has a great
importance to conclude that anemia is a common hematologic disorder among people with TB in Africa, which
can negatively influence the treatment outcome. Therefore, TB care and treatment interventions should consider
mitigating the adverse consequences of anemia on people with TB such as death by instituting routine anemia
screening at TB diagnosis.
The notable strength of this review is that studies were included in the meta-analysis after thorough qual-
ity assessment. However, the study is subjected to limitations. First, the measurement of anemia and the levels
of anemia are inconsistent across the studies; the hemoglobin cut-off values for defining the outcomes are not
based on the WHO criteria. Therefore, the outcome measurement may be over- or underestimated among the
included studies. Second, the use of different study populations could contribute to the varied prevalence of
anemia among studies which could results in a potential publication bias. Third, the searches have concentrated
on a limited number of repertories of journals and grey literature sources and relevant articles might be omitted
from the review. The inclusion of small sample studies in the meta-analysis resulted in almost equal weight for
small studies and large studies. These findings might be undesirable in meta-analysis and could be due to the

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Study %

ID ES (95% CI) Weight

Mohammed MAS (2016) 72.50 (58.66, 86.34) 19.07

Abdelkareem et al. (2015) 37.00 (27.54, 46.46) 20.20

Atomsa et al. (2014) 13.89 (7.37, 20.41) 20.77

Bashir et al. (2015) 8.00 (2.68, 13.32) 20.95

Yesuf M (2017) 34.09 (20.08, 48.10) 19.02

Overall (I-squared = 95.8%, p = 0.000) 32.34 (13.74, 50.94) 100.00

NOTE: Weights are from random effects analysis

0 30

Figure 7.  The pooled prevalence of normocytic normochromic anemia at TB diagnosis.

Number of studies = 17 Root MSE = 6.517

Std_Eff Coef. Std. Err. t P>|t| [95% Conf. Interval]

slope 95.69245 5.817123 16.45 0.000 83.29355 108.0914

bias -7.646856 2.756643 -2.77 0.014 -13.5225 -1.771212

Test of H0: no small-study effects P = 0.014

adj. Kendall's Score (P-Q) = -34

Std. Dev. of Score = 24.28
Number of Studies = 17
z = -1.40
Pr > |z| = 0.161
z = 1.36 (continuity corrected)
Pr > |z| = 0.174 (continuity corrected)

Funnel plot with pseudo 95% confidence limits

0
2
s.e. of prevalence
4
6
8

20 40 60 80 100
prevalence

Figure 8.  Funnel plot of included studies in the meta-analysis of the prevalence of anemia in TB.

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small studies might be poor quality. And the methodological error related to the use of random effects model in
the meta-analysis might contribute for the substantive conclusion of resulting similar weight for small studies
and large studies.
HIV status of study participants were not included among most studies reviewed for the meta-analysis and
due to lack of data on the HIV status of participants’ sub-group analysis was not done to determine the effects
of HIV status on the heterogeneity of studies. Lastly, the funnel plot suggests the likelihood of publication bias
then, our results must be interpreted with caution.
In conclusion, despite the aforementioned limitations, the review indicates a high prevalence of anemia
among people with TB in Africa. Anemia is frequently noted in female TB population than males at TB diagno-
sis. Whereas, the commonest types of anemia that presented at the time of TB diagnosis are anemia of chronic
disease, mild and normochromic normocytic anemia. Hence, it is recommended to institute the routine screening
of anemia at TB diagnosis and follow up to improve future treatment outcomes.

Methods
Literature search strategies. In this systematic review and meta-analysis, the preferred reporting items
for systematic review and meta-analysis (PRISMA) guidelines were u ­ sed26. We searched Medline/PubMed,
Cochrane library, Science Direct, JBI database, the web of science, Google Scholar, WorldCat, Open Grey,
Scopus, Agency for Healthcare Research and Quality, ProQuest, and African Journals Online to include both
published articles and grey literature. The following terms, “tuberculosis,” “anemia,” “anaemia,” iron deficiency,”
“hematological abnormality,” “haematological abnormality”, “micronutrient deficiency” were employed in the
electronic search. The reference lists of included articles were also hand searched.

Eligibility criteria. Studies that fulfilled inclusion criteria such as studies reported the prevalence of ane-
mia among people with TB ≥ 15 years-old, both pulmonary and extra-pulmonary TB population with anemia,
People with TB with or without HIV, clinical trials, cohort studies, case–control studies, cross-sectional studies,
written in English, and conducted in Africa were included in the current review.
Studies were excluded if they were case reports, case series, commentaries, systematic reviews, and meta-
analyses, non-English language publications, and reported prevalence of anemia among people with TB after
initiation of anti-TB treatment, and retreatment cases.

Study selection procedure. The search included articles published from April 2000 to December 2021
published in English language. The diagnosis of anemia was done by studies and studies were included in the
analysis as long as they included the classification of anemia irrespective of the criteria used to diagnose anemia.
The search was done between April and October 2021. The study selection was performed by two reviewers to
determine which studies are suitable for systematic review and meta-analysis. Duplicated studies were excluded.
The two reviewers independently screened articles as per the specified inclusion criteria. Disagreements between
the two reviewers were resolved with discussions. Eligible studies were extracted by reviewing full texts. All stud-
ies that met the inclusion criteria were included in the final analysis.

Data abstraction process. Two independent reviewers (YA & MS) extracted and recorded data from all
included studies using predesigned abstraction checklists prepared in Microsoft Excel Spreadsheet. The data
extracted included: author’s name, country, publication year, population, forms of TB, study design, sample
size, anemia, levels of anemia, and morphological patterns of anemia, definitions, and measurement of anemia.
Disagreements between reviewers were resolved with discussions.

Quality assessment. The methodological quality of included studies were assessed based on standard-
ized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and
Review Instrument (JBI-MAStARI)43.

Data synthesis. The data extracted from included studies were recorded in Microsoft Excel spreadsheet
and were exported to STATA version 14 for further analysis. A random-effects model was used to calculate
the pooled estimate with 95% CI. DerSimonian and Laird method was used as a variance estimator. Studies
with small sample size were included in the meta-analysis. The meta-analysis used random effects model and
there is substantial heterogeneity then the weights tend to become more equal. In this case a small study may
have almost the same weight as a large one. Heterogeneity among studies was assessed with the ­I2 test statistic.
Subgroup analysis was done based on sex category. Publication bias was assessed with funnel plot, and egger’s
regression test. A p-value of less than 0.05 was used to declare the presence of publication bias.

Data availability
All relevant data are addressed in the manuscript, and additional data can be obtained upon reasonable request
from the corresponding author.

Received: 26 May 2022; Accepted: 30 March 2023

References
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2. de Benoist, B., McLean, E., Egli, I. & Cogswell, M. Worldwide Prevalence of Anaemia 1993–2005: WHO Global Database on Anaemia
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Acknowledgements
We would like to thank the primary authors of the studies included in this systematic review and meta-analysis.

Author contributions
Y.A. & A.A. conceived and designed the study; All authors analyzed and interpreted the data, and drafted and
approved the manuscript.

Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to Y.A.
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