Genotypic Diversity and Recent Transmission Patterns of Mycobacterium Tuberculosis in Ethiopia: a Systematic Review and Meta-analysis

Abstract Background Mycobacterium tuberculosis complex (MTBC) remains a leading cause of global morbidity and mortality. Despite its relatively low mutation and recombination rates, considerable genotypic variation exists, influencing disease progression, transmission, and the emergence of drug resistance. This systematic review and meta-analysis aimed to synthesize evidence on the genotypic diversity and recent transmission of Mycobacterium tuberculosis in Ethiopia. Methods A comprehensive literature search was conducted across multiple electronic databases, including MEDLINE/PubMed, Web of Science, Google Scholar, the Cochrane Library, and grey literature sources. We included studies conducted in Ethiopia that characterized M. tuberculosis using spoligotyping, mycobacterial interspersed repetitive-unit variable-number tandem-repeat (MIRU–VNTR), or whole-genome sequencing (WGS) and were published in English. Data were analyzed using R version 4.5.2. Random-effects meta-analysis, heterogeneity assessment using the I 2 statistic, and subgroup analyses were performed. Results Twenty-four eligible studies involving 3601 M . tuberculosis isolates were included in the systematic review. Spoligotyping, MIRU–VNTR, and/or whole-genome sequencing (WGS) were used to characterize MTBC diversity and transmission patterns in Ethiopia . Among the isolates, the most frequently reported Spoligotype International Types (SITs), SIT149 (14/24, 58.3%) and SIT53 (12/24, 50.0%), were identified. Lineage 4 (Euro-American) predominated, followed by lineage 3 (Delhi/CAS), and these were the predominant MTBC lineages reported in Ethiopia. Less frequently reported lineages included lineages 1, 2, 5, and the Ethiopia-specific lineage 7. Lineage distribution and strain composition varied considerably across geographic regions (including Amhara, Oromia, and Tigray) and study methods, reflecting high heterogeneity. Orphan strains varied widely, reaching up to 91.1% in some studies. Overall pooled clustering and recent transmission index (RTI) were 57% and 45%, respectively. Conclusions This review demonstrates substantial genetic diversity and ongoing transmission of M. tuberculosis in Ethiopia, with lineage−4 predominating. High clustering and recent transmission rates suggest ongoing transmission of tuberculosis (TB), with substantial regional variation. However, the fragmented and region-specific nature of the available evidence limits a comprehensive national understanding of transmission dynamics. Strengthening molecular surveillance and targeted public health interventions is essential to control ongoing transmission.