The WHO estimated 0.93 and 4.6% MDR/RR-TB, respectively, among new and retreatment cases (5). However, there are varying prevalence rates of DR-TB reported in the country including 1.6 and 11% among new and previously treated TB patients, respectively (36), similar to another report of 12% MDR-TB among retreatment cases (34).

The WHO estimates of MDR/RR-TB in the country are 1.2 and 4.1% among new and retreatment cases, respectively (5), a slight reduction from 1.6 to 14% estimated in 2016. However, national survey between 2006 and 2007 found 2 and 14.5% MDR-TB, respectively, among new and retreatment cases (37).

The island country has an estimated 0.69 and 12% MDR/RR-TB among new and previously treated TB cases, respectively, whereas the actual number of cases confirmed stood at two patients who were all put on an appropriate treatment regimen (5).

The estimated figures are 3.5 and 16% MDR/RR-TB, respectively, among new and retreatment cases in the country (5). This correlates with a 10-year national survey which found 4.5 and 22% RR-TB among new and previously treated TB cases in the country (35). A cohort of 81 MDR-TB patients monitored in a pneumology unit, faced debilitating side effects leading to dropouts (39.2%), deaths (15.2%), diverse attacks (30.4%), and only 5% cured (38).

The WHO estimated 1.2 and 7.8% MDR/RR-TB among new and retreatment cases, respectively (5). However, an earlier study reported no MDR-TB among new cases but 12.6% among retreatment cases in The Country (33).

The WHO estimated 1.9 and 3.6% MDR/RR-TB among new and retreatment cases in Ghana (5). The first national DR-TB survey reported MDR/RR-TB rate of 3.1% (39) whereas a recent survey also reported a high rate of 5.6% (40) with 3.1% among new cases and as high as 33.3% among retreatment cases. Other studies in different parts of the country reported MDR/RR rates of 2.9% in the Greater Accra region (41), 3.31% in the Southern and Northern sectors (23), 3.5% in the Southern and Northern sectors (42), 3.1% in the Northern sector (43), and 8.1% in the Volta region (44). Additionally, a recent analysis of MTBC isolates from difficult-to-treat TB cases from Ghana over 2 years reported MDR/RR rate of 42% and pre-XDR-TB rate of 6.4% (45) agreeing with an earlier reported higher proportion of pre-XDR-TB (35%) among MDR-TB patients in the first pre-XDR-TB (33, 46) and XDR-TB case in the country (47).

The WHO estimated 0.73 and 47% MDR/RR-TB, respectively, among new and retreatment TB cases in the country (5). A study in the country also estimated 10 and 40% MDR/RR-TB, respectively, among new and retreatment cases but a mere 25% of these cases are diagnosed (48). To exacerbate the situation, about 45% of the diagnosed never complete treatment and for the remaining 55% who completed the treatment, success rate was only 34% (48).

The WHO estimated 1.2 and 54% MDR/RR-TB among new and retreatment cases, respectively (5). However, there is limited information on the actual burden of TB as well as DR-TB in the country. Nevertheless, there is a report of a high treatment cure rate (80.6%) MDR-TB in the country (49).

As one of the three high TB burden countries in WA, the WHO estimated 2.1 and 4.8% MDR/RR-TB among new and retreatment cases, respectively (5). However, report by Borgenproject.org in collaboration with the national TB control program stipulates 2.5% prevalence of MDR/RR-TB in the country (https://borgenproject.org/tuberculosis-in-liberia/). Contrary to these estimates, two independent studies have reported very high MDR-TB prevalence of including 38.3% (50) and 23.5% (51) in the country.

The WHO estimate 1 and 8.8% MDR/RR-TB (5) contrary to the 3.3 and 58.6% MDR-TB (33), respectively, among new and retreatment TB cases in Mali. A similar report (3.4 and 66.3% among new and retreatment TB patients, respectively) has also been published (52). Furthermore, the investigators identified 18.8% resistance to second-line TB drugs among a random 38 (50%) of MDR isolates. The first 2 cases of XDR-TB were reported in 2017 with genomic evidence of nosocomial transmission from the first patient to the second. Of great concern, it took 10 months after diagnosis for the patients to receive appropriate treatment (53).

The WHO estimated 2.7 and 12% MDR/RR-TB among, respectively, new and previously treated TB cases in the country. The country seems to have a good program with 132 out of the 135 confirmed cases put on an appropriate treatment regimen (5).

Nigeria is one of the WHO recognized 30 high MDR/RR-TB burden countries with estimated 2.1% among new cases and 14% among previously treated TB cases (5). A recent study reported 3.5 and 7% MDR-TB among new cases and retreatment cases, respectively, in the country (54). However, relatively high prevalence of MDR/RR-TB 6 and 32%, respectively, among new and retreatment cases was also reported from a systematic review of studies from different parts of the country (55). A study did not distinguish new and retreatment cases reported MDR/RR-TB rate of 6.3 and 0.8% pre-XDR-TB (56).

The WHO estimated 0.82 and 4.4% MDR/RR-TB, respectively, among new and retreatment cases (5). The National TB Control Program (NTP) of Senegal reported an increase in number of MDR-TB cases from 36 in 2010 to 77 in 2015 and MDR-TB rates of 0.5 and 17.9% among new and previously treated TB cases in 2014. However, an independent study in Senegal found the rate of MDR-TB to be 5.5 and 25% among new cases and retreatment cases, respectively (33).

There has been no national survey but the WHO estimated 1.3 and 15% MDR/RR-TB among new and retreatment cases, respectively (5). A recent study reported 14.7% MDR/RR-TB incidence (57) and a systematic review of reports from the country showed that among 628 identified MDR/RR-TB cases, 440 (70.1%) were retreatment cases with most being males (374/440) (58).

The WHO estimated 0.67 and 3% MDR/RR-TB, respectively, among new and retreatment cases (5). Nevertheless, a study monitoring a cohort of previously treated TB patients using GeneXpert and BACTEC MGIT found 24 and 25% of MDR-TB cases, respectively (59).

Accurate and timely diagnosis of DR-TB is essential for appropriate treatment plan. Several diagnostic methods including both phenotypic (culture-based) and DNA-based tests are available for detecting DR-TB. Due to the drawbacks of culture-based drug susceptibility testing (DST) methods such as requiring specialized laboratories, high expertise and often take weeks to provide results (60, 61), DNA-based using of polymerase chain reaction (PCR) are preferably used. For example, many of the countries are usingXpert MTB/RIF assay (Cepheid) detects rifampicin resistance (RR) and the line probe assays (Hain LifeSciences) (62). Nevertheless, these may not be accessible in some remote settings (63, 64). Furthermore, difficulty in maintenance of these equipment leads to referral of diagnostic services to distant reference labs leading to delayed diagnosis and initiation of appropriate treatment (64–66). Additionally, the paucibacillary nature of TB among HIV co-infected cases and children poses a diagnostic challenge, resulting in false-negative results and eventual underestimation of DR-TB (67).

Treating DR-TB requires the use of multiple drugs for an extended duration, typically from 6 to 9 months (https://www.cdc.gov/tb/topic/drtb/bpal/default.htm#print). This long and complex treatment regimen poses significant challenges. First, the combination of drugs used can have significant side effects, including gastrointestinal disturbances, hepatotoxicity, ototoxicity, and psychiatric effects (68). These side effects can potentially lead to treatment discontinuation, non-adherence, and hence decreased treatment effectiveness. Secondly, availability of these second-line drugs may be limited in resource-constrained settings such as WA, affecting the ability to provide appropriate treatment to all diagnosed DR-TB patients (69). For example, out of the total 1,131 MDR-TB cases diagnosed in Ghana from 2018 to 2022, those that were put on treatment were 956 (84.5%) (Ghana, National Tuberculosis Control Program, Annual Report 2022, Unpublished). Albeit this proportion can be considered one of the highest in WA, it is still below the 90% enrolment recommended by the WHO (70). Consequently, limited access to these drugs can potentially lead to suboptimal treatment regimens that compromise treatment outcomes and contribute to the development of additional drug resistance.

A critical step in addressing DR-TB in WA is political will of respective governments to reduce overreliance on foreign aid (71, 108). They must be committed to strengthen their health care systems to be more responsive/sensitive and resilient. Notwithstanding the significant help these aid agencies offer, their activities are affected by shocks such as outbreaks of other diseases as was seen with COVID-19 (64, 66, 86, 109, 110). Therefore, ensuring uninterrupted DR-TB control activities in WA demands governments in WA to set aside significant portions of their annual budgets toward improving laboratory facilities for accurate and timely diagnosis of DR-TB, ensuring access to DST, and establishing robust treatment programs that do not run out of required drugs (71, 111). In addition to physical structure and supplies, there is also the need to offer specialized training for healthcare providers in the diagnosis, management, and treatment of DR-TB, as well as improving infection control (112, 113).

There is the need for comprehensive surveillance system that tracks DR-TB patterns and monitors the spread of resistant strains in endemic communities (82, 114). Such surveillance system requires sensitive, rapid diagnostics for point-of-care testing and real-time data collection analysis tools to promote early detection of outbreaks as well as monitor cross-border importation/exportation of DR-TB (115). The deployment of GeneXpert MTB/RIF in WA, allowing dual diagnosis of TB and rifampicin resistance within hours is commendable (116, 117). The new GeneXpert MTB/XDR deployed in few reference labs in the sub-region work in concert with the GeneXpert MTB/RIF to give better resolution on MTBC susceptibility to RIF, INH, RQs and (118, 119). Nevertheless, the GeneXpert is inapplicable as a point of care tool in rural areas. On the other hand, the newly introduced Seegene-Anyplex-II-MTB/MDR/XDR (120), a real-time PCR-based diagnostics may account for some limitations of the GeneXpert platform, but requires evaluation in WA the hot-spot of MTBC diversity to access its sensitivity and specificity (7, 121, 122). Furthermore, efficient contact tracing and follow-up of individuals exposed to DR-TB patients with regular testing and screening can promote early detection of potential emerging cases and help prevent secondary transmissions whilst improving treatment outcomes with appropriate treatment regimens (123, 124).

In the past two decade, some West African scientists are gradually making progress in basic scientific research toward understanding the biology of the MTBC (122, 125–130) and the potential impact of MTBC diversity on TB control (47, 131–133). This is because WA harbors seven out of the nine phylogenetic lineages (L1-L4, L7 & L8 making up M. tuberculosis sensu stricto [Mtbss] and L5, L6 & L9 making up M. africanum [Maf]) of the MTBC (6, 90) with a couple of WA-restricted several lineages (Maf lineages) and sub-lineages (Ghana and Cameroun sub-lineages of L4) (7). Some highlights of research findings from WA are described below. Maf transmits equally as Mtbss but progresses relatively slowly to active disease and is associated with relatively smaller transmission clusters (134, 135). Whereas, INH-resistance among Mtbss is driven by katG mutations conferring high-level resistance, INH-resistance among Maf is driven by inhApro mutations conferring low-level resistance (23). Maf lineages L5 and L6 are two distinct pathogens restricted to WA by unknown mechanisms (122). Maf L5 is also more likely to be associated with DR-TB compared to L6 similar to the association of Mtbss L4 Ghana genotype with DR-TB in WA (23, 43). Finally slower in vitro growth of Maf (136) in concomitance with its slower sputum-smear conversion rate (137) may warrant review of DOTS in West Africa as the 6 months may not be adequate for TB caused by Maf (138). Nevertheless, there is still room for further TB research in WA to contribute knowledge toward development of more efficient control tools.

The continuous evolution of DR limits treatment options for DR-TB and threatens to eventually make TB untreatable. Therefore, new and more effective drugs are crucial for combating DR-TB. Current treatment regimens for DR-TB are lengthy, complex, and associated with significant side effects (70). Investing in research and development of potent but less toxic drugs is essential whereas those that can give shorter treatment duration would be an added advantage. Most current efforts toward development of new TB treatment regimens involve exploring new drug targets and repurposing existing drugs (94, 139, 140). However, WA is home to numerous plant-based medicines for treating myriad of diseases including TB for centuries. Some of these plant preparations have recently been scientifically assessed for their anti-mycobacteria activity with promising outcomes (141). There is the need to invest in taking these promising preparations into pre-clinical trials for further development and advance research into identify and characterizing the active compound (s) as leads for new anti-TB drugs. Expedite development of novel anti-TB agents originating from the sub-region as well as integration of traditional, complementary, and alternative medicine into the health care system, particularly in rural areas where they are most prevalent, can enhance access to TB treatment, provided safety and efficacy standards are met. The provision of independent expert advice and support to countries in this regard by the WHO and African Centres for Disease Control are thence commendable (142).

There are many innovative communication platforms that can be used for public education on DR-TB including mass media, social media, community meetings, workshops, and educational materials tailored to different populations using local languages to enhance the reach and impact of the message (71, 143–147). Such campaigns must engage communities, healthcare providers, policymakers, and other influential persons including but not limited to celebrities and local leaders in efforts to prevent the spread of DR-TB (143). The campaign should rely on experts to provide accurate and accessible information about TB, its causes, transmission, and preventive measures to help dispel misconceptions surrounding TB that negatively impact timely diagnosis and treatment (70, 147–150). Dispelling such myths will dispel stigma and discriminations against TB patients and fostering understanding, empathy, and acceptance as well as support for those affected. Secondly, such campaigns must raise awareness on antibiotic stewardship that promotes responsible use of antibiotics emphasizing the importance of completing prescribed courses of treatment and avoiding the use of antibiotics without prescription to help protect the potency of available TB drugs (151, 152). In addition, there should be a system for monitoring the campaign activities and evaluating the impact of the campaign on knowledge acquisition and attitudinal changes in relation to TB and DR-TB in the catchment communities as well as identify areas for improvement. Finally, such public education efforts must be sustained for longer periods to ensure that the intended knowledge becomes part and parcel of the target.

Addressing the complex challenge of DR-TB requires collaboration and partnerships among stakeholders including national TB control programs, government agencies, non-governmental organizations, healthcare providers, donors, religious bodies, traditional leaders, industry, and academia across the region. Such collaborative efforts can help mobilize resources, share expertise, coordinate activities, and advocate for enactment of new policies as well as modification of existing policies to fight DR-TB in the sub-region (153, 154). The initiative by the West African Network for Tuberculosis, AIDs, and Malaria (WANETAM) including 14 institutions in eight West African countries needs commendation. WANETAM is funded by the European and Development Countries Clinical Trials Partnership (EDCTP) to build capacity in standardized laboratory techniques essential for clinical trials and public health relevant diagnostics and research since 2008 (https://wanetam.org). Over the years the network has trained several clinicians, laboratory technicians, research administrators and research scientists as well as built both physical and electronic infrastructure in WA contributing to the fight against diseases of public health importance including DR-TB. There is, however, the need for several of such within sub-region collaborations funded by local governments for sustainability.