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BioMed Research International
Volume 2014 (2014), Article ID 238532, 12 pages
Strain Diversity of Mycobacterium tuberculosis Isolates from Pulmonary Tuberculosis Patients in Afar Pastoral Region of Ethiopia
1Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia
2Section for International Health, Department of Community Medicine, Institute for Health and Society, University of Oslo, P.O. Box 1130, Blindern, 0318 Oslo, Norway
3WHO Supranational TB Reference Laboratory, TB & Mycobacteria Unit, Institut Pasteur de la Guadeloupe, 97183 Abymes, France
Received 24 November 2013; Accepted 22 January 2014; Published 6 March 2014
Academic Editor: Tomasz Jagielski
Copyright © 2014 Mulugeta Belay et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Data on genotypic diversity of Mycobacterium tuberculosis complex (MTBC) is important to understand its epidemiology, human adaptation, clinical phenotypes, and drug resistance. This study aimed to characterize MTBC clinical isolates circulating in a predominantly pastoralist area in Ethiopia, a country where tuberculosis is the second leading cause of mortality. Culture of sputum samples collected from a total of 325 pulmonary TB suspects was done to isolate MTBC. Spoligotyping was used to characterize 105 isolates from culture positive slopes and the result was compared with an international database. Forty-four spoligotype patterns were observed to correspond to 35 shared-types (SITs) containing 96 isolates and 9 orphan patterns; 27 SITs containing 83 isolates matched a preexisting shared-type in the database, whereas 8 SITs ( isolates) were newly created. A total of 19 SITs containing 80 isolates were clustered within this study (overall clustering of 76.19%). Three dominant lineages (T, CAS, and Manu) accounted for 76.19% of the isolates. SIT149/T3-ETH was one of the two most dominant sublineages. Unlike previous reports, we show that Manu lineage strains not only constitute a dominant lineage, but are also associated with HIV infection in Afar region of Ethiopia. The high level of clustering suggests the presence of recent transmission that should be further studied using additional genotyping markers.
Tuberculosis (TB) is among the 10 major causes of death  and it is only outranked by HIV/AIDS among infectious causes of death worldwide . Despite the global effort towards controlling TB for the last 20 years, the burden remains high with over 8.7 million incident cases and 1.4 million deaths in 2011 . The HIV epidemics and the spread of MDR-TB are among the major obstacles for the successful control of TB and, in this regard, Africa is lagging behind in achieving to halve the 1990s mortality by 2015 .
Ethiopia is among the 22 high TB as well as the 27 high MDR-TB burden countries . According to the Ministry of Health, TB is the second leading cause of death . Apart from other factors, the HIV epidemics and the emergence of MDR-TB have contributed to the high TB burden in the country. According to the recent national TB prevalence survey, the prevalence of smear positive pulmonary TB is highest among pastoral communities .
Genotypic variations among M. tuberculosis strains as well as the existence of human genetic polymorphism linked to TB have resulted in the changing relationship between M. tuberculosis and the human host. Such changes have complicated TB control efforts . Data on strain diversity of mycobacterial isolates is important to understand the transmission dynamics and phylogeographical distribution of dominant circulating strains of M. tuberculosis.
This study was part of a major project on molecular epidemiology, clinical epidemiology, and immunology of TB in a pastoral community and their livestock in Ethiopia. Some studies have reported the dominant strains among human isolates in central highlands of Ethiopia [7–11]; besides, strains isolated from goats and camels have been reported from Afar region recently [12, 13]. This study reports strains of M. tuberculosis isolates circulating in the Afar pastoral communities.
2.1. Study Area
The study area has been described elsewhere . Briefly, the study was conducted in two public (Awash Health Centre and Dubti Hospital) health facilities in Afar region and three private (Selam hospital, Bati Hospital, and Amir Higher Clinic) health facilities in Dessie town. The reason for including these private health facilities is because they provide diagnostic services for a substantial number of TB patients coming from Afar region.
2.2. Study Design and Study Participants
A health facility-based cross-sectional study was conducted between September 2009 and March 2010. A total of 325 pulmonary TB suspects (≥18 years of age) who were residents of Afar region during the study period and came to the selected health facilities with cough lasting more than 2 weeks were included consecutively. TB patients who were already taking anti-TB drugs were excluded.
2.3. Data Collection
A semi-structured, pretested questionnaire was used to collect data on basic sociodemographic characteristics as well as clinically relevant symptoms. Three sputum samples (spot-morning-spot) were collected and smear microscopic examination for AFB was done at the respective health facilities according to the national TB and Leprosy control programme guideline . The rest of the sputa were stored at +4°C and transported to Aklilu Lemma Institute of Pathobiology (ALIPB), Addis Ababa University, within 1 week. Participants were tested for HIV according to the national guideline .
2.4. Mycobacterial Culture
The three sputa from each participant were pooled at ALIPB laboratory; culture was done according to the WHO guideline . Briefly, sputum samples were homogenized and decontaminated with equal volume of 4% NaOH and shaken for 15 minutes at room temperature. Subsequently, it was centrifuged at 3000 rpm for 15 minutes. After the supernatant was poured off, the sediment was neutralized with 2 N HCL and 2–4 loopfuls of the centrifuged sediment were inoculated into four slopes of LJ medium. Inspection of media was done every week for growth until 8 weeks. Based on colony morphology and smear microscopy, those with growth were identified and two colonies were transferred to eppendorf tube with 300 μL distilled water. Mycobacterial genomic DNA was extracted by heating isolates at 80°C for 60 minutes. Heat-killed isolates were stored at −20°C until spoligotyping was done.
2.5. Spoligotyping and Database Comparison
Spoligotyping of 105 isolates was performed using a commercially available kit from Ocimum Biosolutions Company, Iisselstein, The Netherlands, according to the company’s instructions and as described previously [9, 18]. Briefly, the direct repeat (DR) region was amplified by a Thermal Cycler PCR machine (VWR International) using oligonucleotides and primers derived from this region. The amplified product was hybridized to a set of 43 immobilized oligonucleotides, each corresponding to one of the unique spacer. Hybridized DNA was detected by chemiluminescence method (Amersham Biosciences, Little Chalfont, UK) and by exposure to X-ray film (Hyperfilm ECL, Amersham Biosciences), as specified by the manufacturer. The hybridization patterns were converted into binary and octal formats and compared with previously reported strains in the in-house SITVIT2 proprietary database of Institut Pasteur de la Guadeloupe, which is an updated version of the recently released SITVITWEB database . In this database, a Spoligotype International Type (SIT) designates a pattern shared by 2 or more patient isolates, whereas “orphan” represents a pattern reported for a single isolate. At the time of this comparison, SITVIT2 contained genotyping data on more than 110,000 MTBC clinical isolates from 160 countries of patient origin, and >3500 SITs. Major phylogenetic clades were essentially assigned according to signatures provided earlier ; these included specific signatures for various MTBC members as well as rules defining major lineages/sublineages for M. tuberculosis sensu stricto. The latter included the Beijing clade, the Central-Asian (CAS) clade and its 2 sublineages, the East-African-Indian (EAI) clade with its 9 sublineages, the Haarlem clade and its 3 sublineages, the Latin-American-Mediterranean (LAM) clade and its 10 sublineages, the “Manu” family and its 3 sublineages, the IS6110-low banding X clade and its 3 sublineages, and the ill-defined T clade and its 5 sublineages. The high phylogeographical specificity of LAM10-CAM prototype SIT61 for Cameroon has led to its designation as the Cameroon lineage , whereas LAM7-TUR lineage was tentatively reclassified as the Turkey lineage .
We also studied the worldwide distribution of all major spoligotyping clusters in our study (clusters containing 3 or more isolates) by interrogating the database for their distribution in macrogeographical regions and subregions according to the United Nations (http://unstats.un.org/unsd/methods/m49/m49regin.htm; for further details please refer to the footnote of Table 3). Lastly, the distribution of predominant spoligotype patterns in this study ( strains) was further compared to all other strains reported from Ethiopia in the international database ( strains excluding the present study) as well as the five African subregions ( strains), and the neighboring Western Asian countries ( strains; for further details please refer to the footnote of Table 4).
Minimum spanning trees (MSTs) illustrating evolutionary relationships between the M. tuberculosis spoligotypes and various sociodemographic variables were constructed using BioNumerics software version 6.6 (Applied Maths, Sint-Martens-Latem, Belgium). MST is an undirected network in which all of the samples are linked together with the fewest possible linkages between nearest neighbors. Lastly, Spoligoforest trees which represent another way to illustrate probable strain evolutionary relationships between spoligotypes were drawn [22, 23] using spolTools online utilities available through http://www.emi.unsw.edu.au/spolTools. As opposed to the MSTs, the spoligoforest trees are directed and only evolve by loss of spacers. GraphViz software (http://www.graphviz.org/ ) was used to color the strains based on their lineages on the spoligoforest trees.
2.6. Ethics Statement
The study has been ethically cleared by the Norwegian Ethics Committee and the Ethiopian National Ethics Committee. Written informed consent was obtained from each study participant.
2.7. Statistical Analysis
Chi-square test using STATA software version 12 was used to evaluate whether or not significant association may exist between lineages or SITs with sociodemographic and epidemiological characteristics. Pearson’s Chi-square test was used when more than 80% of data had an expected value greater than 5 and Fisher’s Exact Test for remaining data with smaller expected values (at least 20% of data having values less than 5). values less than 0.05 were considered as statistically significant.
3.1. Demographic Characteristics of Study Participants
Among 325 pulmonary TB suspects, a total of 105 patients were confirmed to have culture positive pulmonary TB and included for further analysis. The median age of patients was 29 (IQR: 22.5–40.0) years and the majority were males with a male to female ratio of 1.92. Thirty-nine (37%) of culture confirmed TB patients were positive for acid fast bacilli on sputum smear examination. Besides, HIV result was available for 95 of the patients and 39% of them were found to be HIV co-infected. The majority (77.1%) of the study participants were new cases of pulmonary TB. Pastoralists represented 42.9% of the study participants. The proportion of HIV positives among ethnic Afar (8.7%) was significantly lower compared to other ethnic groups (28.0–47.5%) ().
3.2. Genetic Diversity and Distribution of Isolates
Overall, 103 (98.1%) isolates had spoligotypes characteristic of M. tuberculosis complex and 2 (1.9%) isolates had spoligotypes characteristic of M. bovis. A total of 9 isolates showed orphan patterns (Table 1), whereas 16 strains were unique making the total number of unclustered isolates to be 25 (23.81%). On the other hand, 19 SITs containing 80 isolates (76.19%) were clustered within this study (2 to 10 isolates per cluster). Besides, a total of 44 spoligotype patterns were observed and, therefore, the overall diversity of the isolates was 41.9%. A total of 27 SITs containing 83 isolates matched a preexisting shared-type in the SITVIT2 database, whereas 8 SITs ( isolates) did not match any of the previous isolates in the database and hence were newly created (Table 2).
The majority (76.19%) of the isolates belonged to the following three dominant lineages: T (, 40.95%), Manu (, 19.05%), and CAS (, 16.19%). The other minor lineages in this study include X (, 5.71%), Haarlem (, 3.81%), EAI (, 3.81%), LAM (, 2.86%), BOV (, 1.90%), AFRI (, 0.95%), Turkey (, 0.95%), and S (, 0.95%) (Table 2). Three isolates (2.86%) had patterns with signatures that do not belong to any of the major lineages described in the database and hence labelled as “unknown” (Tables 1 and 2). No Beijing strains were identified in this study.
The dominant SITs in this study included SIT 149 of the T3-ETH lineage, SIT 37 of the T3 lineage, SIT 53 of the T1 lineage, and SIT 54 of the Manu2 lineage all together accounting for 36.2% of the isolates (Table 3). On comparing the dominant isolates from this study with the isolates in the SITVIT2 database from Ethiopia, the five African regions, and neighboring Western Asia, statistically significant differences were observed (Table 4). Significantly higher proportions of T2 (), X1 () and H () lineages/sublineages were found among isolates in this study compared to their representations in the SITVIT2 database from Ethiopia. Notably, the Manu lineage was significantly higher compared to previous isolates from Africa and neighboring Western Asia (). Besides, this lineage has not been reported to SITVIT2 database from Ethiopia so far. On the other hand, there was no significant difference in the distribution of T1, T3, T3-ETH, and CAS1-Delhi lineages compared to previous isolates from Ethiopia ().
A minimum spanning tree (MST) illustrating evolutionary relationships among the strains has been constructed (Figure 1). In this evolutionary tree, MANU strains were closest to the central node of the unrooted tree which is represented by SIT53, whereas CAS strains are further away from the central node of the tree. On spoligoforest trees (Figure 2), SIT149/T3-ETH and SIT37/T3 are the biggest nodes (each with 10 isolates), followed by SIT53/T1 and SIT54/Manu2 (each with 9 isolates); SIT52/T2 (), SIT25, and SIT26/CAS1-Delhi (each with 4 isolates) are the other dominant isolates in our study.
On investigating the association between strains and HIV co-infection, strains belonging to Manu2 lineage were significantly associated with HIV infection compared to strains belonging to CAS lineage (Fisher’s Exact Test, ). However, strain clustering was not significantly associated with HIV infection and other sociodemographic characteristics of the study participants.
Analysis of strain diversity and comparison with international database is key to have an insight into the global distribution of M. tuberculosis strains. In this regard, we describe the strain diversity of M. tuberculosis complex among clinical isolates of pulmonary TB patients from a predominantly pastoralist area in Northeast Ethiopia and compared the strains with SITVIT2 database strains.
Among 105 isolates, the majority (98.1%) of the isolates were identified as M. tuberculosis complex with only 2 (1.9%) isolates being M. bovis. This finding is in agreement with previous reports from Ethiopia [25, 26]. Unlike a previous study from Ethiopia  which reported a significant contribution (17%) of bovine TB among TB lymphadenitis patients, the contribution of M. bovis to human TB seems to be minimal and mainly restricted to the pastoral communities as supported by current evidence [25, 26].
In our study, the overall clustering was 76.19% indicating a high rate of recent transmission in the study area. Although this high level of spoligotyping based clustering should be further studied using additional genotyping markers, it is comparable with a previous study from Addis Ababa . The recent national TB prevalence survey also argues for an ongoing TB epidemic mainly affecting the young probably indicating a defect in the TB control programme . Besides, we have previously reported  that TB patients in Afar region suffered long diagnostic delays contributing to continued transmission with strain circulation.
Three dominant lineages were identified in this study and in agreement with previous reports [8, 9], the ill-defined T-lineage is the most dominant lineage accounting for 40.95% of the isolates. Among the T-lineages, T3-ETH is the most common lineage accounting for 25.6% of the T-lineage in this study. Similarly, previous studies from Ethiopia [8, 9, 11] reported a high proportion of T3-ETH among isolates indicating that this lineage is one of the dominant lineages in the country. CAS-Delhi lineage is the other dominant lineage in this study accounting for 16.19% of the isolates. In agreement with our finding, this lineage has been reported in previous studies as one of the dominant lineages in Ethiopia [7–9, 11] as well as in neighboring Djibouti . EAI lineage was also isolated in smaller proportion in the study area. Both CAS and EAI are mainly prevalent in Middle East and Central Asia (Table 3). Two hypotheses could explain the presence of these lineages in Ethiopia as well: (i) it could have emerged in Ethiopia and migrated to Middle East and Central Asia, a hypothesis in agreement with the suggestion that East Africa is the cradle of M. tuberculosis complex species ; this is supported by a recent evidence  that MTBC co-evolved with the modern human host and migrated from Africa (particularly East Africa) to Asia and other parts of the world; (ii) alternatively, it could be due to migration of this lineage from Middle East and Central Asia to Ethiopia due to the recent human migrations from these areas to Ethiopia as suggested by a previous study .
Interestingly, Manu is one of the dominant lineages in our study contributing to 19.05% of the isolates. In agreement with this, investigators from Egypt reported a high proportion (27%) of Manu among their isolates . In Ethiopia, only one study  from the Central highlands reported SIT 54 contributing to 8.33% of the isolates which is similar to our finding for SIT 54. However, Manu has not been reported from Ethiopia in other previous studies [7, 8, 11] as well as in the SITVIT2 database in which SIT 54 (Manu2) has been mainly reported from South and East Asia, Middle East including Egypt, and America. Furthermore, a recent study on a relatively large number of isolates mainly from Djibuti  did not find Manu lineage. The diverse distribution of strains in the study areas included in Ethiopia so far implies the need to map the distribution of Mycobacterium tuberculosis in the country. Interestingly, Manu2 lineage was found to be significantly associated with HIV infection although the reason for such association is not apparent from the current study.
Regarding the evolutionary relationship among strains, as opposed to CAS strains, the Manu strains in the MST tree are the ones closest to the dominant T lineage as reported before . Besides, the T1 strain represented by its prototype SIT53 constitutes the central node of this unrooted tree and SIT 52 of T2 and SIT 37 of T3 are the other big nodes closest to the central node (Figure 1(a)). SIT149 (T3-ETH), which is the commonest lineage in Ethiopia, is further from the central node.
In conclusion, this study identified the presence of high level of clustering suggesting the presence of recent transmission in the study area. Nonetheless, one limitation of the present study is the fact that Mycobacterial interspersed repetitive units-variable number of tandem repeats (MIRU-VNTR) [35, 36] that allows splitting certain spoligotyping defined clusters in smaller subclusters  could not be used in the present study. Considering a recent study showing that some of the Manu lineage strains could result from mixed or polyclonal infections , and seeing the higher than usual proportion of Manu lineage strains in our study, it might be important to systematically perform MIRU typing of all spoligotyping clusters in future studies in the Afar pastoral region. We suggest that a nationwide study aiming to map the population structure of M. tuberculosis complex should be planned using spoligotyping, MIRU-VNTRs, and SNP in Ethiopia.
Conflict of Interests
The authors declared that they have no competing interests.
Mulugeta Belay was involved in the design, data collection and laboratory work, statistical analysis, and interpretation of data and drafted the manuscript; Fekadu Abebe was involved in the design, interpretation, and critical revision of the paper; Gunnar Bjune was involved in the design, interpretation, and critical revision of the paper; Gobena Ameni was involved in data collection, spoligotyping of the isolates, and critical revision of the paper. Nalin Rastogi and David Couvin analyzed the strains and compared them with SITVIT2 database; besides, both were involved in the critical revision of the paper. All authors have read and approved the paper for submission.
This study was supported by the Norwegian Programme for Development, Research and Education (NUFU) (Project no. NUFUPRO.2007/10198), and the Norwegian Research Council (Project no. 196397/S50). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the paper. The authors’ sincere gratitude goes to Mr. Adane Worku at Aklilu Lemma Institute of Pathobiology for carrying out spoligotyping. Laboratory technicians working at the respective health facilities deserve our sincere gratitude for collecting samples. The authors would like to acknowledge participants for consenting to participate in the study.
- D. Bleed, C. Dye, and M. C. Raviglione, “Dynamics and control of the global tuberculosis epidemic,” Current Opinion in Pulmonary Medicine, vol. 6, no. 3, pp. 174–179, 2000.
- T. R. Frieden, T. R. Sterling, S. S. Munsiff, C. J. Watt, and C. Dye, “Tuberculosis,” The Lancet, vol. 362, no. 9387, pp. 887–899, 2003.
- WHO, Global Tuberculosis Report, WHO, Geneva, Switzerland, 2012.
- Federal Ministry of Health, Guidelines For Clinical and Programmatic Management of TB, Leprosy and TB/HIV in Ethiopia, Federal Ministry of Health, Addis Ababa, Ethiopia, 12th edition, 2012.
- Z. Alebachew, “Ethiopian National TB Prevalence survey 2010–2011: Preliminary Result,” http://www.who.int/tb/advisory_bodies/impact_measurement_taskforce/meetings/lille_oct11_ethiopia.pdf.
- C. Dye and B. G. Williams, “The population dynamics and control of tuberculosis,” Science, vol. 328, no. 5980, pp. 856–861, 2010.
- B. Tessema, J. Beer, M. Merker, et al., “Molecular epidemiology and transmission dynamics of Mycobacterium tuberculosis in Northwest Ethiopia: new phylogenetic lineages found in Northwest Ethiopia,” BMC Infectious Diseases, vol. 13, article 131, 2013.
- A. Mihret, Y. Bekele, A. G. Loxton, et al., “Diversity of Mycobacterium tuberculosis isolates from new pulmonary tuberculosis cases in Addis Ababa, Ethiopia,” Tuberculosis Research and Treatment, vol. 2012, Article ID 892079, 7 pages, 2012.
- L. Garedew, A. Mihret, G. Mamo, et al., “Strain diversity of mycobacteria isolated from pulmonary tuberculosis patients at Debre Birhan Hospital, Ethiopia,” International Journal of Tuberculosis and Lung Disease, vol. 17, no. 8, pp. 1076–1081, 2013.
- A. Deribew, G. Abebe, L. Apers et al., “Prevalence of pulmonary TB and spoligotype pattern of Mycobacterium tuberculosis among TB suspects in a rural community in Southwest Ethiopia,” BMC Infectious Diseases, vol. 12, article 54, 2012.
- M. Agonafir, E. Lemma, D. Wolde-Meskel et al., “Phenotypic and genotypic analysis of multidrug-resistant tuberculosis in Ethiopia,” International Journal of Tuberculosis and Lung Disease, vol. 14, no. 10, pp. 1259–1265, 2010.
- G. Mamo, F. Abebe, Y. Worku et al., “Tuberculosis in goats and sheep in afar pastoral region of ethiopia and isolation of Mycobacterium tuberculosis from goat,” Veterinary Medicine International, vol. 2012, Article ID 869146, 8 pages, 2012.
- G. Mamo, G. Bayleyegn, T. S. Tessema et al., “Pathology of camel tuberculosis and molecular characterization of its causative agents in pastoral regions of Ethiopia,” PLoS ONE, vol. 6, no. 1, Article ID e15862, 2011.
- M. Belay, G. Bjune, G. Ameni, M. Abebe, and F. Abebe, “Serodiagnostic performance of rESAT-6-CFP-10 in the diagnosis of pulmonary tuberculosis in Ethiopia,” Mycobacterial Diseases, vol. 1, no. 2, article 103, 2011.
- Federal Ministry of Health, Tuberculosis, Leprosy and TB/HIV Prevention and Control Programme, Federal Ministry of Health, Addis Ababa, Ethiopia, 4th edition, 2008.
- HAPCO, Guidelines for HIV Counselling and Testing in Ethiopia, HAPCO, Addis Ababa, Ethiopia, 2007.
- WHO, Laboratory Services in Tuberculosis Control: Culture. Part III, WHO, Geneva, Switzerland, 1998.
- J. Kamerbeek, L. Schouls, A. Kolk et al., “Simultaneous detection and strain differentiation of Mycobacterium tuberculosis for diagnosis and epidemiology,” Journal of Clinical Microbiology, vol. 35, no. 4, pp. 907–914, 1997.
- C. Demay, B. Liens, T. Burguière et al., “SITVITWEB—a publicly available international multimarker database for studying Mycobacterium tuberculosis genetic diversity and molecular epidemiology,” Infection, Genetics and Evolution, vol. 12, no. 4, pp. 755–766, 2012.
- F. Koro Koro, Y. Kamdem Simo, F. F. Piam, et al., “Population dynamics of tuberculous Bacilli in Cameroon as assessed by spoligotyping,” Journal of Clinical Microbiology, vol. 51, no. 1, pp. 299–302, 2013.
- O. Kisa, G. Tarhan, S. Gunal et al., “Distribution of spoligotyping defined genotypic lineages among drug-resistant Mycobacterium tuberculosis complex clinical isolates in Ankara, Turkey,” PLoS ONE, vol. 7, no. 1, Article ID e30331, 2012.
- J. F. Reyes, A. R. Francis, and M. M. Tanaka, “Models of deletion for visualizing bacterial variation: an application to tuberculosis spoligotypes,” BMC Bioinformatics, vol. 9, article 496, 2008.
- C. Tang, J. F. Reyes, F. Luciani, A. R. Francis, and M. M. Tanaka, “spolTools: online utilities for analyzing spoligotypes of the Mycobacterium tuberculosis complex,” Bioinformatics, vol. 24, no. 20, pp. 2414–2415, 2008.
- J. G. E. Ellson, E. Koutsofios, S. C. North, and G. Woodhull, “Graphviz and Dynagraph—Static and Dynamic Graph Drawing Tools,” 2002, http://www.graphviz.org/Documentation/EGKNW03.pdf.
- R. Firdessa, S. Berg, E. Hailu, et al., “Mycobacterial lineages causing pulmonary and extrapulmonary tuberculosis,” Emerging Infectious Diseases, vol. 19, no. 3, pp. 460–463, 2013.
- B. Gumi, E. Schelling, S. Berg et al., “Zoonotic transmission of tuberculosis between pastoralists and their livestock in south-east Ethiopia,” EcoHealth, vol. 9, no. 2, pp. 139–149, 2012.
- D. Kidane, J. O. Olobo, A. Habte et al., “Identification of the causative organism of tuberculous lymphadenitis in Ethiopia by PCR,” Journal of Clinical Microbiology, vol. 40, no. 11, pp. 4230–4234, 2002.
- A. Kebede, Z. Alebachew, F. Tsegaye, et al., “Background document 6: The First Ethiopian National Population-based TB Prevalence Survey,” http://www.who.int/tb/advisory_bodies/impact_measurement_taskforce/meetings/tf5doc06_keyresultsprevalencesurveyethiopia2010.pdf.
- M. Belay, G. Bjune, G. Ameni, and F. Abebe, “Diagnostic and treatment delay among Tuberculosis patients in Afar Region, Ethiopia: a cross-sectional study,” BMC Public Health, vol. 12, article 369, 2012.
- S. Godreuil, F. Renaud, M. Choisy et al., “Highly structured genetic diversity of the Mycobacterium tuberculosis population in Djibouti,” Clinical Microbiology and Infection, vol. 16, no. 7, pp. 1023–1026, 2010.
- G. M Cristina, S. Brisse, R. Brosch et al., “Ancient origin and gene mosaicism of the progenitor of Mycobacterium tuberculosis,” PLoS Pathogens, vol. 1, no. 1, article e5, 2005.
- I. Comas, M. Coscolla, T. Luo et al., “Out-of-Africa migration and Neolithic coexpansion of Mycobacterium tuberculosis with modern humans,” Nat Genet, vol. 45, no. 10, pp. 1176–1182, 2013.
- Z. H. Helal, M. S. E.-D. Ashour, S. A. Eissa et al., “Unexpectedly high proportion of ancestral manu genotype Mycobacterium tuberculosis strains cultured from tuberculosis patients in Egypt,” Journal of Clinical Microbiology, vol. 47, no. 9, pp. 2794–2801, 2009.
- Y. Blouin, Y. Hauck, C. Soler, et al., “Significance of the identification in the horn of Africa of an exceptionally deep branching Mycobacterium tuberculosis clade,” PLoS ONE, vol. 7, no. 12, Article ID e52841, 2012.
- P. Supply, S. Lesjean, E. Savine, K. Kremer, D. van Soolingen, and C. Locht, “Automated high-throughput genotyping for study of global epidemiology of Mycobacterium tuberculosis based on mycobacterial interspersed repetitive units,” Journal of Clinical Microbiology, vol. 39, no. 10, pp. 3563–3571, 2001.
- P. Supply, C. Allix, S. Lesjean et al., “Proposal for standardization of optimized mycobacterial interspersed repetitive unit-variable-number tandem repeat typing of Mycobacterium tuberculosis,” Journal of Clinical Microbiology, vol. 44, no. 12, pp. 4498–4510, 2006.
- C. Sola, I. Filliol, E. Legrand et al., “Genotyping of the Mycobacterium tuberculosis complex using MIRUs: association with VNTR and spoligotyping for molecular epidemiology and evolutionary genetics,” Infection, Genetics and Evolution, vol. 3, no. 2, pp. 125–133, 2003.
- L. C. O. Lazzarini, J. Rosenfeld, R. C. Huard et al., “Mycobacterium tuberculosis spoligotypes that may derive from mixed strain infections are revealed by a novel computational approach,” Infection, Genetics and Evolution, vol. 12, no. 4, pp. 798–806, 2012.