First-time detection of mycobacterium species from goats in Ethiopia

A scoping review of zoonotic parasites and pathogens associated with abattoirs in Eastern Africa and recommendations for abattoirs as disease surveillance sites

Abattoirs are facilities where livestock are slaughtered and are an important aspect in the food production chain. There are several types of abattoirs, which differ in infrastructure and facilities, sanitation and PPE practices, and adherence to regulations. In each abattoir facility, worker exposure to animals and animal products increases their risk of infection from zoonotic pathogens. Backyard abattoirs and slaughter slabs have the highest risk of pathogen transmission because of substandard hygiene practices and minimal infrastructure. These abattoir conditions can often contribute to environmental contamination and may play a significant role in disease outbreaks within communities. To assess further the risk of disease, we conducted a scoping review of parasites and pathogens among livestock and human workers in abattoirs across 13 Eastern African countries, which are hotspots for zoonoses. Our search results (n = 104 articles) showed the presence of bacteria, viruses, fungi, and macroparasites (nematodes, cestodes, etc.) in cattle, goats, sheep, pigs, camels, and poultry. Most articles reported results from cattle, and the most frequent pathogen detected was Mycobacterium bovis, which causes bovine tuberculosis. Some articles included worker survey and questionnaires that suggested how the use of PPE along with proper worker training and safe animal handling practices could reduce disease risk. Based on these findings, we discuss ways to improve abattoir biosafety and increase biosurveillance for disease control and mitigation. Abattoirs are a 'catch all' for pathogens, and by surveying animals at abattoirs, health officials can determine which diseases are prevalent in different regions and which pathogens are most likely transmitted from wildlife to livestock. We suggest a regional approach to biosurveillance, which will improve testing and data gathering for enhanced disease risk mapping and forecasting. Next generation sequencing will be key in identifying a wide range of pathogens, rather than a targeted approach.

Fascioliasis may promote tuberculous infectivity in small ruminants

Fascioliasis and bovine tuberculosis (TB) are global impediments to livestock development. We investigated the co-infectivity of fascioliasis and TB in small ruminants at slaughter. A total of 84 goats and 16 sheep were investigated from different slaughter houses in Mymensingh city, Bangladesh from June 2019 to February 2020. Grossly, acute fascioliasis was characterized by hemorrhagic tracts in the liver and chronic fascioliasis with biliary cirrhosis and pipe-stem liver. Grossly, seven goats and two sheep were associated with the acute and sixty goats and seven sheep were associated with the chronic phase of fascioliasis. Five goats’ livers showed both the acute and chronic phases of fascioliasis. In TB, granulomas with central core of caseous necrosis were seen in the lymph nodes (21), livers (10) and lungs (01) of goats or in the lymph nodes (03) and liver (01) of sheep. Histopathologically, biliary cirrhosis was seen in fascioliasis and granuloma, caseous necrosis and calcification in TB. In co-infection revealed granuloma (TB) with acid-fast bacilli and widespread biliary cirrhosis in the livers of goats (14) and sheep (02). The fragments of the 16S rRNA gene (372 bp, M. tuberculosis complex) and MPB83 gene (600 bp, M. bovis) were detected in the lymph nodes, livers and lungs using polymerase chain reaction. This study showed the existence of co-infectivity of Fasciola and M. bovis in goats and sheep in Bangladesh. Chronic fascioliasis may be associated with establishing tuberculous infection in small ruminants. Therefore, extremely zoonotic bovine TB control programs require active management of fascioliasis.

Mycobacterium tuberculosis sensu stricto in African Apes, What Is Its True Health Impact?

Since the Symposium on Mycobacterial Infections of Zoo Animals held at the National Zoological Park, Smithsonian Institution in 1976, our understanding of tuberculosis (TB) in non-domestic animals has greatly expanded. Throughout the past decades, this knowledge has resulted in improved zoo-habitats and facilities design, stricter biosecurity measures, and advanced diagnostic methods, including molecular techniques, that have significantly decreased the number of clinical disease caused by Mycobacterium tuberculosis in apes under human care settings. In the other hand, exponential growth of human populations has led to human encroachment in wildlife habitat which has resulted in increased inter-species contact and recurrent conflict between humans and wild animals. Although it is widely accepted that non-human primates are susceptible to M. tb infection, opinions differ with regard to the susceptibility to develop disease amongst different taxa. Specifically, some authors suggest that African apes are less susceptible to clinical tuberculosis than other species of primates. The aim of this review article is to evaluate the current scientific literature to determine the actual health impact of disease caused by Mycobacterium tuberculosis and more specifically Mycobacterium tuberculosis sensu stricto in African apes. The literature review included literature databases: Web of Science, Pubmed, Scopus, Wiley, Springer and Science direct, without temporal limit and proceedings of annual conferences in the field of wildlife health. Our general inclusion criteria included information about serological, molecular, pathological (macroscopic and/or microscopic), and clinical evidence of TB in African apes; while our, our more stringent inclusion selection criteria required that in addition to a gross pathology, a molecular test confirmed Mycobacterium tuberculosis sensu stricto as the cause of disease or death. We identified eleven reports of tuberculosis in African apes; of those, only four reports met the more stringent selection criteria that confirmed M. tb sensu stricto in six individuals. All reports that confirmed M. tb sensu stricto originated from zoological collections. Our review suggests that there is little evidence of disease or mortality caused by M. tb in the different species of African apes both under human care and free ranging populations. Additional studies are needed in free-ranging, semi-captive populations (sanctuaries) and animals under human care (zoos and rescue centers) to definitely conclude that this mycobacteria has a limited health effect in African ape species.

Prioritizing smallholder animal health needs in East Africa, West Africa, and South Asia using three approaches: Literature review, expert workshops, and practitioner surveys

Managing the health needs of livestock contributes to reducing poverty and improving the livelihoods of smallholder and pastoralist livestock keepers globally. Animal health practitioners, producers, policymakers, and researchers all must prioritize how to mobilize limited resources. This study employed three approaches to prioritize animal health needs in East and West Africa and South Asia to identify diseases and syndromes that impact livestock keepers. The approaches were a) systematic literature review, b) a series of expert workshops, and c) a practitioner survey of veterinarians and para-veterinary professionals. The top constraints that emerged from all three approaches include endo/ ectoparasites, foot and mouth disease, brucellosis, peste des petits ruminants, Newcastle disease, and avian influenza. Expert workshops additionally identified contagious caprine pleuropneumonia, contagious bovine pleuropneumonia, mastitis, and reproductive disorders as constraints not emphasized in the literature review. Practitioner survey results additionally identified nutrition as a constraint for smallholder dairy and pastoralist small ruminant production. Experts attending the workshops agreed most constraints can be managed using existing veterinary technologies and best husbandry practices, which supports a shift away from focusing on individual diseases and new technologies towards addressing systemic challenges that limit access to veterinary services and inputs. Few research studies focused on incidence/ prevalence of disease and impact, suggesting better incorporation of socio-economic impact measures in future research would better represent the interests of livestock keepers.

Goat γδ T cells

Goats are important food animals and are disseminated globally because of their high adaptability to varying environmental conditions and feeding regimes that provide them with a comparative advantage. Productivity is impacted by infectious diseases; this then contributes to societal poverty, food insecurity, and international trade restrictions. Since γδ T cells have been shown to have vital roles in immune responses in other mammals we reviewed the literature regarding what is known about their functions, distribution in tissues and organs and their responses to a variety of infections in goats. It has been shown that caprine γδ T cells produce interferon-γ and IL-17, are found in a variety of lymphoid and nonlymphoid tissues and constitute a significant population of blood mononuclear cells. Their representation in tissues and their functional responses may be altered concomitant with infection. This review summarizes caprine γδ T cell responses to Brucella melitensis, Fasciola hepatica, Mycobacterium avium paratuberculosis, caprine arthritis encephalitis virus (CAEV), and Schistosoma bovis in infected or vaccinated goats. Caprine γδ T cells have also been evaluated in goats infected with M. caprae, Ehrilichia ruminantium, Haemonchus contortus and peste des petits ruminants (PPR) virus but found to have an unknown or limited response or role in either protective immunity or immunopathogenesis in those cases.

Tuberculosis in small ruminants and dromedary camels in Ethiopia: A systematic review and meta-analysis

Tuberculosis (TB) is a chronic infectious disease of livestock with serious economic and public health impact in Ethiopia. The disease is reported from cattle, small ruminants and dromedary camels in the country. However, there is no organized summary report on the magnitude and distribution pattern of TB in small ruminants and dromedary camels, unlike that of bovine TB. Consequent to this gap, this review was organized to provide pooled prevalence estimates, and examine level of heterogeneity among studies at national level. In addition, it attempts to illustrate the spatial distribution patterns along the three livestock species based on available reports. Tuberculosis articles on the aforesaid livestock species were searched online using PubMed, CAB direct, Web of Science and AJOL databases. Eighteen articles published from January 2000 to May 15, 2020, written in the English language that fulfill the selection quality criteria were considered for the review. Altogether, 50 district based observational studies conducted on 10,371 goats, 6262 dromedary camels, and 1457 sheep were used for analysis. Accordingly, the pooled prevalence estimates of TB, in a random effect model were 2.3 % (95 % CI: 1.7, 3.1) for goats, 0.8 % (95 % CI: 0.5, 1.4) for sheep and 8.2 % (95 % CI: 6.6, 10.2) for dromedary camels. The subgroup analysis revealed presence of statistically significant differences (p < 0.001) in pooled prevalence estimates among the three species. In multivariable meta-regression model, diagnostic methods used for screening (single intra-dermal comparative cervical tuberculin test (SICCTT)> 2mm, SICCTT > 4mm and detailed postmortem inspection) were the only predictors identified to show statistically significant difference (p<0.001) and explained 68.6 % of the explainable heterogeneity (R² =0.686) in goat TB studies. In general, study reports on small ruminant and dromedary camel TB are limited throughout the country. The most significant data gaps were in Gambella, and Benshangul-Gumuz regional states, where no single report could be retrieved on small ruminant TB. Limitation of study reports and lack of comparable categories constrained further investigation on other predictors in sheep and camel studies. Thus, the authors would like to emphasize the need for more representative studies in the species of concern in all regions of the country. Meanwhile, the relatively higher proportion of TB in dromedary camels demands special attention in arid and semiarid parts of the country, as it is the leading livestock species on which agropastoralist and pastoralists livelihoods depend.

Review on Epidemiology and Public Health Importance of Goat Tuberculosis in Ethiopia

Small ruminant is an important and integral part of livestock in Ethiopia. Especially, goats are attractive to people of Ethiopia because of the ability to resist challenges, easily adapt to different ecological regions, and need small land to rearing and small initial capital in which poor people can engaged in the production system. In spite of the presence of large number of goat population in Ethiopia, it fails to utilize expected productivity due to many factors. Among the factors, which limit the economic returns of goats, diseases stand frontline. Tuberculosis is one the diseases that affect goats' health and production in Ethiopia. Goat tuberculosis is a chronic disease, which is characterized by the development of granulomas, essentially in the respiratory tract and related lymph nodes, from which the mycobacteria are discharged and contaminate other susceptible animals. Goat tuberculosis has a public health implication in Ethiopia because of the farmers' habit of consuming raw goat milk and its products, and they do have consistent or day-to-day contact with their goats. The etiological agents also transmitted to humans through the aerogenous route from those animals with active cases in the herd. The infection has been reported from several parts of different areas of the country dependent on the abattoir inspections. Therefore, attention should be given towards the control of tuberculosis in livestock; public health education on zoonotic importance of the disease or awareness creation and the national tuberculosis control needs to consider the one health approach, and further epidemiological studies should be undertaken.

Epidemiology of Mycobacterium bovis and Mycobacterium tuberculosis in animals: Transmission dynamics and control challenges of zoonotic TB in Ethiopia

Mycobacterium tuberculosis complex is the cause of tuberculosis (TB) in humans and other animals. Specifically, Mycobacterium bovis (M. bovis) and Mycobacterium tuberculosis (M. tuberculosis) are highly pathogenic mycobacteria that may infect different animal species and are the sources of TB in humans. The objective of this paper was to review the epidemiology of M. bovis and M. tuberculosis in animals. The review also highlighted the transmission dynamics of M. bovis and M. tuberculosis in humans and animals and control challenges of zoonotic TB in Ethiopia. The literature review focused on scientific peer-reviewed articles from studies exclusively conducted in Ethiopia that were published from 1998 to 2017. Husbandry system, breed and herd size have significant role in the epidemiology of bovine tuberculosis (BTB) in Ethiopia. The information presented reveals that different strains of M. bovis are widely distributed in domestic animals predominantly in the Ethiopian cattle and the main strain was found to be SB1176. In addition, the isolation of M. tuberculosis from domestic animals in different settings signifies the circulation of the agent between humans and animals in Ethiopia. The life styles of the Ethiopian communities, close contact with domestic animals and/or the habit of consuming raw animal products, are suggested as the main factors for transmission of M. bovis and M. tuberculosis between human and animal which may have impact on the TB control program in human. In Ethiopia, a human TB control program has been widely implemented, however, the role of animal in the transmission of the causative agent has been neglected which could be one of the challenges for an effective control program. This warrants the need for incorporating animal TB control programs using "One Health" approach for effective TB control for both human and animal.

Prevalence of bovine and avian tuberculosis in camel herds and associated public health risk factors in Isiolo County, Kenya

A cross-sectional study was conducted among 308 lactating camels selected from 15 herds from three different camel milk clusters in Isiolo County, Kenya, to determine prevalence of bovine and avian tuberculosis using Single Comparative Intradermal Tuberculin Skin test. Seventy-five (75) questionnaires were administered to pastoralists/herders, and focus group discussions were conducted among 3-5 pastoralists/herders selected from each camel herd to collect information on camel husbandry and health management practices and knowledge on tuberculosis in livestock and wildlife. An overall prevalence of bovine and avian reactors was 3.57 and 18.18%, respectively, with bovine and avian reactors for different clusters being 2.38, 3.82, and 4.48% and 25, 17.2, and 11.94%, respectively. There was significant difference (p < 0.05) in prevalence of bovine and avian reactors between different clusters. There was a negative correction (r = -0.1399) between herd size and bovine reactors, while there was a positive correlation (r = 0.0445) between herd size and avian reactors. The respondents indicated that camel herds are exposed to several risk factors like close contact with other herds or livestock or wildlife during grazing and at watering points. Pastoralists have poor knowledge on mode of infection and transmission of bovine or avian tuberculosis. The high prevalence of bovine and avian reactors and pastoralists' poor knowledge on mode of transmission signify potential risk to public health.

An assessment of caprine tuberculosis prevalence in Lubumbashi slaughterhouse, Democratic Republic of Congo

Caprine tuberculosis is a major health problem for goats and a major zoonosis of veterinary public health interest. In order to prepare a response to and control of caprine tuberculosis, to evaluate the potential risks to public health, and to assess the prevalence of the disease in Katanga province, Democratic Republic of Congo, 656 goats that were slaughtered at the Kabasele abattoir of Mzee Laurent-Desire Kabila Market in Lubumbashi were subjected to rigorous veterinary inspection during June to August 2012. All goat specimens came from the Kasumbalesa, Kasenga, and Kipushi areas of Katanga province. Consequently, suspected organs presenting signs of tuberculosis were collected and examined using Ziehl-Neelsen stains for diagnosis. Through this investigative inspection in the province, we found an overall prevalence of caprine tuberculosis of 1.68%. Although females showed higher prevalence of caprine tuberculosis (1.07%) compared to males (0.61%), and adults showed higher prevalence (1.22%) than juveniles (0.45%), these comparisons were not statically significant. However, lung and intestine infection by tuberculosis showed significantly higher prevalence of positive cases (1.21 and 0.46%, respectively) (p < 0.05). Goats from Kasumbalesa had the highest prevalence of caprine tuberculosis (1.22%) compared to goats from Kipushi (0.31%) and Kasenga (0.18%). These findings show the risk of caprine tuberculosis in the province for the first time, and we therefore recommend the implementation of strict animal biosecurity and tuberculosis controlling protocols.

Overview and phylogeny of Mycobacterium tuberculosis complex organisms: implications for diagnostics and legislation of bovine tuberculosis

Members of the Mycobacterium tuberculosis complex (MTBC) cause a serious disease with similar pathology, tuberculosis; in this review, bovine tuberculosis will be considered as disease caused by any member of the MTBC in bovids. Bovine tuberculosis is responsible for significant economic loss due to costly eradication programs and trade limitations and poses a threat to both endangered and protected species as well as to public health. We here give an overview on all members of the MTBC, focusing on their isolation from different animal hosts. We also review the recent advances made in elucidating the evolutionary and phylogenetic relationships of members of the MTBC. Because the nomenclature of the MTBC is controversial, its members have been considered species, subspecies or ecotypes, this review discusses the possible implications for diagnostics and the legal consequences of naming of new species.

First-time detection of Mycobacterium bovis in livestock tissues and milk in the West Bank, Palestinian Territories

Background

Bovine tuberculosis, bTB, is classified by the WHO as one of the seven neglected zoonontic diseases that cause animal health problems and has high potential to infect humans. In the West Bank, bTB was not studied among animals and the prevalence of human tuberculosis caused by M. bovis is unknown. Therefore, the aim of this study was to estimate the prevalence of bTB among cattle and goats and identify the molecular characteristics of bTB in our area.

Methodology/principal findings

A total of 208 tissue samples, representing 104 animals, and 150 raw milk samples, obtained from cows and goats were examined for the presence of mycobacteria. The tissue samples were collected during routine meat inspection from the Jericho abattoir. DNA was extracted from all samples, milk and tissue biopsies (n = 358), and screened for presence of TB DNA by amplifying a 123-bp segment of the insertion sequence IS6110. Eight out of 254 animals (3.1%) were found to be TB positive based on the IS6110-PCR. Identification of M. bovis among the positive TB samples was carried out via real time PCR followed by high resolution melt curve analysis, targeting the A/G transition along the oxyR gene. Spoligotyping analysis revealed a new genotype of M. bovis that was revealed from one tissue sample.

Significance

Detection of M. bovis in tissue and milk of livestock suggests that apparently healthy cattle and goats are a potential source of infection of bTB and may pose a risk to public health. Hence, appropriate measures including meat inspection at abattoirs in the region are required together with promotion of a health campaign emphasizing the importance of drinking pasteurized milk. In addition, further studies are essential at the farm level to determine the exact prevalence of bTB in goats and cattle herds in the West Bank and Israel.

Bovine tuberculosis (caused by Mycobacterium bovis) is a zoonotic disease causing major public health concerns. Animals, both wild and domestic, tested positive to bovine tuberculosis are being slaughtered and the affected herds are placed under temporary movement restrictions. Hence, bTB can have strong economic implications. In the West Bank, bTB has not been reported during the past 20 years. Our study determined the presence of M. bovis in tissue and milk samples of goats and cattle. Tissues were collected from slaughtered animals during routine meat inspection at the abattoir and were categorized as negative for mycobacteria. The frequency of the detected bTB was low but indicated the low sensitivity of the routine meat inspection compared to diagnosis of M. bovis infection via PCR assay. Furthermore, M. bovis was found in goat milk samples. As bTB is considered a neglected disease, known in high frequency in Africa and Asia, we recommend conducting a regional survey to assess the prevalence of the disease among cattle, sheep and goat herds. The results of the survey will undoubtedly be a platform for new public health policies.

Abattoir-based study on the epidemiology of caprine tuberculosis in Ethiopia using conventional and molecular tools

Background

Despite the important role of goats for meat and milk production in Ethiopia, little information is available on the epidemiology of caprine tuberculosis (TB). Caprine TB is important as milk is usually consumed raw particularly by Ethiopian pastoralists. The objectives of the present study were to estimate the prevalence of TB in goats at an abattoir, to evaluate associated risk factors and to characterize the causative mycobacteria.

Methods

A cross-sectional study was conducted on 1990 randomly selected male goats that were slaughtered at Luna Export Abattoir of central Ethiopia. Postmortem examination, mycobacterial culturing and molecular typing techniques like genus typing, deletion typing and spoligotyping were used.

Result

The overall prevalence of caprine TB-like lesions was 3.5%. The lesion prevalence increased significantly with increasing age. Mycobacteria were found by culture and seen as acid fast bacilli in 12% of the goats with TB-like lesions. Characterization of the eight isolates using multiplex polymerase chain reaction (PCR) indicated that five of them belonged to the genus Mycobacterium. Four of the latter were confirmed to be members of the M. tuberculosis complex. Further characterization of the three M. tuberculosis isolates by spoligotyping identified them as type SIT53 and two new spoligotypes.

Conclusion

The isolation of M. tuberculosis from goats in this study indicates a potential risk of transmission of M. tuberculosis between humans and goats.

Low prevalence of bovine tuberculosis in Somali pastoral livestock, southeast Ethiopia

A cross-sectional study of bovine tuberculosis (BTB) detected by the comparative intradermal tuberculin test (CIDT) was conducted in livestock of the Somali region in southeast Ethiopia--in four pastoral associations from January to August 2009. In 94 herds, each of 15 cattle, camels, and goats was tested per herd leading to a total of 1,418 CIDT tested animals, with 421 cattle, 479 camels, and 518 goats. A herd was considered positive if it had at least one reactor. Prevalence per animal species was calculated using a xtgee model for each species. The individual animal prevalence was 2.0% [95% confidence interval (CI), 0.5-8.4], 0.4% (95% CI, 0.1-3%), and 0.2% (95% CI, 0.03-1.3) in cattle, camels, and goats, respectively. Prevalence of avian mycobacterium purified protein derivative (PPD) reactors in cattle, camels, and goats was 0.7% (95% CI, 0.2-2.0%), 10.0% (95% CI, 7.0-14.0%), and 1.9 (95% CI, 0.9-4.0%), respectively, whereby camels had an odds ratio of 16.5 (95% CI, 5.0-55.0) when compared to cattle. There was no significant difference between livestock species in BTB positivity. In the present study, the prevalence of bovine tuberculosis was low in Somali pastoral livestock in general and in camels and goats in particular. The high proportion of camel reactors to avian PPD needs further investigation of its impact on camel production.

Tuberculosis in Goats and Sheep in Afar Pastoral Region of Ethiopia and Isolation of Mycobacterium tuberculosis from Goat

A cross sectional study was conducted on 2231 small ruminants in four districts of the Afar Pastoral Region of Ethiopia to investigate the epidemiology of tuberculosis in goats and sheep using comparative intradermal tuberculin skin test, postmortem examination, mycobacteriological culture and molecular typing methods. The overall animal prevalence of TB in small ruminants was 0.5% (95% CI: 0.2%-0.7%) at ≥4 mm and 3.8% (95% CI: 3%-4.7%) at cutoff ≥2 mm. The herd prevalence was 20% (95% CI: 12-28%) and 47% (95% CI: 37-56%) at ≥4 mm and ≥2 mm cut-off points, respectively. The overall animal prevalence of Mycobacterium avium complex infection was 2.8% (95% CI: 2.1-3.5%) and 6.8% (95% CI: 5.8-7.9%) at ≥4 mm and ≥2 mm cut-off points, respectively. Mycobacteriological culture and molecular characterization of isolates from tissue lesions of tuberculin reactor goats resulted in isolation of Mycobacterium tuberculosis (SIT149) and non-tuberculosis mycobacteria as causative agents of tuberculosis and tuberculosis-like diseases in goats, respectively. The isolation of Mycobacterium tuberculosis in goat suggests a potential transmission of the causative agent from human and warrants further investigation in the role of small ruminants in epidemiology of human tuberculosis in the region.

Zoonotic transmission of tuberculosis between pastoralists and their livestock in South-East Ethiopia

Despite huge global efforts in tuberculosis (TB) control, pastoral areas remain under-investigated. During two years sputum and fine needle aspirate (FNA) specimens were collected from 260 Ethiopian pastoralists of Oromia and Somali Regional States with suspected pulmonary TB and from 32 cases with suspected TB lymphadenitis. In parallel, 207 suspected tuberculous lesions were collected from cattle, camels and goats at abattoirs. All specimens were processed and cultured for mycobacteria; samples with acid-fast stained bacilli (AFB) were further characterized by molecular methods including genus and deletion typing as well as spoligotyping. Non-tuberculous mycobacteria (NTM) were sequenced at the 16S rDNA locus. Culturing of AFB from human sputum and FNA samples gave a yield of 174 (67%) and 9 (28%) isolates, respectively. Molecular typing was performed on 173 of these isolates and 160 were confirmed as Mycobacterium tuberculosis, three as M. bovis, and the remaining 10 were typed as NTMs. Similarly, 48 AFB isolates (23%) yielded from tuberculous lesions of livestock, of which 39 were molecular typed, including 24 M. bovis and 4 NTMs from cattle, 1 M. tuberculosis and 1 NTM from camels and 9 NTMs from goats. Isolation of M. bovis from humans and M. tuberculosis from livestock suggests transmission between livestock and humans in the pastoral areas of South-East Ethiopia.