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Sata E, Seife F, Ayele Z, Murray SA, Wickens K, Le P, Zerihun M, Melak B, Chernet A, Jensen KA, Gessese D, Zeru T, Dawed AA, Debebe H, Tadesse Z, Callahan EK, Martin DL, Nash SD. Wait and watch: A trachoma surveillance strategy from Amhara region, Ethiopia. PLoS Negl Trop Dis 2024; 18:e0011986. [PMID: 38386689 PMCID: PMC10914254 DOI: 10.1371/journal.pntd.0011986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/05/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Trachoma recrudescence after elimination as a public health problem has been reached is a concern for control programs globally. Programs typically conduct district-level trachoma surveillance surveys (TSS) ≥ 2 years after the elimination threshold is achieved to determine whether the prevalence of trachomatous inflammation-follicular (TF) among children ages 1 to 9 years remains <5%. Many TSS are resulting in a TF prevalence ≥5%. Once a district returns to TF ≥5%, a program typically restarts costly mass drug administration (MDA) campaigns and surveys at least twice, for impact and another TSS. In Amhara, Ethiopia, most TSS which result in a TF ≥5% have a prevalence close to 5%, making it difficult to determine whether the result is due to true recrudescence or to statistical variability. This study's aim was to monitor recrudescence within Amhara by waiting to restart MDA within 2 districts with a TF prevalence ≥5% at TSS, Metema = 5.2% and Woreta Town = 5.1%. The districts were resurveyed 1 year later using traditional and alternative indicators, such as measures of infection and serology, a "wait and watch" approach. METHODS/PRINCIPAL FINDINGS These post-surveillance surveys, conducted in 2021, were multi-stage cluster surveys whereby certified graders assessed trachoma signs. Children ages 1 to 9 years provided a dried blood spot and children ages 1 to 5 years provided a conjunctival swab. TF prevalence in Metema and Woreta Town were 3.6% (95% Confidence Interval [CI]:1.4-6.4) and 2.5% (95% CI:0.8-4.5) respectively. Infection prevalence was 1.2% in Woreta Town and 0% in Metema. Seroconversion rates to Pgp3 in Metema and Woreta Town were 0.4 (95% CI:0.2-0.7) seroconversions per 100 child-years and 0.9 (95% CI:0.6-1.5) respectively. CONCLUSIONS/SIGNIFICANCE Both study districts had a TF prevalence <5% with low levels of Chlamydia trachomatis infection and transmission, and thus MDA interventions are no longer warranted. The wait and watch approach represents a surveillance strategy which could lead to fewer MDA campaigns and surveys and thus cost savings with reduced antibiotic usage.
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Affiliation(s)
- Eshetu Sata
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Fikre Seife
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Zebene Ayele
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Sarah A. Murray
- Trachoma Control Program, The Carter Center, Atlanta, Georgia, United States of America
| | - Karana Wickens
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Internships and Fellowships, Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, United States of America
| | - Phong Le
- Trachoma Control Program, The Carter Center, Atlanta, Georgia, United States of America
| | - Mulat Zerihun
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Berhanu Melak
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Ambahun Chernet
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Kimberly A. Jensen
- Trachoma Control Program, The Carter Center, Atlanta, Georgia, United States of America
| | - Demelash Gessese
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Taye Zeru
- Research and Technology Transfer Directorate, Amhara Public Health Institute, Bahir Dar, Ethiopia
| | - Adisu Abebe Dawed
- Department of Health Promotion and Disease Prevention, Amhara Regional Health Bureau, Bahir Dar, Ethiopia
| | - Hiwot Debebe
- Department of Health Promotion and Disease Prevention, Amhara Regional Health Bureau, Bahir Dar, Ethiopia
| | - Zerihun Tadesse
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - E. Kelly Callahan
- Trachoma Control Program, The Carter Center, Atlanta, Georgia, United States of America
| | - Diana L. Martin
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Scott D. Nash
- Trachoma Control Program, The Carter Center, Atlanta, Georgia, United States of America
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D. Nash S, Chernet A, Weiss P, W. Nute A, Zerihun M, Sata E, Gessese D, A. Jensen K, Ayele Z, Melak B, Zeru T, Mengistu A, Abebe A, Seife F, Tadesse Z, Callahan EK. Prevalence of Ocular Chlamydia trachomatis Infection in Amhara Region, Ethiopia, after 8 Years of Trachoma Control Interventions. Am J Trop Med Hyg 2023; 108:261-267. [PMID: 36623484 PMCID: PMC9896333 DOI: 10.4269/ajtmh.22-0535] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/14/2022] [Indexed: 01/11/2023] Open
Abstract
Although trachoma mass drug administration (MDA) programs target ocular Chlamydia trachomatis, the global trachoma control program does not monitor infection as a measure of impact but instead relies on monitoring clinical indicators. This study aimed to monitor the prevalence of ocular C. trachomatis among a population-based sample of children ages 1-5 years throughout Amhara, Ethiopia, a region that has received approximately 8 years of annual MDA as part of trachoma control. Between 2014 and 2021, trachoma impact surveys and surveillance surveys were conducted in all 156 districts of Amhara using a multistage cluster randomized methodology. Certified graders assessed individuals ages ≥ 1 year for trachomatous inflammation-follicular (TF), and a random subset of children ages 1-5 years also provided a conjunctival swab. Polymerase chain reaction was used to test for C. trachomatis. A total of 28,410 conjunctival swabs were collected from children ages 1-5 years across Amhara. The regional C. trachomatis infection prevalence was 4.7% (95% uncertainty interval: 4.3-5.1%). Infection was detected in all 10 zones of the region and ranged from 0.2% in Awi Zone to 11.9% in Waghemra Zone. Infection was detected in 17 (26%) districts with a TF prevalence < 10% and in 7 (21%) districts with a TF prevalence < 5%. Through programmatic monitoring of C. trachomatis infection, this study demonstrated that considerable infection remained throughout Amhara despite approximately 8 years of trachoma interventions and that enhanced interventions such as more frequent than annual MDA will be needed if elimination thresholds are to be reached.
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Affiliation(s)
- Scott D. Nash
- Trachoma Control Program, The Carter Center, Atlanta, Georgia;,Address correspondence to Scott Nash, The Carter Center, 453 John Lewis Freedom Pkwy. NE, Atlanta, GA 30307. E-mail:
| | - Ambahun Chernet
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Paul Weiss
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Andrew W. Nute
- Trachoma Control Program, The Carter Center, Atlanta, Georgia
| | - Mulat Zerihun
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Eshetu Sata
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Demelash Gessese
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | | | - Zebene Ayele
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Berhanu Melak
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
| | - Taye Zeru
- Amhara Public Health Institute, Bahir, Dar, Ethiopia
| | | | - Adisu Abebe
- Amhara Regional Health Bureau, Bahir Dar, Ethiopia
| | | | - Zerihun Tadesse
- Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia
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Abstract
Trachoma is a neglected tropical disease caused by infection with conjunctival strains of Chlamydia trachomatis. It can result in blindness. Pathophysiologically, trachoma is a disease complex composed of two linked chronic processes: a recurrent, generally subclinical infectious-inflammatory disease that mostly affects children, and a non-communicable, cicatricial and, owing to trichiasis, eventually blinding disease that supervenes in some individuals later in life. At least 150 infection episodes over an individual's lifetime are needed to precipitate trichiasis; thus, opportunity exists for a just global health system to intervene to prevent trachomatous blindness. Trachoma is found at highest prevalence in the poorest communities of low-income countries, particularly in sub-Saharan Africa; in June 2021, 1.8 million people worldwide were going blind from the disease. Blindness attributable to trachoma can appear in communities many years after conjunctival C. trachomatis transmission has waned or ceased; therefore, the two linked disease processes require distinct clinical and public health responses. Surgery is offered to individuals with trichiasis and antibiotic mass drug administration and interventions to stimulate facial cleanliness and environmental improvement are designed to reduce infection prevalence and transmission. Together, these interventions comprise the SAFE strategy, which is achieving considerable success. Although much work remains, a continuing public health problem from trachoma in the year 2030 will be difficult for the world to excuse.
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Mahmud H, Landskroner E, Amza A, Aragie S, Godwin WW, de Hostos Barth A, O’Brien KS, Lietman TM, Oldenburg CE. Stopping azithromycin mass drug administration for trachoma: A systematic review. PLoS Negl Trop Dis 2021; 15:e0009491. [PMID: 34237074 PMCID: PMC8266061 DOI: 10.1371/journal.pntd.0009491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The World Health Organization (WHO) recommends continuing azithromycin mass drug administration (MDA) for trachoma until endemic regions drop below 5% prevalence of active trachoma in children aged 1–9 years. Azithromycin targets the ocular strains of Chlamydia trachomatis that cause trachoma. Regions with low prevalence of active trachoma may have little if any ocular chlamydia, and, thus, may not benefit from azithromycin treatment. Understanding what happens to active trachoma and ocular chlamydia prevalence after stopping azithromycin MDA may improve future treatment decisions. We systematically reviewed published evidence for community prevalence of both active trachoma and ocular chlamydia after cessation of azithromycin distribution. We searched electronic databases for all peer-reviewed studies published before May 2020 that included at least 2 post-MDA surveillance surveys of ocular chlamydia and/or the active trachoma marker, trachomatous inflammation–follicular (TF) prevalence. We assessed trends in the prevalence of both indicators over time after stopping azithromycin MDA. Of 140 identified studies, 21 met inclusion criteria and were used for qualitative synthesis. Post-MDA, we found a gradual increase in ocular chlamydia infection prevalence over time, while TF prevalence generally gradually declined. Ocular chlamydia infection may be a better measurement tool compared to TF for detecting trachoma recrudescence in communities after stopping azithromycin MDA. These findings may guide future trachoma treatment and surveillance efforts. Trachoma, caused by repeated infections with ocular Chlamydia trachomatis, substantially contributes to the global burden of blindness. Community-wide distribution of the oral antibiotic azithromycin in trachoma endemic regions has contributed to significant decline in the prevalence of both ocular chlamydia infection and clinical findings of active trachoma. After azithromycin mass drug administration (MDA) stops, both ocular chlamydia and active trachoma can return. Our systematic review finds that ocular chlamydia infection may return to communities faster than signs of active trachoma, which may help better understand the utility of different trachoma indicators for post-MDA surveillance.
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Affiliation(s)
- Hamidah Mahmud
- University of California, San Francisco School of Medicine, San Francisco, California, United States of America
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Emma Landskroner
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Abdou Amza
- Programme National de Santé Oculaire, Niamey, Niger
| | | | - William W. Godwin
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Anna de Hostos Barth
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, United States of America
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, United States of America
- * E-mail:
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