Integrating an NTD with one of "The big three": combined malaria and trachoma survey in Amhara Region of Ethiopia

The Epidemiology of Ocular Chlamydia trachomatis Infection within Districts Persistently Endemic for Trachoma in Amhara, Ethiopia

Persistent trachoma is a growing concern to trachoma control programs globally and programs serving Ethiopia specifically. Persistent trachoma is defined as a district with two or more trachoma impact surveys (TISs) at which the prevalence of trachomatous inflammation-follicular (TF) among children ages 1-9 years is ≥5%, the elimination threshold. Because the global target for trachoma elimination as a public health problem is 2030, research is needed to better characterize persistent trachoma. This study described the epidemiology of ocular Chlamydia trachomatis infection, the causative bacteria of trachoma, in seven contiguous districts experiencing persistent trachoma. In 2019, multistage cluster random sampling TISs were conducted in the seven districts after 10 years of interventions. All individuals ages ≥1 year were examined for trachoma clinical signs by certified graders, and conjunctival swabs were collected from children ages 1-5 years to test for C. trachomatis infection. The district TF prevalence ranged from 11.8% (95% CI:7.6-16.0%) to 36.1% (95% CI:27.4-44.3%). The range of district-level C. trachomatis infection prevalence was between 2.7% and 34.4%. Statistically significant spatial clustering of high-infection communities was observed in the study districts, and children with infection were more likely than those without to be found in households with clinical signs of trachoma and those without latrines. These seven districts appear to constitute a persistent hotspot in Amhara, where an additional 3-5 years or more of interventions will be required. The global program will need to strengthen and enhance intervention strategies within persistent districts if elimination by 2030 is to be achieved.

Impact of a School Trachoma Program Emphasizing Facial Cleanliness and Environmental Improvement in Amhara, Ethiopia

The SAFE (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) strategy is the WHO's endorsed approach for eliminating trachoma as a public health problem; however, not all components have been treated equally. Historically, the F and E components have not been prioritized owing to their perceived complexity. With school enrollment increasing in Ethiopia, development of a national school health program that is focused on the F and E components represents an opportunity to strengthen the SAFE strategy in the country. In 2016, the Trachoma Control Program in Amhara, Ethiopia, along with its partners, developed a School Trachoma Program (STP) that offers grade-specific lessons to improve sanitation and hygiene knowledge and practices among primary school-aged children. To assess its impact, schools were sampled before implementation and then up to 1 year after STP rollout. The aim of this report is to detail STP outcomes and the associations between outcomes and school-level variables. By 2018, adoption of an STP was strong within Amhara, with 85% of the 137 surveyed schools completing their quarterly reports and nearly 80% having at least one teacher trained in the STP. By the end of the third quarter, nearly all schools (86%) had access to a latrine, and 89% of students had a clean face. A schoolwide orientation was associated with increased STP lessons and activities (P = 0.01). Development of an STP, with buy-in from principals and teachers, represents a promising approach for the adoption of a new F- and E-specific curriculum and may help advance efforts to eliminate trachoma.

Prevalence of active trachoma among 1-9 years of age children in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

The objective of this study is to determine the pooled prevalence of active trachoma among 1-9 years old children in Ethiopia.

DESIGN

A systematic review and meta-analysis were employed in accordance with the Preferred Reporting Items for Systematic Reviews.

DATA SOURCES

Medline/PubMed, Scopus, Web of Science, African Journal of Online and Google scholar databases were systematically explored to find studies published in English until July 2023.

ELIGIBILITY CRITERIA

The following criteria apply: (1) condition (Co): studies examined the prevalence of trachoma among children (1-9) years old; (2) context (Co): studies conducted in Ethiopia; (3) population (Pop): studies that were done among children (1-9) years old; (4) study type: observational studies and (5) language: studies published in English.

DATA EXTRACTION AND SYNTHESIS

The data were extracted using a Microsoft Excel spreadsheet. DerSimonian-Laird random effect model was used to estimate the pooled prevalence of active trachoma among 1-9 years old children. Cochrane Q-tests and I2 statistics were used across studies to assess heterogeneity. To identify possible publication bias, Egger's test was performed.

PRIMARY OUTCOME

Prevalence of active trachoma among children aged (1-9 years old)".

RESULTS

Overall, a total of 42 articles with 235 005 study participants were included in the final analysis. The estimated pooled prevalence of active trachoma using random effect model was 24% (95% CI 20% to 27%). The subgroup analysis by region revealed that the highest prevalence of trachoma was 36% (95% CI 13% to 58%) in the Tigray region, and publication year revealed the prevalence of trachoma was decreasing from 32% to 19% after 2015.

CONCLUSION

In this review, the pooled prevalence of active trachoma was found to be high in Ethiopia compared with WHO threshold level. This underscores the need for increased focus on high-risk age groups to decrease trachoma and to achieve the elimination of trachoma from the country by 2030.

Wait and watch: A trachoma surveillance strategy from Amhara region, Ethiopia

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.

Spatio-Temporal Variation of Malaria Incidence and Risk Factors in West Gojjam Zone, Northwest Ethiopia

Introduction

Malaria is a life-threatening acute febrile illness which is affecting the lives of millions globally. Its distribution is characterized by spatial, temporal, and spatiotemporal heterogeneity. Detection of the space-time distribution and mapping high-risk areas is useful to target hot spots for effective intervention.

Methods

Time series cross sectional study was conducted using weekly malaria surveillance data obtained from Amhara Public Health Institute. Poisson model was fitted to determine the purely spatial, temporal, and space-time clusters using SaTScan™ 9.6 software. Spearman correlation, bivariate, and multivariable negative binomial regressions were used to analyze the relation of the climatic factors to count of malaria incidence.

Result

Jabitenan, Quarit, Sekela, Bure, and Wonberma were high rate spatial cluster of malaria incidence hierarchically. Spatiotemporal clusters were detected. A temporal scan statistic identified 1 risk period from 1 July 2013 to 30 June 2015. The adjusted incidence rate ratio showed that monthly average temperature and monthly average rainfall were independent predictors for malaria incidence at all lag-months. Monthly average relative humidity was significant at 2 months lag.

Conclusion

Malaria incidence had spatial, temporal, spatiotemporal variability in West Gojjam zone. Mean monthly temperature and rainfall were directly and negatively associated to count of malaria incidence respectively. Considering these space-time variations and risk factors (temperature and rainfall) would be useful for the prevention and control and ultimately achieve elimination.

Baseline malaria prevalence at the targeted pre-elimination districts in Ethiopia

Background

Encouraged by the previous success in malaria control and prevention strategies, the Ethiopian ministry of health launched malaria elimination with a stepwise approach by primarily targeting the low-transmission Districts and their adjacent areas/zones in order to shrink the country’s malaria map progressively. Hence, this community survey was conducted to establish baseline malaria information at the preliminary phase of elimination at targeted settings.

Methods

A community-based cross-sectional survey was conducted at 20 malaria-elimination targeted Districts selected from five Regional states and one city administration in Ethiopia. The GPS-enabled smartphones programmed with Open Data Kit were used to enumerate 9326 study households and collect data from 29,993 residents. CareStart™ Malaria PAN (pLDH) Rapid Diagnostic Tests (RDTs) were used for blood testing at the field level. Armpit digital thermometers were used to measure axillary temperature.

Result

Overall malaria prevalence by RDTs was 1.17% (339/28973). The prevalence at District levels ranged from 0.0 to 4.7%. The proportion of symptomatic cases (axillary temperature > 37.5^oc) in the survey was 9.2% (2760/29993). Among the 2510 symptomatic individuals tested with RDTs, only 3.35% (84/2510) were malaria positive. The 75.2% (255/339) of all malaria positives were asymptomatic. Of the total asymptomatic malaria cases, 10.2% (26/255) were under-five children and 89.8% (229/255) were above 5 years of age.

Conclusion

The study shows a decrease in malaria prevalence compared to the reports of previous malaria indicator surveys in the country. The finding can be used as a baseline for measuring the achievement of ongoing malaria elimination efforts. Particularly, the high prevalence of asymptomatic individuals (0.88%) in these transmission settings indicates there may be sustaining hidden transmission. Therefore, active case detection with more sensitive diagnostic techniques is suggested to know more real magnitude of residual malaria in the elimination-targeted areas.

How can we better integrate the prevention, treatment, control and elimination of neglected tropical diseases with other health interventions? A systematic review

Background

Globally, about 1.7 billion people living in poverty are affected by one or more of a group of disabling, disfiguring and poverty-promoting conditions known as neglected tropical diseases (NTDs). Major global health actors, like the WHO, have endorsed a shift from vertical to integrated NTD management.

Objective

This systematic review aimed to evaluate how integration is being conducted and how we can improve it.

Methods

PubMed, Medline, Cochrane library, Web of Science, Trip, Embase, Global Health and Google Scholar were searched from 1 April to 22 July 2020. We included peer-reviewed articles published between 1 January 2000 and 22 July 2020 in English.

Results

Database searches produced 24 565 studies, of which 35 articles met the inclusion criteria. Twenty of these articles were conducted in sub-Saharan Africa. Twenty articles were also published between 2015 and 2020. Literature revealed that NTDs have been integrated—among themselves; with water, sanitation and hygiene programmes; with vector control; with primary healthcare; with immunisation programmes; and with malaria management. Integrated mass drug administration for multiple NTDs was the most common method of integration. The three complex, yet common characteristics of successful integration were good governance, adequate financing and total community engagement.

Conclusion

The dataset identified integrated management of NTDs to be cost effective and potentially to increase treatment coverage. However, the identified modes of integration are not exclusive and are limited by the available literature. Nonetheless, integration should urgently be implemented, while considering the programmatic and sociopolitical context.

PROSPERO registration number

The study protocol was registered with PROSPERO number, CRD42020167358.

The population-based prevalence of trachomatous scarring in a trachoma hyperendemic setting: results from 152 impact surveys in Amhara, Ethiopia

BACKGROUND

Trachomatous scarring (TS) results from repeated infection with the bacterium Chlamydia trachomatis. Pronounced scarring is an underlying cause of trachomatous trichiasis (TT) that can lead to blindness. Since the condition is irreversible, TS in adults has been considered a marker of past exposure to trachoma infection. The aim of this report was to estimate the population-based prevalence of TS within Amhara, Ethiopia, a region with a historically high burden of trachoma.

METHODS

District-level multi-stage cluster surveys were conducted in all districts between 2010 and 2015 to monitor the impact of approximately 5 years of trachoma interventions. Approximately 40 households were sampled per cluster and all participants ages ≥ 1 year were graded for the 5 World Health Organization simplified signs. Before each survey round, trachoma graders participated in a 7-day training and reliability exam that included cases of TS. TS prevalence estimates were weighted to account for sampling design and adjusted for age and sex using post-stratification weighting.

RESULTS

Across the 152 districts in Amhara, 208,510 individuals ages 1 year and older were examined for the signs of trachoma. Region-wide, the prevalence of TS was 8.2 %, (95 % Confidence Interval [CI]: 7.7-8.6 %), and the prevalence among individuals ages 15 years and older (n = 110,137) was 12.6 % (95 % CI: 12.0-13.3 %). District-level TS prevalence among individuals ages 15 years and older ranged from 0.9 to 36.9 % and was moderately correlated with district prevalence of TT (r = 0.31; P < 0.001). The prevalence of TS increased with age, reaching 22.4 % among those ages 56 to 60 years and 24.2 % among those ages 61 to 65 years. Among children ages 1 to 15 years TS prevalence was 2.2 % (95 % CI: 1.8-2.8 %), increased with age (P < 0.001), and 5 % of individuals with TS also had trachomatous inflammation-intense (TI).

CONCLUSIONS

These results suggest that Amhara has had a long history of trachoma exposure and that a large population remains at risk for developing TT. It is promising, however, that children, many born after interventions began, have low levels of TS compared to other known trachoma-hyperendemic areas.

Comparing malaria early detection methods in a declining transmission setting in northwestern Ethiopia

Background

Despite remarkable progress in the reduction of malaria incidence, this disease remains a public health threat to a significant portion of the world’s population. Surveillance, combined with early detection algorithms, can be an effective intervention strategy to inform timely public health responses to potential outbreaks. Our main objective was to compare the potential for detecting malaria outbreaks by selected event detection methods.

Methods

We used historical surveillance data with weekly counts of confirmed Plasmodium falciparum (including mixed) cases from the Amhara region of Ethiopia, where there was a resurgence of malaria in 2019 following several years of declining cases. We evaluated three methods for early detection of the 2019 malaria events: 1) the Centers for Disease Prevention and Control (CDC) Early Aberration Reporting System (EARS), 2) methods based on weekly statistical thresholds, including the WHO and Cullen methods, and 3) the Farrington methods.

Results

All of the methods evaluated performed better than a naïve random alarm generator. We also found distinct trade-offs between the percent of events detected and the percent of true positive alarms. CDC EARS and weekly statistical threshold methods had high event sensitivities (80–100% CDC; 57–100% weekly statistical) and low to moderate alarm specificities (25–40% CDC; 16–61% weekly statistical). Farrington variants had a wide range of scores (20–100% sensitivities; 16–100% specificities) and could achieve various balances between sensitivity and specificity.

Conclusions

Of the methods tested, we found that the Farrington improved method was most effective at maximizing both the percent of events detected and true positive alarms for our dataset (> 70% sensitivity and > 70% specificity). This method uses statistical models to establish thresholds while controlling for seasonality and multi-year trends, and we suggest that it and other model-based approaches should be considered more broadly for malaria early detection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10850-5.

Population-Based Prevalence of Chlamydia trachomatis Infection and Antibodies in Four Districts with Varying Levels of Trachoma Endemicity in Amhara, Ethiopia

The Trachoma Control Program in Amhara region, Ethiopia, scaled up the surgery, antibiotics, facial cleanliness, and environmental improvement (SAFE) strategy in all districts starting in 2007. Despite these efforts, many districts still require additional years of SAFE. In 2017, four districts were selected for the assessment of antibody responses against Chlamydia trachomatis antigens and C. trachomatis infection to better understand transmission. Districts with differing endemicity were chosen, whereby one had a previous trachomatous inflammation-follicular (TF) prevalence of ≥ 30% (Andabet), one had a prevalence between 10% and 29.9% (Dera), one had a prevalence between 5% and 10% (Woreta town), and one had a previous TF prevalence of < 5% (Alefa) and had not received antibiotic intervention for 2 years. Survey teams assessed trachoma clinical signs and took conjunctival swabs and dried blood spots (DBS) to measure infection and antibody responses. Trachomatous inflammation-follicular prevalence among children aged 1–9 years was 37.0% (95% CI: 31.1–43.3) for Andabet, 14.7% (95% CI: 10.0–20.5) for Dera, and < 5% for Woreta town and Alefa. Chlamydia trachomatis infection was only detected in Andabet (11.3%). Within these districts, 2,195 children provided DBS. The prevalence of antibody responses to the antigen Pgp3 was 36.9% (95% CI: 29.0–45.6%) for Andabet, 11.3% (95% CI: 5.9–20.6%) for Dera, and < 5% for Woreta town and Alefa. Seroconversion rate for Pgp3 in Andabet was 0.094 (95% CI: 0.069–0.128) events per year. In Andabet district, where SAFE implementation has occurred for 11 years, the antibody data support the finding of persistently high levels of trachoma transmission.

Twelve-Year Longitudinal Trends in Trachoma Prevalence among Children Aged 1-9 years in Amhara, Ethiopia, 2007-2019

Trachoma control in the Amhara region of Ethiopia, where all districts were once endemic, began in 2001 and attained full scale-up of the Surgery, Antibiotics, Facial cleanliness, and Environmental improvement (SAFE) strategy by 2010. Since scaling up, the program has distributed approximately 14 million doses of antibiotic per year, implemented village- and school-based health education, and promoted latrine construction. This report aims to provide an update on the prevalence of trachoma among children aged 1-9 years as of the most recent impact or surveillance survey in all 160 districts of Amhara. As of 2019, 45 (28%) districts had a trachomatous inflammation-follicular (TF) prevalence below the 5% elimination threshold. There was a statistically significant relationship between TF prevalence observed at the first impact survey (2010-2015) and eventual achievement of TF < 5% (2015-2019). Of the 26 districts with a first impact survey < 10% TF, 20 (76.9%) had < 5% TF at the most recent survey. Of the 75 districts with a first survey between 10% and 29.9% TF, 21 (28.0%) had < 5% TF at the most recent survey. Finally, among 59 districts ≥ 30% TF at the first survey, four (6.8%) had < 5% TF by 2019. As of 2019, 30 (18.8%) districts remained with TF ≥ 30%. Amhara has seen considerable reductions of trachoma since the start of the program. A strong commitment to the SAFE strategy coupled with data-driven enhancements to that strategy is necessary to facilitate timely elimination of trachoma as a public health problem regionally in Amhara and nationwide in Ethiopia.

Ocular Chlamydia trachomatis infection and infectious load among pre-school aged children within trachoma hyperendemic districts receiving the SAFE strategy, Amhara region, Ethiopia

BACKGROUND

After approximately 5 years of SAFE (surgery, antibiotics, facial cleanliness, environmental improvement) interventions for trachoma, hyperendemic (trachomatous inflammation-follicular (TF) ≥30%) districts remained in Amhara, Ethiopia. This study's aim was to characterize the epidemiology of Chlamydia trachomatis (Ct) infection and load among pre-school aged children living under the SAFE strategy.

METHODS

Conjunctival swabs from a population-based sample of children aged 1-5 years collected between 2011 and 2015 were assayed to provide Ct infection data from 4 endemic zones (comprised of 58 districts). Ct load was determined using a calibration curve. Children were graded for TF and trachomatous inflammation-intense (TI).

RESULTS

7,441 children were swabbed in 4 zones. TF and TI prevalence were 39.9% (95% confidence Interval [CI]: 37.5%, 42.4%), and 9.2% (95% CI: 8.1%, 10.3%) respectively. Ct infection prevalence was 6.0% (95% CI: 5.0%, 7.2%). Infection was highest among children aged 2 to 4 years (6.6%-7.0%). Approximately 10% of infection occurred among children aged 1 year. Ct load decreased with age (P = 0.002), with the highest loads observed in children aged 1 year (P = 0.01) vs. aged 5 years. Participants with TF (P = 0.20) and TI (P<0.01) had loads greater than individuals without active trachoma.

CONCLUSIONS

In this hyperendemic setting, it appears that the youngest children may contribute in meaningful ways towards persistent active trachoma.

Progress to Eliminate Trachoma as a Public Health Problem in Amhara National Regional State, Ethiopia: Results of 152 Population-Based Surveys

At baseline in 2006, Amhara National Regional State, Ethiopia, was the most trachoma-endemic region in the country. Trachoma impact surveys (TIS) were conducted in all districts between 2010 and 2015, following 3–5 years of intervention with the WHO-recommended SAFE (surgery, antibiotics, facial cleanliness, and environmental improvement) strategy. A multistage cluster random sampling design was used to estimate the district-level prevalence of trachoma. In total, 1,887 clusters in 152 districts were surveyed, from which 208,265 individuals from 66,089 households were examined for clinical signs of trachoma. The regional prevalence of trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense among children aged 1–9 years was 25.9% (95% CI: 24.9–26.9) and 5.5% (95% CI: 5.2–6.0), respectively. The prevalence of trachomatous scarring and trachomatous trichiasis among adults aged ≥ 15 years was 12.9% (95% CI: 12.2–13.6) and 3.9% (95% CI: 3.7–4.1), respectively. Among children aged 1–9 years, 76.5% (95% CI: 75.3–77.7) presented with a clean face; 66.2% (95% CI: 64.1–68.2) of households had access to water within 30 minutes round-trip, 48.1% (95% CI: 45.5–50.6) used an improved water source, and 46.2% (95% CI: 44.8–47.5) had evidence of a used latrine. Nine districts had a prevalence of TF below the elimination threshold of 5%. In hyperendemic areas, 3–5 years of implementation of SAFE is insufficient to achieve trachoma elimination as a public health problem; additional years of SAFE and several rounds of TIS will be required before trachoma is eliminated.

Absence of Serological Evidence of Exposure to Treponema pallidum among Children Suggests Yaws Is No Longer Endemic in Kiribati

Yaws is a neglected tropical disease targeted for eradication by 2020. Kiribati, a Pacific Island nation, was previously endemic for yaws but lacks recent data from which its current endemicity status could be determined. This study tested antibody responses to Treponema pallidum to determine if transmission of yaws is taking place among children in Kiribati. Using a commercially available T. pallidum particle agglutination kit (Serodia^®, Fujirebio Inc., Tokyo, Japan), we tested dried blood spots, collected during population-based trachoma prevalence surveys on Tarawa Atoll and Kiritimati Island, for long-lived treponemal antibodies. Dried blood spots from 1,420 children aged 1-9 years were tested. Only two were positive, suggesting T. pallidum is not being widely transmitted among children in the settings sampled. These data require support from additional surveys to demonstrate the absence of clinical signs of disease and molecular evidence of infection, to confirm that yaws is no longer endemic in Kiribati.

Prevalence and associated factors of active trachoma among children in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Trachoma is the commonest infectious cause of blindness. It is prevalent in areas where personal and community hygiene is poor, and it mainly affects deprived and marginalized communities most importantly in Ethiopia. Hence, the aim of this study was to determine the prevalence and associated factors of active trachoma among children in Ethiopia.

METHOD

A systematic review and meta-analysis was employed to determine the prevalence of active trachoma and associated factors among children in Ethiopia. We searched databases, including PubMed, Google Scholar, Science Direct, EMBASE and Cochrane Library. To estimate the prevalence, studies reporting the prevalence of active trachoma and its associated factors were included. Data were extracted using a standardized data extraction format prepared in Microsoft excel and the analysis was done using STATA 14 statistical software. To assess heterogeneity, the Cochrane Q test statistics and I² test were used. Since the included studies revealed considerable heterogeneity, a random effect meta- analysis model was used to estimate the pooled prevalence of active trachoma. Moreover, the association between factors and active trachoma were examined.

RESULTS

The result of 30 eligible studies showed that the overall prevalence of active trachoma among children in Ethiopia was 26.9% (95% CI: 22.7, 31.0%). In the subgroup analysis, while the highest prevalence was reported in SNNP (35.8%; 95% CI: 22.7, 48.8), the lowest prevalence was reported in Oromia region (20.2%; 95% CI: 12.2, 28.2). Absence of latrine: OR 6.0 (95% CI 2.0, 17.5), the unclean faces of children: OR 5.5 (95% CI 2.8, 10.9), and no reported use of soap for washing: OR 3.3 (95% CI 1.8, 6.0) have shown a positive association with active trachoma among children.

CONCLUSION

From this review, it has been concluded that active trachoma among children is still a public health problem in different districts of Ethiopia. The prevalence of almost all studies are significantly higher than WHO target for elimination. Absence of latrine, unclean faces of children, no reported use of soap for washing are the important factors associated with active trachoma among children.

Associations between Water, Sanitation and Hygiene (WASH) and trachoma clustering at aggregate spatial scales, Amhara, Ethiopia

Background

Trachoma is the leading infectious cause of blindness globally. The WHO has recommended the SAFE (Surgery, Antibiotics, Facial cleanliness and Environmental improvements) strategy to eliminate trachoma as a public health problem. The F and E arms of the strategy will likely be important for sustained disease reductions, yet more evidence is needed detailing relationships between hygiene, sanitation and trachoma in areas with differing endemicity. This study addressed whether the regional differences in water, sanitation, and hygiene (WASH) variables were associated with the spatial distribution of trachomatous inflammation-follicular (TF) among children aged 1 to 9 years in the Amhara National Regional State of Ethiopia.

Methods

Data from 152 multi-stage cluster random trachoma surveys were used to understand the degree of clustering of trachoma on two spatial scales (district and village) in Amhara using a geographical information system and the Getis-Ord G_i* (d) statistic for local clustering. Trained and certified graders examined children for the clinical signs of trachoma using the WHO simplified system. Socio-demographic, community, and geoclimatic factors thought to promote the clustering of the disease were included as covariates in a logistic regression model.

Results

The mean district prevalence of TF among children aged 1 to 9 years in Amhara was 25.1% (standard deviation = 16.2%). The spatial distribution of TF was found to exhibit global spatial dependency with neighboring evaluation units at both district and village level. Specific clusters of high TF were identified at both the district and the village scale of analysis using weighted estimates of the prevalence of the disease. Increased prevalence of children without nasal and ocular discharge as well as increased prevalence of households with access to a water source within 30 minutes were statistically significantly negatively associated with clusters of high TF prevalence.

Conclusions

Water access and facial cleanliness were important factors in the clustering of trachoma within this hyperendemic region. Intensified promotion of structural and behavioral interventions to increase WASH coverage may be necessary to eliminate trachoma as a public health problem in Amhara and perhaps other hyper-endemic settings.

Ocular Chlamydia trachomatis Infection Under the Surgery, Antibiotics, Facial Cleanliness, and Environmental Improvement Strategy in Amhara, Ethiopia, 2011-2015

Background

World Health Organization (WHO) recommendations for starting and stopping mass antibiotic distributions are based on a clinical sign of trachoma, which is indirectly related to actual infection with the causative agent, Chlamydia trachomatis.

Methods

This study aimed to understand the effect of SAFE (surgery, antibiotics, facial cleanliness, and environmental improvement) interventions on ocular chlamydia in Amhara, Ethiopia, by describing the infection prevalence in a population-based sample of children aged 1-5 years. Trachoma surveys were conducted in all districts of Amhara, from 2011 to 2015 following approximately 5 years of SAFE. Ocular swabs were collected from randomly selected children to estimate the zonal prevalence of chlamydial infection. The Abbott RealTime polymerase chain reaction assay was used to detect C. trachomatis DNA.

Results

A total of 15632 samples were collected across 10 zones of Amhara. The prevalence of chlamydial infection in children aged 1-5 years was 5.7% (95% confidence interval, 4.2%-7.3%; zonal range, 1.0%-18.5%). Chlamydial infection and trachomatous inflammation-intense (TI) among children aged 1-9 years were highly correlated at the zonal level (Spearman correlation [r] = 0.93; P < .001), while chlamydial infection and trachomatous inflammation-follicular were moderately correlated (r = 0.57; P = .084).

Conclusions

After 5 years of SAFE, there is appreciable chlamydial infection in children aged 1-5 years, indicating that transmission has not been interrupted and that interventions should continue. The sign TI was highly correlated with chlamydial infection and can be used as a proxy indicator of infection.

Trachoma prevalence remains below threshold in five districts after stopping mass drug administration: results of five surveillance surveys within a hyperendemic setting in Amhara, Ethiopia

Background

The World Health Organization (WHO) recommends conducting trachoma surveillance surveys in districts where the elimination targets have been met and following a minimum 2-year period after cessation of mass drug administration (MDA) in order to determine the sustainability of low trachoma levels.

Methods

In 2015, population-based surveillance surveys were conducted in five districts of Amhara, Ethiopia. All five districts had a prior trachomatous inflammation–follicular (TF) prevalence among children 1–9 y of age of <5% determined by an impact survey and had not received MDA for ≥2 y. Surveys included examinations for trachoma clinical signs and conjunctival swabbing to determine Chlamydia trachomatis infection prevalence.

Results

Approximately 1000 children 1–9 y of age were examined for TF and 200 children 1–5 y of age were swabbed per district. All five surveillance districts had a TF prevalence of <5% and infection was only detected in one district. The prevalence of trachomatous trichiasis in adults ≥15 y of age was ≥1% in all districts.

Conclusions

In a trachoma hyperendemic region, a TF prevalence <5% was successfully maintained in five districts for ≥2 years after stopping MDA. MDA is still not warranted for these districts, however, the S, F and E components of the SAFE strategy should continue.

Prevalence of trachoma in the Afar Region of Ethiopia: results of seven population-based surveys from the Global Trachoma Mapping Project

PURPOSE

Trachoma is to be eliminated as a public health problem by 2020. To help the process of planning interventions where needed, and to provide a baseline for later comparison, we set out to complete the map of trachoma in Afar, Ethiopia, by estimating trachoma prevalence in evaluation units (EUs) of grouped districts ("woredas").

METHODS

We conducted seven community-based surveys from August to October 2013, using standardised Global Trachoma Mapping Project (GTMP) survey methodologies.

RESULTS

We enumerated 5065 households and 18,177 individuals in seven EUs covering 19 of Afar's 29 woredas; the other ten were not accessible. 16,905 individuals (93.0%) were examined, of whom 9410 (55.7%) were female. One EU incorporating four woredas (Telalak, Dalefage, Dewe, Hadele Ele) was shown to require full implementation of the SAFE strategy for three years before impact survey, with a trachomatous inflammation-follicular (TF) prevalence in 1-9-year-olds of 17.1% (95%CI 9.4-25.5), and a trichiasis prevalence in adults aged ≥15 years of 1.2% (95%CI 0.6-2.0). Five EUs, covering 13 woredas (Berahle, Aba'ala, Dupti, Kurri, Elidihare, Ayesayeta, Afamboo, Bure Mudaitu, Gewane, Amibara, Dulecho, Dalolo, and Konebo), had TF prevalences in children of 5-9.9% and need one round of azithromycin mass treatment and implementation of the F and E components of SAFE before re-survey; three of these EUs had trichiasis prevalences in adults ≥0.2%. The final EU (Mile, Ada'ar) had a sub-threshold TF prevalence and a trichiasis prevalence in adults just >0.2%.

CONCLUSION

Trachoma is a public health problem in Afar, and implementation of the SAFE strategy is required.

Feasibility and safety of mass drug coadministration with azithromycin and ivermectin for the control of neglected tropical diseases: a single-arm intervention trial

BACKGROUND

Mass drug administration has made a major contribution to the public health control of several important neglected tropical diseases. For settings with more than one endemic disease, combined mass drug administration has potential practical advantages compared with separate programmes but needs confirmation of feasibility and safety. We undertook a study of mass drug administration in the Solomon Islands for trachoma and scabies control using ivermectin and azithromycin, key drugs in the control of neglected tropical diseases worldwide.

METHODS

The entire population of Choiseul province, Solomon Islands, was eligible to participate. An azithromycin-based mass drug administration regimen was offered in line with standard recommendations for trachoma elimination (oral azithromycin or topical tetracycline). An ivermectin-based mass drug administration regimen was offered at the same time (oral ivermectin or topical permethrin), with a further dose 7-14 days later, using a modified version of a regimen demonstrated to be effective for scabies control. All participants underwent safety assessments 7-14 days later. Participants in ten randomly selected sentinel villages underwent a more detailed safety assessment. Routine health system reports of hospital or clinic admissions and deaths were also obtained to compare health outcomes in the 12 month period before and after the mass drug administration.

FINDINGS

The study enrolled 26 188 participants, 99·3% of the estimated resident population as determined at the 2009 census. Of those enrolled, 25 717 (98·2%) received the trachoma regimen and 25 819 (98·6%) received the first dose of the scabies regimen between Sept 1, and Oct 2, 2015. A second dose of the scabies regimen was received by 21 931 (83·7%) of participants. Adverse events, all mild and transient, were recorded in 571 (2·6%) of the entire study population and 58 (4·1%) of participants in the ten sentinel villages. In the 12 months before and after the mass drug administration the numbers of hospital admissions (1530 vs 1602) and deaths (73 vs 83) were similar. In the month after the mass drug administration, 84 individuals were admitted to hospital and two died, compared with a monthly median of 116 admissions (IQR 106-159) and six deaths (IQR 4-7) in the 12 months before and after the mass drug administration.

INTERPRETATION

In the largest trial so far involving coadministration of regimens based on ivermectin and azithromycin, the combination was safe and feasible in a population of more than 26 000 people. Coadministration of mass drug administration based on these two drugs opens up new potential for the control of neglected tropical diseases.

FUNDING

International Trachoma Initiative, Murdoch Children's Research Institute, Scobie and Claire Mackinnon Trust, Wellcome Trust.

Prevalence of soil-transmitted helminths and Schistosoma mansoni among a population-based sample of school-age children in Amhara region, Ethiopia

Background

From 2011 to 2015, seven trachoma impact surveys in 150 districts across Amhara, Ethiopia, included in their design a nested study to estimate the zonal prevalence of intestinal parasite infections including soil-transmitted helminths (STH) and Schistosoma mansoni.

Methods

A multi-stage cluster random sampling approach was used to achieve a population-based sample of children between the ages of 6 and 15 years. Stool samples of approximately 1 g were collected from assenting children, preserved in 10 ml of a sodium acetate-acetic acid-formalin solution, and transported to the Amhara Public Health Research Institute for processing with the ether concentration method and microscopic identification of parasites. Bivariate logistic and negative binomial regression were used to explore associations with parasite prevalence and intensity, respectively.

Results

A total of 16,955 children were selected within 768 villages covering 150 districts representing all ten zones of the Amhara region. The final sample included 15,455 children of whom 52% were female and 75% reported regularly attending school. The regional prevalence among children of 6 to 15 years of age was 36.4% (95% confidence interval, CI: 34.9–38.0%) for any STH and 6.9% (95% CI: 5.9–8.1%) for S. mansoni. The zonal prevalence of any STH ranged from 12.1 to 58.3%, while S. mansoni ranged from 0.5 to 40.1%. Categories of risk defined by World Health Organization guidelines would indicate that 107 districts (71.3%) warranted preventive chemotherapy (PC) for STH and 57 districts (38.0%) warranted PC for schistosomiasis based solely on S. mansoni. No statistical differences in the prevalence of these parasites were observed among boys and girls, but age and school attendance were both associated with hookworm infection (prevalence odds ratio, POR: 1.02, P = 0.03 per 1 year, and POR: 0.81, P = 0.001, respectively) and age was associated with infection by any STH (POR: 1.02, P = 0.03). Age was also associated with reduced intensity of Ascaris lumbricoides infection (unadjusted rate ratio: 0.96, P = 0.02) and increased intensity of hookworm infection (unadjusted rate ratio: 1.07, P < 0.001).

Conclusions

These surveys determined that between 2011 and 2015, STH and Schistosoma mansoni were present throughout the region, and accordingly, these results were used to guide PC distribution to school-age children in Amhara.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-3008-0) contains supplementary material, which is available to authorized users.

Effect of water, sanitation and hygiene interventions on active trachoma in North and South Wollo zones of Amhara Region, Ethiopia: A Quasi-experimental study

Background

Trachoma is chronic kerato conjunctivitis, which is caused by repeated infection with Chlamydia trachomatis bacterium. It is hyper endemic in many rural areas of Ethiopia. The objective of this study was to measure the effect of water, sanitation and hygiene interventions on active trachoma in selected woredas of North and South Wollo zones of Amhara Region, Ethiopia.

Methodology

A community based quasi-experimental study was conducted from October 2014 to December 2015 among children aged 1–8 years at baseline and among one year older same children after intervention. A four-stage random cluster-sampling technique was employed to select study participants. From each selected household, one child was clinically assessed for active trachoma. Structured questionnaire was used to collect socio demographic and behavioral data. MacNemar test was applied to compare the prevalence of active trachoma between baseline and after the intervention period at both intervention and non-intervention study areas.

Results

The prevalence of active trachoma was reduced from baseline prevalence of 26% to 18% after one-year intervention period in the intervention woredas (P≤0.001). MacNemar test result showed significant reduction of active trachoma prevalence after the intervention period in the intervention woredas compared to the non-intervention woredas (P≤0.001). Water, sanitation and hygiene related activities were significantly improved after the intervention period in the intervention woredas (P<0.05).

Conclusions

There was a significant reduction of active trachoma prevalence between the baseline and after the intervention period in the intervention woredas, but not in the non-intervention ones. Improved water, sanitation and hygiene interventions contributed to the reduction of active trachoma. However, the magnitude of active trachoma prevalence observed after the intervention is still very high in the studied areas of North and South Wollo Zones communities. To achieve the global trachoma elimination target by the year 2020 as set by the WHO, continued WaSH interventions and periodic monitoring, evaluation and reporting of the impact of WaSH on active trachoma is warranted.

Trachoma is an infectious disease of the eye, which is caused by repeated infection with Chlamydia trachomatis bacterium. The disease is the leading cause of preventable blindness. Ethiopia is the most trachoma affected country in the world. The World Health Organization (WHO) recommends Water, Sanitation and Hygiene (WaSH) interventions to control and eliminate blinding trachoma. With the aim of assessing the effect of WaSH intervention on active trachoma in selected woredas/districts of North and South Wollo zones of Amhara Region, Ethiopia, we selected intervention and control woredas, and WaSH program was implemented in the intervention woredas for one year. Baseline trachoma prevalence was conducted in both intervention and control areas before WaSH program was implemented. Prevalence was determined in both study areas after one-year intervention period and was compared with the baseline. The finding showed that the prevalence of active trachoma was reduced from baseline prevalence of 26% to 18% after one-year WaSH program implementation in the intervention woredas compared to the non-intervention woredas. However, as the magnitude of active trachoma prevalence observed after the intervention is still very high. Continued WaSH interventions and periodic monitoring, evaluation and reporting of the impact of WaSH on active trachoma is warranted in the studied areas of Ethiopia.

The burden of and risk factors for active trachoma in the North and South Wollo Zones of Amhara Region, Ethiopia: a cross-sectional study

BACKGROUND

Trachoma is a disease of the eye, caused by the bacteria Chlamydia trachomatis, which can lead to blindness if left untreated. Ethiopia is one of the most trachoma-affected countries in the world. The objective of this study was to determine the prevalence of and associated risk factors for active trachoma among children in selected woredas of North and South Wollo Zones in Amhara Region, Ethiopia.

METHODS

This study was a community-based, cross-sectional study, which was conducted from October to December 2014 among children aged 1-8. A four-stage random cluster sampling technique was employed to select the study areas and participants. From each selected household, one child was clinically assessed for active trachoma. A structured questionnaire was used to collect sociodemographic, behavioral, and clinical data. Multivariate logistic regression analysis was used to analyze the association between predictor variables and active trachoma.

RESULTS

The overall prevalence of active trachoma among 1358 children was found to be 21.6% (95% CI: 19.4-23.8%). When analyzed by the presence or absence of individual WHO simplified system signs of active trachoma, trachomatous inflammation-follicular cases constituted18% (95% CI: 15.9-20.2%), while 4.7% (95% CI: 3.6-5.8%) were trachomatous inflammation-intense cases. Ocular discharge (aOR = 5.2; 95% CI: 3.3-8.2), nasal discharge (aOR = 1.8; 95% CI: 1.2-2.7), time taken to fetch water (aOR = 0.02; 95% CI: 0.01-0.05), frequency of hand and face washing (aOR = 4.4; 95% CI: 1.1-17.8), and access to a latrine (aOR = 0.006; 95% CI: 0.001-0.030) were found to be independently associated with the presence of active trachoma.

CONCLUSIONS

There is a high burden of active trachoma among children in the study areas. Lack of personal hygiene and limited access to a safe water supply and latrines were associated with increased prevalence of active trachoma. In order to reduce the burden of active trachoma, facial cleanliness and environmental improvement components of the SAFE strategy should be upgraded in the study areas.

Surveillance in easy to access population subgroups as a tool for evaluating malaria control progress: A systematic review

Background

The need for surveillance systems generating targeted, data-driven, responsive control efforts to accelerate and sustain malaria transmission reduction has been emphasized by programme managers, policy makers and scientists. Surveillance using easy-to-access population subgroups (EAGs) may result in considerable cost saving compared to household surveys as the identification and selection of individuals to be surveyed is simplified, fewer personnel are needed, and logistics are simpler. We reviewed available literature on the validation of estimates of key indicators of malaria control progress derived from EAGs, and describe the options to deal with the context specific bias that may occur.

Methods

A literature search was conducted of all documents reporting validation of estimates of malaria control indicators from EAG surveys before the 31^st of December 2016. Additional records were identified through cross-reference from selected records, other applicable policy documents and grey literature. After removal of duplicates, 13, 180 abstracts were evaluated and 2,653 eligible abstracts were identified mentioning surveillance in EAGs, of which 29 full text articles were selected for detailed review. The nine articles selected for systematic review compared estimates from health facility and school surveys with those of a contemporaneous sample of the same population in the same geographic area.

Results

Review of the available literature on EAGs suitable for surveillance of malaria control progress revealed that little effort has been made to explore the potential approach and settings for use of EAGs; and that there was wide variation in the precision of estimates of control progress between and within studies, particularly for estimates of control intervention coverage. Only one of the studies evaluated the geospatial representativeness of EAG samples, or carried out geospatial analyses to assess or control for lack of geospatial representativeness. Two studies attempted to measure the degree of bias or improve the precision of estimates by controlling for bias in a multivariate analysis; and this was only successful in one study. The observed variability in accuracy of estimates is likely to be caused by selection and/or information bias due to the inherent nature of EAGs. The reviewed studies provided insight into the design and analytical approaches that could be used to limit bias.

Conclusion

The utility EAGs for routine surveillance of progress in malaria control at the district or sub-district programmatic level will be driven by several factors including whether serial point estimates to measure transmission reduction or more precise geospatial distribution to track ‘hot-spots’ is required, the acceptable degree of precision, the target population, and the resources available for surveillance. The opportunities offered by novel geostatistical analyses and hybrid sampling frames to overcome bias justify a renewed exploration of use of EAGs for malaria monitoring and evaluation.

Integrating malaria surveillance with climate data for outbreak detection and forecasting: the EPIDEMIA system

Background

Early indication of an emerging malaria epidemic can provide an opportunity for proactive interventions. Challenges to the identification of nascent malaria epidemics include obtaining recent epidemiological surveillance data, spatially and temporally harmonizing this information with timely data on environmental precursors, applying models for early detection and early warning, and communicating results to public health officials. Automated web-based informatics systems can provide a solution to these problems, but their implementation in real-world settings has been limited.

Methods

The Epidemic Prognosis Incorporating Disease and Environmental Monitoring for Integrated Assessment (EPIDEMIA) computer system was designed and implemented to integrate disease surveillance with environmental monitoring in support of operational malaria forecasting in the Amhara region of Ethiopia. A co-design workshop was held with computer scientists, epidemiological modelers, and public health partners to develop an initial list of system requirements. Subsequent updates to the system were based on feedback obtained from system evaluation workshops and assessments conducted by a steering committee of users in the public health sector.

Results

The system integrated epidemiological data uploaded weekly by the Amhara Regional Health Bureau with remotely-sensed environmental data freely available from online archives. Environmental data were acquired and processed automatically by the EASTWeb software program. Additional software was developed to implement a public health interface for data upload and download, harmonize the epidemiological and environmental data into a unified database, automatically update time series forecasting models, and generate formatted reports. Reporting features included district-level control charts and maps summarizing epidemiological indicators of emerging malaria outbreaks, environmental risk factors, and forecasts of future malaria risk.

Conclusions

Successful implementation and use of EPIDEMIA is an important step forward in the use of epidemiological and environmental informatics systems for malaria surveillance. Developing software to automate the workflow steps while remaining robust to continual changes in the input data streams was a key technical challenge. Continual stakeholder involvement throughout design, implementation, and operation has created a strong enabling environment that will facilitate the ongoing development, application, and testing of the system.

Active trachoma and community use of sanitation, Ethiopia

Objective

To investigate, in Amhara, Ethiopia, the association between prevalence of active trachoma among children aged 1–9 years and community sanitation usage.

Methods

Between 2011 and 2014, prevalence of trachoma and household pit latrine usage were measured in five population-based cross-sectional surveys. Data on observed indicators of latrine use were aggregated into a measure of community sanitation usage calculated as the proportion of households with a latrine in use. All household members were examined for clinical signs, i.e. trachomatous inflammation, follicular and/or intense, indicative of active trachoma. Multilevel logistic regression was used to estimate prevalence odds ratios (OR) and 95% confidence intervals (CI), adjusting for community, household and individual factors, and to evaluate modification by household latrine use and water access.

Findings

In surveyed areas, prevalence of active trachoma among children was estimated to be 29% (95% CI: 28–30) and mean community sanitation usage was 47% (95% CI: 45–48). Despite significant modification (p < 0.0001), no pattern in stratified ORs was detected. Summarizing across strata, community sanitation usage values of 60 to < 80% and ≥ 80% were associated with lower prevalence odds of active trachoma, compared with community sanitation usage of < 20% (OR: 0.76; 95% CI: 0.57–1.03 and OR: 0.67; 95% CI: 0.48–0.95, respectively).

Conclusion

In Amhara, Ethiopia, a negative correlation was observed between community sanitation usage and prevalence of active trachoma among children, highlighting the need for continued efforts to encourage higher levels of sanitation usage and to support sustained use throughout the community, not simply at the household level.

Prevalence of malaria and associated factors in Benna Tsemay district of pastoralist community, Southern Ethiopia

BACKGROUND

Though the burden of malaria is declining, challenges in control continue globally, regionally and nationally as the transmission of malaria is dynamic and determinants differ by place and time, and across populations. The current level of knowledge on malaria prevalence and associated factors in specific communities, such as pastoralist communities of Ethiopia, is lacking.

METHODS

A community based cross-sectional survey was conducted among pastoralist communities from December 2011 to January 2012. Background information and peripheral blood samples were collected from 461 randomly selected study participants. Multivariate regression analysis was done to explore the risk factors associated to malaria.

RESULT

The prevalence of malaria among 461 examined study participants was 6.1 % (95 % CI = 4.2, 8.5). The infection rate with Plasmodium falciparum and Plasmodium vivax was 64.3 % (95 % CI = 45.5, 80.2) and 21.4 % (95 % CI = 19.8, 54.5), respectively, while mixed infection was 14.3 % (95 % CI = 4.7, 30.9). The infection rate was higher among lactating (22.2 %, 95 % CI =7.5, 45.3) and pregnant (17.6 %, 95 % CI = 4.7, 40.9) women compared with other community groups like infants (12 %). Mosquito net coverage of the study population was 90.1 % with an average of 1.8 per household. Traditional practices related to malaria prevention and treatment were not significantly associated with malaria infection (p > 0.05). Pregnancy (adjusted Odds Ratio [AOR]: 12.6, 95 % CI = 1.7, 94.7) and saving mosquito net for later use (AOR 9.6: 95 % CI = 2.2, 42.8) were independently associated with prevalent malaria infection.

CONCLUSION

In spite of high coverage of mosquito nets, prevalence of malaria in this pastoralist community was high, affecting pregnant and lactating women at a higher rate. Pregnancy and saving mosquito nets for later use were identified as the associated risk factors. Health education on prevalence of malaria and knowledge on risk factors might be able to change the health behavior in this pastoralist community which consequently can decrease the malaria morbidity and mortality.

TRIAL REGISTRATION

ISRCTN ISRCTN73824458, Registered 28 September 2014.

Impact of Trichiasis Surgery on Quality of Life: A Longitudinal Study in Ethiopia

BACKGROUND

Trachomatous trichiasis significantly reduces vision and health related quality of life (QoL). Although trichiasis surgery is widely performed to treat trichiasis, there is little data on the effect of surgery on QoL. We measured the impact of trichiasis surgery on vision and health related QoL in a longitudinal study from Amhara Region, Ethiopia.

METHODOLOGY/PRINCIPAL FINDINGS

We recruited 1000 adult participants with trichiasis (cases) and 200 comparison participants, matched to every fifth trichiasis case on age (+/- two years), sex and location. Vision-related quality of life (VRQoL) and health-related quality of life (HRQoL) were measured using the WHO/PBD-VF20 and WHOQOL-BREF questionnaires respectively, at enrolment and 12 months after enrolment. All trichiasis cases received free standard trichiasis surgery immediately after enrolment. The mean difference in QoL scores between enrolment and follow-up for cases and comparison participants, and the difference-in-differences by baseline trichiasis status was analysed using random effects linear regression, the later adjusted for age, sex and socioeconomic status. At 12-months follow-up, data was collected from 980 (98%) and 198 (98%) trichiasis cases and comparison participants respectively. At this follow-up visit, VRQoL and HRQoL scores of trichiasis cases improved substantially in all subscales and domains by 19.1-42.0 points (p<0.0001) and 4.7-17.2 points (p<0.0001), respectively. In contrast, among the comparison participants, there was no evidence of improvement in VRQoL and HRQoL domain scores during follow-up. The improvement in VRQoL and HRQoL in cases was independent of the presence of visual acuity improvement at 12 months.

CONCLUSIONS/SIGNIFICANCE

Trichiasis surgery substantially improves both VRQoL and HRQoL regardless of visual acuity change. Unprecedented effort is needed to scale-up trichiasis surgical programmes not only to prevent the risk of sight loss but also to improve overall wellbeing and health perception of affected individuals.

Impacts of neglected tropical disease on incidence and progression of HIV/AIDS, tuberculosis, and malaria: scientific links

The neglected tropical diseases (NTDs) are the most common infections of humans in Sub-Saharan Africa. Virtually all of the population living below the World Bank poverty figure is affected by one or more NTDs. New evidence indicates a high degree of geographic overlap between the highest-prevalence NTDs (soil-transmitted helminths, schistosomiasis, onchocerciasis, lymphatic filariasis, and trachoma) and malaria and HIV, exhibiting a high degree of co-infection. Recent research suggests that NTDs can affect HIV and AIDS, tuberculosis (TB), and malaria disease progression. A combination of immunological, epidemiological, and clinical factors can contribute to these interactions and add to a worsening prognosis for people affected by HIV/AIDS, TB, and malaria. Together these results point to the impacts of the highest-prevalence NTDs on the health outcomes of malaria, HIV/AIDS, and TB and present new opportunities to design innovative public health interventions and strategies for these 'big three' diseases. This analysis describes the current findings of research and what research is still needed to strengthen the knowledge base of the impacts NTDs have on the big three.

The Impact of Trachomatous Trichiasis on Quality of Life: A Case Control Study

Background

Trachomatous trichiasis is thought to have a profound effect on quality of life (QoL), however, there is little research in this area. We measured vision and health-related QoL in a case-control study in Amhara Region, Ethiopia.

Methodology/Principal Findings

We recruited 1000 adult trichiasis cases and 200 trichiasis-free controls, matched to every fifth trichiasis case on age (+/- two years), sex and location. Vision-related quality of life (VRQoL) and health-related quality of life (HRQoL) were measured using the WHO/PBD-VF20 and WHOQOL-BREF questionnaires. Comparisons were made using linear regression adjusted for age, sex and socioeconomic status. Trichiasis cases had substantially lower VRQoL than controls on all subscales (overall eyesight, visual symptom, general functioning and psychosocial, p<0.0001), even in the sub-group with normal vision (p<0.0001). Lower VRQoL scores in cases were associated with longer trichiasis duration, central corneal opacity, visual impairment and poor contrast sensitivity. Trichiasis cases had lower HRQoL in all domains (Physical-health, Psychological, Social, Environment, p<0.0001), lower overall QoL (mean, 34.5 v 64.6; p<0.0001) and overall health satisfaction (mean, 38.2 v 71.7; p<0.0001). This association persisted in a sub-group analysis of cases and controls with normal vision. Not having a marriage partner (p<0.0001), visual impairment (p = 0.0068), daily labouring (p<0.0001), presence of other health problems (p = 0.0018) and low self-rated wealth (p<0.0001) were independently associated with lower overall QoL scores in cases. Among cases, trichiasis caused 596 (59%) to feel embarrassed, 913 (91.3%) to worry they may lose their remaining eyesight and 681 (68.1%) to have sleep disturbance.

Conclusions/Significance

Trachomatous trichiasis substantially reduces vision and health related QoL and is disabling, even without visual impairment. Prompt trichiasis intervention is needed both to prevent vision loss and to alleviate physical and psychological suffering, social exclusion and improve overall well-being. Implementation of the full SAFE strategy is needed to prevent the development of trachomatous trichiasis.

There is clear evidence that visual impairment generally reduces quality of life. However, relatively little is known about the impact that trachomatous trichiasis (TT) has on the lives of affected people with and without the presence of visual impairment. We measured the impact of TT on vision and health-related quality of life in 1000 people with TT using standard WHO quantitative tools and compared these with 200 trichiasis-free controls, matched to every fifth trichiasis case on age, sex and location. We found TT cases had lower vision and health related quality of life than controls regardless of visual impairment and other health problems suggesting the burden of TT goes beyond visual loss. The results provide solid data for advocacy and encourage programme leaders and funders to secure resources to promote trichiasis intervention. Trichiasis causes considerable physical and psychosocial trauma including sleep disturbance, low self-esteem and possibly a less stable marriage regardless of visual impairment. These suggest that, timely treatment is needed not only to prevent visual loss but also alleviate physical and psychological suffering and social exclusion of TT patients, thereby improving their physical and psychological health, general functioning and social relations.

Trachoma and Relative Poverty: A Case-Control Study

BACKGROUND

Trachoma is widely considered a disease of poverty. Although there are many epidemiological studies linking trachoma to factors normally associated with poverty, formal quantitative data linking trachoma to household economic poverty within endemic communities is very limited.

METHODOLOGY/PRINCIPAL FINDINGS

Two hundred people with trachomatous trichiasis were recruited through community-based screening in Amhara Region, Ethiopia. These were individually matched by age and gender to 200 controls without trichiasis, selected randomly from the same sub-village as the case. Household economic poverty was measured through (a) A broad set of asset-based wealth indicators and relative household economic poverty determined by principal component analysis (PCA, (b) Self-rated wealth, and (c) Peer-rated wealth. Activity participation data were collected using a modified 'Stylised Activity List' developed for the World Bank's Living Standards Measurement Survey. Trichiasis cases were more likely to belong to poorer households by all measures: asset-based analysis (OR = 2.79; 95%CI: 2.06-3.78; p<0.0001), self-rated wealth (OR, 4.41, 95%CI, 2.75-7.07; p<0.0001) and peer-rated wealth (OR, 8.22, 95% CI, 4.59-14.72; p<0.0001). Cases had less access to latrines (57% v 76.5%, p = <0.0001) and higher person-to-room density (4.0 v 3.31; P = 0.0204) than the controls. Compared to controls, cases were significantly less likely to participate in economically productive activities regardless of visual impairment and other health problems, more likely to report difficulty in performing activities and more likely to receive assistance in performing productive activities.

CONCLUSIONS/SIGNIFICANCE

This study demonstrated a strong association between trachomatous trichiasis and relative poverty, suggesting a bidirectional causative relationship possibly may exist between poverty and trachoma. Implementation of the full SAFE strategy in the context of general improvements might lead to a virtuous cycle of improving health and wealth. Trachoma is a good proxy of inequality within communities and it could be used to target and evaluate interventions for health and poverty alleviation.

Azithromycin, fluoroquinolone and chloramphenicol resistance of non-chlamydia conjunctival bacteria in rural community of Ethiopia

Aim:

To determine profiles of non-chlamydia conjunctival bacteria and their antimicrobial susceptibility from adults who underwent trachomatous trichiasis surgery in rural areas of Ethiopia.

Materials and Methods:

A cross-sectional study was conducted in rural districts in West Gojjam administrative zone. Conjunctival swabs were collected during surgery and transported using Stuart transport broth (Oxoid, UK). Antibiotic susceptibility of conjunctival isolates was determined using the Kirby-Bauer disc-diffusion method.

Results:

Non-chlamydia pathogenic bacteria were recovered from conjunctiva of 438 (31%) participants before treatment. The isolated conjunctival bacteria were Staphylococcus aureus, coagulase-negative Staphylococci, Streptococcus group (A, C, F and G), Enterococci, Streptococcus pneumoniae, Moraxella spp., Escherichia coli, Citrobacter spp., Proteus spp., Klebsiella spp., Pseudomonas spp. and Enterobacter spp. Overall, resistance rates of 57.8% to azithromycin and 68.5% to chloramphenicol were found. However, 86-94.4% sensitivity was demonstrated to ciprofloxacin and norfloxacin. Moderate sensitivity rates (61.8-78.4%) were observed to ceftriaxone, tetracycline and cotrimoxazole.

Conclusion:

Fluoroquinolones that have activity against the majority of bacterial isolates were potent at in vitro. However, unacceptably high levels of resistance to azithromycin and chloramphenicol in rural community indicated a need for further study and antimicrobial resistance surveillance.

Seasonal associations of climatic drivers and malaria in the highlands of Ethiopia

BACKGROUND

The impacts of interannual climate fluctuations on vector-borne diseases, especially malaria, have received considerable attention in the scientific literature. These effects can be significant in semi-arid and high-elevation areas such as the highlands of East Africa because cooler temperature and seasonally dry conditions limit malaria transmission. Many previous studies have examined short-term lagged effects of climate on malaria (weeks to months), but fewer have explored the possibility of longer-term seasonal effects.

METHODS

This study assessed the interannual variability of malaria occurrence from 2001 to 2009 in the Amhara region of Ethiopia. We tested for associations of climate variables summarized during the dry (January-April), early transition (May-June), and wet (July-September) seasons with malaria incidence in the early peak (May-July) and late peak (September-December) epidemic seasons using generalized linear models. Climate variables included land surface temperature (LST), rainfall, actual evapotranspiration (ET), and the enhanced vegetation index (EVI).

RESULTS

We found that both early and late peak malaria incidence had the strongest associations with meteorological conditions in the preceding dry and early transition seasons. Temperature had the strongest influence in the wetter western districts, whereas moisture variables had the strongest influence in the drier eastern districts. We also found a significant correlation between malaria incidence in the early and the subsquent late peak malaria seasons, and the addition of early peak malaria incidence as a predictor substantially improved models of late peak season malaria in both of the study sub-regions.

CONCLUSIONS

These findings suggest that climatic effects on malaria prior to the main rainy season can carry over through the rainy season and affect the probability of malaria epidemics during the late malaria peak. The results also emphasize the value of combining environmental monitoring with epidemiological surveillance to develop forecasts of malaria outbreaks, as well as the need for spatially stratified approaches that reflect the differential effects of climatic variations in the different sub-regions.

Mass drug administration for trachoma: how long is not long enough?

Background

Blinding trachoma is targeted for elimination by 2020 using the SAFE strategy (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements). Annual mass drug administration (MDA) with azithromycin is a cornerstone of this strategy. If baseline prevalence of clinical signs of trachomatous inflammation – follicular among 1-9 year-olds (TF1-9) is ≥10% but <30%, the World Health Organization guidelines are for at least 3 annual MDAs; if ≥30%, 5. We assessed the likelihood of achieving the global elimination target of TF1-9 <5% at 3 and 5 year evaluations using program reports.

Methodology/Principal Findings

We used the International Trachoma Initiative’s prevalence and treatment database. Of 283 cross-sectional survey pairs with baseline and follow-up data, MDA was conducted in 170 districts. Linear and logistic regression modeling was applied to these to investigate the effect of MDA on baseline prevalence. Reduction to <5% was less likely, though not impossible, at higher baseline TF1-9 prevalences. Increased number of annual MDAs, as well as no skipped MDAs, were significant predictors of reduced TF1-9 at follow-up. The probability of achieving the <5% target was <50% for areas with ≥30% TF1-9 prevalence at baseline, even with 7 or more continuous annual MDAs.

Conclusions

Number of annual MDAs alone appears insufficient to predict program progress; more information on the effects of baseline prevalence, coverage, and underlying environmental and hygienic conditions is needed. Programs should not skip MDAs, and at prevalences >30%, 7 or more annual MDAs may be required to achieve the target. There are five years left before the 2020 deadline to eliminate blinding trachoma. Low endemic settings are poised to succeed in their elimination goals. However, newly-identified high prevalence districts warrant immediate inclusion in the global program. Intensified application of the SAFE strategy is needed in order to guarantee blinding trachoma elimination by 2020.

Trachoma, the world’s leading infectious cause of blindness, is scheduled for elimination by 2020. Reaching this elimination target depends on successful implementation of the SAFE strategy (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements). Annual mass antibiotic distributions are key to breaking the cycle of transmission in a community. However, it is not clear how many annual mass treatments need to be carried out in order to achieve elimination. Our study analyzes the effect of mass antibiotic distribution on different baseline prevalence levels of trachoma, in order to assess factors that affect the success of reaching elimination goals. We find that the prevailing belief, which suggests that 3 annual mass treatments can achieve local elimination of trachoma at prevalences between 10–30%, and 5 annual mass treatments for districts above this benchmark, is probably incorrect. In fact, much longer intervals may be required with “business as usual” programmatic strategies, which often include skipped years of treatment. Districts with high prevalence levels may require more intense treatment strategies to eliminate trachoma. Intensified recommendations must be implemented without delay in order to reach the 2020 elimination deadline.

Towards effective prevention and control of helminth neglected tropical diseases in the Western Pacific Region through multi-disease and multi-sectoral interventions

Neglected tropical diseases (NTDs) cause serious health, social and economic burdens in the countries of the World Health Organization Western Pacific Region. Among the NTDs, helminth infections are particularly prominent with regard to the number of infected individuals and health impact. Co-endemicity is common among impoverished and marginalized populations. To achieve effective and sustainable control of helminth NTDs, a deeper understanding of the social-ecological systems governing their endemicity and strategies beyond preventive chemotherapy are required to tackle the multiple causes of infection and re-infection. We discuss the feasibility of implementing multi-disease, multi-sectoral intervention packages for helminth NTDs in the Western Pacific Region. After reviewing the main determinants for helminth NTD endemicity and current control strategies, key control activities that involve or concern other programmes within and beyond the health sector are discussed. A considerable number of activities that have an impact on more than one helminth NTD are identified in a variety of sectors, suggesting an untapped potential for synergies. We also highlight the challenges of multi-sectoral collaboration, particularly of involving non-health sectors. We conclude that multi-sectoral collaboration for helminth NTD control is feasible if the target diseases and sectors are carefully selected. To do so, an incentive analysis covering key stakeholders in the sectors is crucial, and the disease-control strategies need to be well understood. The benefits of multi-disease, multi-sectoral approaches could go beyond immediate health impacts by contributing to sustainable development, raising educational attainment, increasing productivity and reducing health inequities.

Multiple correspondence analysis as a tool for analysis of large health surveys in African settings

BACKGROUND

More than two thirds of the total population of Ethiopia is estimated to be at risk of malaria. Therefore, malaria is the leading public health problem in Ethiopia.

OBJECTIVE

To investigate the determinants of malaria Rapid Diagnosis Test (RDT) result and the association between socio-economic, demographic and geographic factors.

METHOD

The study used data from household cluster malaria survey which was conducted from December 2006 to January 2007. A total of 224 clusters of about 25 households each were selected from the Amhara, Oromiya and Southern Nation Nationalities and People (SNNP) regions of Ethiopia. A multiple correspondence analysis was used to jointly analyse malaria RDT result, socio-economic, demographic and geographic factors.

RESULTS

The result from multiple correspondence analysis shows that there is association between malaria RDT result and different socio-economic, demographic and geographic variables.

CONCLUSION

There is an indication that some socio-economic, demographic and geographic factors have joint effects. It is important to confirm the association between socio-economic, demographic and geographic factors using advanced statistical techniques.

Prevalence of trachoma at sub-district level in ethiopia: determining when to stop mass azithromycin distribution

Background

To eliminate blinding trachoma, the World Health Organization emphasizes implementing the SAFE strategy, which includes annual mass drug administration (MDA) with azithromycin to the whole population of endemic districts. Prevalence surveys to assess impact at the district level are recommended after at least 3 years of intervention. The decision to stop MDA is based on a prevalence of trachomatous inflammation follicular (TF) among children aged 1–9 years below 5% at the sub-district level, as determined by an additional round of surveys limited within districts where TF prevalence is below 10%. We conducted impact surveys powered to estimate prevalence simultaneously at the sub-district and district in two zones of Amhara, Ethiopia to determine whether MDA could be stopped.

Methodology

Seventy-two separate population-based, sub-district surveys were conducted in 25 districts. In each survey all residents from 10 randomly selected clusters were screened for clinical signs of trachoma. Data were weighted according to selection probabilities and adjusted for correlation due to clustering.

Principal Findings

Overall, 89,735 residents were registered from 21,327 households of whom 72,452 people (80.7%) were examined. The prevalence of TF in children aged 1–9 years was below 5% in six sub-districts and two districts. Sub-district level prevalence of TF in children aged 1–9 years ranged from 0.9–76.9% and district-level from 0.9–67.0%. In only one district was the prevalence of trichiasis below 0.1%.

Conclusions/Significance

The experience from these zones in Ethiopia demonstrates that impact assessments designed to give a prevalence estimate of TF at sub-district level are possible, although the scale of the work was challenging. Given the assessed district-level prevalence of TF, sub-district-level surveys would have been warranted in only five districts. Interpretation was not as simple as stopping MDA in sub-districts below 5% given programmatic challenges of exempting sub-districts from a highly regarded program and the proximity of hyper-endemic sub-districts.

Trachoma, the leading cause of preventable blindness, is targeted for “elimination as a public health problem” by the year 2020. National programs are implementing the recommended strategy of surgery, antibiotics, facial cleanliness, and environmental improvements (SAFE) to meet this target. Many programs are currently facing the decision of when to scale down interventions, particularly mass drug administration (MDA) of azithromycin. We implemented large population-based surveys in two different zones of the Amhara National Regional State of Ethiopia. Rather than conducting an impact assessment first at the district level, followed by additional sub-district-level surveys, we took a novel approach to measure the prevalence of trachoma at sub-district level to be able to make an immediate decision of whether to stop MDA. Over 72,000 people in 714 communities in 72 sub-districts were examined for clinical signs of trachoma. We identified only six sub-districts that met criteria for being able to stop MDA. Our work demonstrates that determining the prevalence of trachoma at sub-district level is feasible but requires significant resources. In this hyper-endemic setting, sub-district-level surveys were not needed in the majority of districts. Overall, the clinical data suggest some decline in trachoma within these areas since the SAFE strategy was implemented.

Semiparametric models for malaria rapid diagnosis test result

BACKGROUND

More than 75% of the total of Ethiopia is malarious. Therefore, malaria is a leading public health problem in Ethiopia. This study aims to identify socio-economic, geographic and demographic factors contributing to the spread of malaria and is based on the results of a malaria Rapid Diagnosis Test survey.

METHODS

The data used in this study originates from the baseline malaria indicator survey, conducted in the Amhara, Oromiya and Southern Nation Nationalities and People (SNNP) regions of Ethiopia from December 2006 to January 2007. The study applies the method of generalized additive mixed model (GAMM) to analyse data. The response variable is the presence or absence of malaria, using the malaria Rapid Diagnosis Test (RDT).

RESULTS

The results provide an improved insight into the distribution of malaria in relation to the age of affected people, the altitude, the total number of rooms, the total number of mosquito nets, family size, and the number of months that their rooms have been sprayed. The results confirm that positive malaria RDT test results are high for children under 15 years and for older persons. Gender, source of drinking water, time needed to fetch water, toilet facilities, main materials used for the construction of walls, floors and roofs, and use of mosquito nets were all found to have a significant impact on the results of the malaria rapid diagnosis test.

CONCLUSION

The result of the analysis identifies poor socio-economic conditions as a major contributing factor or determinant for the spread of malaria. With the correct use of mosquito nets, indoor residual spraying with insecticide and other preventative measures, the incidence of malaria could be decreased. In addition, improving housing conditions is a means to reduce the risk of malaria. Other measures such as creating awareness of the use of mosquito nets, indoor residual spraying with insecticide, and malaria transmission, can lead to a further reduction in the number of malaria cases.

Evaluation of household latrine coverage in Kewot woreda, Ethiopia, 3 years after implementing interventions to control blinding trachoma

The SAFE strategy for trachoma control includes Surgery, Antibiotic distribution, Facial cleanliness and Environmental improvements, including promotion of latrine construction. In this study, household latrine coverage was estimated in order to evaluate SAFE implementation in a district of Ethiopia where reported coverage in rural areas was 97%. Characteristics of latrine adopters and non-adopters were explored. Interviews were conducted in 442 households selected at random in a multistage cluster sample. Overall, estimated household latrine coverage was 56.2% (95% CI 37.5-74.8%) and in rural areas coverage was 67.7% (95% CI 59.6-75.7%). Previously owning a latrine was reported by 12.7% (95% CI 8.9-16.5%) of respondents, of which 32.0% (95% CI 15.9-48.2%) had built a replacement. Latrine adopters were more likely to be male (P < 0.0001), to report their primary occupation as agriculture (P < 0.0001), have more than five residents in their household (P = 0.004) and live in a rural area (P < 0.0001). Respondents who were advised by a health extension worker (P < 0.0001) or development agent (P < 0.0001) were more likely to have built a latrine. Household latrine coverage has increased from the 2007 zonal estimate (8.9%), but was lower than that reported. Latrine promotion should include emphasis on rebuilding latrines. More support may be needed by small households as well as those with a female head if universal latrine access is to be achieved in Kewot.

A novel electronic data collection system for large-scale surveys of neglected tropical diseases

BACKGROUND

Large cross-sectional household surveys are common for measuring indicators of neglected tropical disease control programs. As an alternative to standard paper-based data collection, we utilized novel paperless technology to collect data electronically from over 12,000 households in Ethiopia.

METHODOLOGY

We conducted a needs assessment to design an Android-based electronic data collection and management system. We then evaluated the system by reporting results of a pilot trial and from comparisons of two, large-scale surveys; one with traditional paper questionnaires and the other with tablet computers, including accuracy, person-time days, and costs incurred.

PRINCIPLE FINDINGS

The electronic data collection system met core functions in household surveys and overcame constraints identified in the needs assessment. Pilot data recorders took 264 (standard deviation (SD) 152 sec) and 260 sec (SD 122 sec) per person registered to complete household surveys using paper and tablets, respectively (P = 0.77). Data recorders felt a lack of connection with the interviewee during the first days using electronic devices, but preferred to collect data electronically in future surveys. Electronic data collection saved time by giving results immediately, obviating the need for double data entry and cross-correcting. The proportion of identified data entry errors in disease classification did not differ between the two data collection methods. Geographic coordinates collected using the tablets were more accurate than coordinates transcribed on a paper form. Costs of the equipment required for electronic data collection was approximately the same cost incurred for data entry of questionnaires, whereas repeated use of the electronic equipment may increase cost savings.

CONCLUSIONS/SIGNIFICANCE

Conducting a needs assessment and pilot testing allowed the design to specifically match the functionality required for surveys. Electronic data collection using an Android-based technology was suitable for a large-scale health survey, saved time, provided more accurate geo-coordinates, and was preferred by recorders over standard paper-based questionnaires.

The geographical distribution and burden of trachoma in Africa

Background

There remains a lack of epidemiological data on the geographical distribution of trachoma to support global mapping and scale up of interventions for the elimination of trachoma. The Global Atlas of Trachoma (GAT) was launched in 2011 to address these needs and provide standardised, updated and accessible maps. This paper uses data included in the GAT to describe the geographical distribution and burden of trachoma in Africa.

Methods

Data assembly used structured searches of published and unpublished literature to identify cross-sectional epidemiological data on the burden of trachoma since 1980. Survey data were abstracted into a standardised database and mapped using geographical information systems (GIS) software. The characteristics of all surveys were summarized by country according to data source, time period, and survey methodology. Estimates of the current population at risk were calculated for each country and stratified by endemicity class.

Results

At the time of writing, 1342 records are included in the database representing surveys conducted between 1985 and 2012. These data were provided by direct contact with national control programmes and academic researchers (67%), peer-reviewed publications (17%) and unpublished reports or theses (16%). Prevalence data on active trachoma are available in 29 of the 33 countries in Africa classified as endemic for trachoma, and 1095 (20.6%) districts have representative data collected through population-based prevalence surveys. The highest prevalence of active trachoma and trichiasis remains in the Sahel area of West Africa and Savannah areas of East and Central Africa and an estimated 129.4 million people live in areas of Africa confirmed to be trachoma endemic.

Conclusion

The Global Atlas of Trachoma provides the most contemporary and comprehensive summary of the burden of trachoma within Africa. The GAT highlights where future mapping is required and provides an important planning tool for scale-up and surveillance of trachoma control.

In order to target resources and drugs to reach trachoma elimination targets by the year 2020, data on the burden of disease are required. Using prevalence data in African countries derived from the Global Atlas of Trachoma (GAT), the distribution of trachoma continues to be focused in East and West Sub-Saharan Africa, North Africa and a few endemic countries in Central Sub-Saharan Africa. Currently, 129.4 million people are estimated to live in areas that are confirmed to be trachoma endemic and 98 million are known to require access to the SAFE strategy. The maps and information presented in this work highlight the GAT as important open-access planning and advocacy tool for efforts to finalize trachoma mapping and assist national programmes in planning interventions.

Spatial distribution of malaria problem in three regions of Ethiopia

Background

The transmission of malaria is the leading public health problem in Ethiopia. From the total area of Ethiopia, more than 75% is malarious. The aim of this study was to identify socio-economic, geographic and demographic risk factors of malaria based on the rapid diagnosis test (RDT) survey results and produce the prevalence map of the area illustrating variation in malaria risk.

Methods

This study accounts for spatial correlation in assessing the effects of socio- economic, demographic and geographic factors on the prevalence of malaria in Ethiopia. A total of 224 clusters of about 25 households each were selected from the Amhara, Oromiya and Southern Nation Nationalities and People’s (SNNP) regions of Ethiopia. A generalized linear mixed model with spatial covariance structure was used to analyse the data where the response variable was the presence or absence of malaria using the RDT.

Results

The results showed that households in the SNNP region were found to be at more risk than Amhara and Oromiya regions. Moreover, households which have toilet facilities clean drinking water, and a greater number of rooms and mosquito nets in the rooms, have less chance of having household members testing positive for RDT. Moreover, from this study, it can be suggested that incorporating spatial variability is necessary for understanding and devising the most appropriate strategies to reduce the risk of malaria.

Intestinal parasite prevalence in an area of ethiopia after implementing the SAFE strategy, enhanced outreach services, and health extension program

Background

The SAFE strategy aims to reduce transmission of Chlamydia trachomatis through antibiotics, improved hygiene, and sanitation. We integrated assessment of intestinal parasites into large-scale trachoma impact surveys to determine whether documented environmental improvements promoted by a trachoma program had collateral impact on intestinal parasites.

Methodology

We surveyed 99 communities for both trachoma and intestinal parasites (soil-transmitted helminths, Schistosoma mansoni, and intestinal protozoa) in South Gondar, Ethiopia. One child aged 2–15 years per household was randomly selected to provide a stool sample of which about 1 g was fixed in sodium acetate-acetic acid-formalin, concentrated with ether, and examined under a microscope by experienced laboratory technicians.

Principal Findings

A total of 2,338 stool specimens were provided, processed, and linked to survey data from 2,657 randomly selected children (88% response). The zonal-level prevalence of Ascaris lumbricoides, hookworm, and Trichuris trichiura was 9.9% (95% confidence interval (CI) 7.2–12.7%), 9.7% (5.9–13.4%), and 2.6% (1.6–3.7%), respectively. The prevalence of S. mansoni was 2.9% (95% CI 0.2–5.5%) but infection was highly focal (range by community from 0–52.4%). The prevalence of any of these helminth infections was 24.2% (95% CI 17.6–30.9%) compared to 48.5% as found in a previous study in 1995 using the Kato-Katz technique. The pathogenic intestinal protozoa Giardia intestinalis and Entamoeba histolytica/E. dispar were found in 23.0% (95% CI 20.3–25.6%) and 11.1% (95% CI 8.9–13.2%) of the surveyed children, respectively. We found statistically significant increases in household latrine ownership, use of an improved water source, access to water, and face washing behavior over the past 7 years.

Conclusions

Improvements in hygiene and sanitation promoted both by the SAFE strategy for trachoma and health extension program combined with preventive chemotherapy during enhanced outreach services are plausible explanations for the changing patterns of intestinal parasite prevalence. The extent of intestinal protozoa infections suggests poor water quality or unsanitary water collection and storage practices and warrants targeted intervention.

Part of the SAFE strategy (surgery, antibiotics, facial cleanliness, and environmental improvement) to eliminate blinding trachoma involves improving access to, and use of, water and sanitation. We combined the assessment of parasitic worm and intestinal protozoa infections with surveys of trachoma in an area of Ethiopia where the SAFE strategy, together with enhanced outreach services and the health extension program, had been implemented for more than 5 years. We compared our findings with results from a survey conducted in the mid-1990s. We documented significant increases in household access and use of latrines and clean water: the F and E components of the SAFE strategy as promoted by the health extension program. We found considerably lower levels of parasitic worm infections than those reported previously. Moreover, we documented, for the first time in this zone, pathogenic intestinal protozoa infections, which indicate poor water quality and unhygienic water collection and storage practices in the communities surveyed. A plausible hypothesis for the decline in parasitic worm infections might be the combined impact of ongoing simultaneous health programs: SAFE strategy for trachoma control alongside the health extension program and regular deworming of preschool-aged children.

The burden of neglected tropical diseases in Ethiopia, and opportunities for integrated control and elimination

Background

Neglected tropical diseases (NTDs) are a group of chronic parasitic diseases and related conditions that are the most common diseases among the 2·7 billion people globally living on less than US$2 per day. In response to the growing challenge of NTDs, Ethiopia is preparing to launch a NTD Master Plan. The purpose of this review is to underscore the burden of NTDs in Ethiopia, highlight the state of current interventions, and suggest ways forward.

Results

This review indicates that NTDs are significant public health problems in Ethiopia. From the analysis reported here, Ethiopia stands out for having the largest number of NTD cases following Nigeria and the Democratic Republic of Congo. Ethiopia is estimated to have the highest burden of trachoma, podoconiosis and cutaneous leishmaniasis in sub-Saharan Africa (SSA), the second highest burden in terms of ascariasis, leprosy and visceral leishmaniasis, and the third highest burden of hookworm. Infections such as schistosomiasis, trichuriasis, lymphatic filariasis and rabies are also common. A third of Ethiopians are infected with ascariasis, one quarter is infected with trichuriasis and one in eight Ethiopians lives with hookworm or is infected with trachoma. However, despite these high burdens of infection, the control of most NTDs in Ethiopia is in its infancy. In terms of NTD control achievements, Ethiopia reached the leprosy elimination target of 1 case/10,000 population in 1999. No cases of human African trypanosomiasis have been reported since 1984. Guinea worm eradication is in its final phase. The Onchocerciasis Control Program has been making steady progress since 2001. A national blindness survey was conducted in 2006 and the trachoma program has kicked off in some regions. Lymphatic Filariasis, podoconiosis and rabies mapping are underway.

Conclusion

Ethiopia bears a significant burden of NTDs compared to other SSA countries. To achieve success in integrated control of NTDs, integrated mapping, rapid scale up of interventions and operational research into co implementation of intervention packages will be crucial.

Risk of trachoma in a SAFE intervention area

To determine prevalence and risk factors of trachoma in communities receiving intervention with the SAFE strategy (surgery, antibiotic, face washing, environmental hygiene), a cross-sectional trachoma survey was undertaken in 2006 in the Enemor district of southern Ethiopia where the SAFE program has been implemented for over five years. A sample of 374 household heads and 2,080 individuals were interviewed and examined for trachoma using an established trachoma grading system of the World Health Organization. The most prominent risk factors were identified with logistic regression analysis. Among individuals >14 years of age, the prevalence of trichiasis was 9.04 % [confidence interval (CI) 7.4-10.6]. People >40 years of age [odds ratio (OR) 1.7; CI 1.2-2.7), women (OR 2.2; CI 1.1-4.3), and illiterates (OR 3; CI 1.4-6.8) had increased risk of trichiasis. Coverage of surgical and antibiotic services was 46 and 85.5 %, respectively. Prevalence of active follicular trachoma (TF) in children aged 1-9 years was 33.1 % (CI 29.4-37.1). Unclean faces (OR 5.9; CI 4.3-8.3) and not being in school (OR 2.1; CI 1.3-3.3) were significantly associated with TF. Clean faces were observed in 56.1 % of children and improved with age and schooling (P < 0.001, Chi-squared test). Household latrine use (74.4 %) was associated with knowledge about SAFE and economic level (P ≤ 0.004, Chi-squared tests). Elderly illiterate women remain at risk of becoming blind from trachoma even in intervention areas. Trachoma particularly affects children without clean faces or opportunity for schooling. Provision of SAFE services with high coverage should be sustained in trachoma-hyperendemic areas.

Why do people not attend for treatment for trachomatous trichiasis in Ethiopia? A study of barriers to surgery

BACKGROUND

Trachomatous trichiasis (TT) surgery is provided free or subsidised in most trachoma endemic settings. However, only 18-66% of TT patients attend for surgery. This study analyses barriers to attendance among TT patients in Ethiopia, the country with the highest prevalence of TT in the world.

METHODOLOGY/PRINCIPAL FINDINGS

Participants with previously un-operated TT were recruited at 17 surgical outreach campaigns in Amhara Region, Ethiopia. An interview was conducted to ascertain why they had not attended for surgery previously. A trachoma eye examination was performed by an ophthalmologist. 2591 consecutive individuals were interviewed. The most frequently cited barriers to previous attendance for surgery were lack of time (45.3%), financial constraints (42.9%) and lack of an escort (35.5% in females, 19.6% in males). Women were more likely to report a fear of surgery (7.7% vs 3.2%, p<0.001) or be unaware of how to access services (4.5% vs 1.0% p<0.001); men were more frequently asymptomatic (19.6% vs 10.1%, p<0.001). Women were also less likely to have been previously offered TT surgery than men (OR = 0.70, 95%CI 0.53-0.94).

CONCLUSIONS/SIGNIFICANCE

The major barriers to accessing surgery from the patients' perspective are the direct and indirect costs of surgery. These can to a large extent be reduced or overcome through the provision of free or low cost surgery at the community level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00522860 and NCT00522912.

Removing the neglect from neglected tropical diseases: the Rwandan experience 2008-2010

While there has been increasing recognition of the importance of neglected tropical diseases (NTDs), national scale action and funding remain limited. In 2007, a 3-year, $1 million per year programme was launched in Rwanda to address NTDs. While more than $100 million had flowed into Rwanda's health sector annually, not $1 was allocated for NTDs. This article describes the development of a national NTD strategy in Rwanda and outlines lessons learned, with particular regard to integrated approaches to NTD prevention. A baseline survey revealed that more than 65% of children had intestinal worms with high levels of concurrent multiple parasite infection. Within a year, mass treatment administration was provided for the first time. A repeat survey found that prevalence of soil-transmitted helminths and Schistosoma mansoni infection had been reduced significantly, including a reduction in prevalence of S. mansoni of 82% and of 72% in hookworm. Infection intensity and signs of early clinical morbidity also decreased significantly. Despite ongoing global neglect, the Rwandan NTD response presents a promising and unheralded success in science-based national public health action at scale. Looking forward, greater integration of the NTD response with water and sanitation activities are needed to consolidate impact and sustainably reduce the disease burden.