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Abstract
Trachoma is a neglected tropical disease caused by infection with conjunctival strains of Chlamydia trachomatis. It can result in blindness. Pathophysiologically, trachoma is a disease complex composed of two linked chronic processes: a recurrent, generally subclinical infectious-inflammatory disease that mostly affects children, and a non-communicable, cicatricial and, owing to trichiasis, eventually blinding disease that supervenes in some individuals later in life. At least 150 infection episodes over an individual's lifetime are needed to precipitate trichiasis; thus, opportunity exists for a just global health system to intervene to prevent trachomatous blindness. Trachoma is found at highest prevalence in the poorest communities of low-income countries, particularly in sub-Saharan Africa; in June 2021, 1.8 million people worldwide were going blind from the disease. Blindness attributable to trachoma can appear in communities many years after conjunctival C. trachomatis transmission has waned or ceased; therefore, the two linked disease processes require distinct clinical and public health responses. Surgery is offered to individuals with trichiasis and antibiotic mass drug administration and interventions to stimulate facial cleanliness and environmental improvement are designed to reduce infection prevalence and transmission. Together, these interventions comprise the SAFE strategy, which is achieving considerable success. Although much work remains, a continuing public health problem from trachoma in the year 2030 will be difficult for the world to excuse.
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Xiong T, Yue Y, Li WX, Choonara I, Qazi S, Chen HJ, Tang J, Shi J, Wang H, Zeng LN, Xia B, Qiao LN, Qu Y, Mu DZ. Effectiveness of azithromycin mass drug administration on trachoma: a systematic review. Chin Med J (Engl) 2021; 134:2944-2953. [PMID: 34665571 PMCID: PMC8710348 DOI: 10.1097/cm9.0000000000001717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUNDS Azithromycin mass drug administration (MDA) is a key part of the strategy for controlling trachoma. This systematic review aimed to comprehensively summarize the present studies of azithromycin MDA on trachoma; provide an overview of the impact of azithromycin MDA on trachoma in different districts; and explore the possible methods to enhance the effectiveness of azithromycin MDA in hyperendemic districts. METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov were searched up to February 2021 with no language restriction. Studies reporting the effect of azithromycin MDA on trachoma were included. Mathematical modeling studies, animal studies, case reports, and reviews were excluded. The trachomatous inflammation-follicular (TF) <5.0% was used to judge the effect of azithromycin MDA on eliminating trachoma as a public health problem. Two researchers independently conducted the selection process and risk of bias assessment. RESULTS A total of 1543 studies were screened, of which 67 studies including 13 cluster-randomized controlled trials and 54 non-randomized studies were included. The effect of azithromycin MDA on trachoma was closely related to the baseline prevalence in districts. For the districts with baseline prevalence between 5.0% and 9.9%, a single round of MDA achieved a TF <5.0%. For the districts with baseline between 10.0% and 29.9%, annual MDA for 3 to 5 years reduced TF <5.0%. However, for the districts with high level of baseline prevalence (TF >30.0%), especially with baseline TF >50.0%, annual MDA was unable to achieve the TF <5.0% even after 5 to 7 years of treatment. Quarterly MDA is more effective in controlling trachoma in these hyperendemic districts. CONCLUSIONS Azithromycin MDA for controlling trachoma depends on the baseline prevalence. The recommendation by the World Health Organization that annual MDA for 3 to 5 years in the districts with TF baseline >10.0% is not appropriate for all eligible districts.
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Affiliation(s)
- Tao Xiong
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yan Yue
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan 610041, China
| | - Wen-Xing Li
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Shamim Qazi
- Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Hong-Ju Chen
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jun Tang
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jing Shi
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Hua Wang
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Li-Nan Zeng
- Department of Pharmacy, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, Chengdu, Sichuan 610041, China
| | - Bin Xia
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Li-Na Qiao
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yi Qu
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - De-Zhi Mu
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan 610041, China
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Borlase A, Blumberg S, Callahan EK, Deiner MS, Nash SD, Porco TC, Solomon AW, Lietman TM, Prada JM, Hollingsworth TD. Modelling trachoma post-2020: opportunities for mitigating the impact of COVID-19 and accelerating progress towards elimination. Trans R Soc Trop Med Hyg 2021; 115:213-221. [PMID: 33596317 PMCID: PMC7928577 DOI: 10.1093/trstmh/traa171] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/10/2020] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has disrupted planned annual antibiotic mass drug administration (MDA) activities that have formed the cornerstone of the largely successful global efforts to eliminate trachoma as a public health problem. METHODS Using a mathematical model we investigate the impact of interruption to MDA in trachoma-endemic settings. We evaluate potential measures to mitigate this impact and consider alternative strategies for accelerating progress in those areas where the trachoma elimination targets may not be achievable otherwise. RESULTS We demonstrate that for districts that were hyperendemic at baseline, or where the trachoma elimination thresholds have not already been achieved after three rounds of MDA, the interruption to planned MDA could lead to a delay to reaching elimination targets greater than the duration of interruption. We also show that an additional round of MDA in the year following MDA resumption could effectively mitigate this delay. For districts where the probability of elimination under annual MDA was already very low, we demonstrate that more intensive MDA schedules are needed to achieve agreed targets. CONCLUSION Through appropriate use of additional MDA, the impact of COVID-19 in terms of delay to reaching trachoma elimination targets can be effectively mitigated. Additionally, more frequent MDA may accelerate progress towards 2030 goals.
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Affiliation(s)
- Anna Borlase
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | | | - E Kelly Callahan
- Trachoma Control Program, The Carter Center, Atlanta, Georgia, USA
| | | | - Scott D Nash
- Trachoma Control Program, The Carter Center, Atlanta, Georgia, USA
| | | | - Anthony W Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organisation, Geneva, Switzerland
| | | | - Joaquin M Prada
- Faculty of Health and Medical Sciences, University of Surrey, UK
| | - T Dèirdre Hollingsworth
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
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Porco TC, Oldenburg CE, Arzika AM, Kalua K, Mrango Z, Cook C, Lebas E, Bailey RL, West SK, Oron AP, Keenan JD, Lietman TM, For The Mordor Study Group. Efficacy of Mass Azithromycin Distribution for Reducing Childhood Mortality Across Geographic Regions. Am J Trop Med Hyg 2020; 103:1291-1294. [PMID: 30734695 PMCID: PMC7470520 DOI: 10.4269/ajtmh.18-1003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Mass azithromycin distribution has been shown to reduce all-cause mortality in preschool children in sub-Saharan Africa. However, substantial heterogeneity in the apparent effect has been noted across geographic settings, suggesting a greater relative benefit in higher mortality settings. Here, we evaluated the relationship between the underlying mortality rate and the efficacy of azithromycin for the prevention of child mortality using data from multiple sites in Ethiopia, Malawi, Niger, and Tanzania. Between regions, we find no strong evidence of effect modification of the efficacy of azithromycin distribution for the prevention of child mortality by the underlying mortality rate (P = 0.12), although a modest effect is consistent with our findings. Higher mortality settings could be prioritized, however, because of the larger number of deaths which could be averted with azithromycin distribution.
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Affiliation(s)
- Travis C Porco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Catherine E Oldenburg
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | | | - Khumbo Kalua
- College of Medicine, University of Malawi, Blantyre, Malawi.,Blantyre Institute for Community Outreach, Blantyre, Malawi
| | - Zakayo Mrango
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Catherine Cook
- Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Elodie Lebas
- Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Robin L Bailey
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sheila K West
- The Dana Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Assaf P Oron
- Institute for Disease Modeling, Bellevue, Washington
| | - Jeremy D Keenan
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Thomas M Lietman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California
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Solomon AW, Hooper PJ, Bangert M, Mwingira UJ, Bakhtiari A, Brady MA, Fitzpatrick C, Jones I, Kabona G, Kello AB, Millar T, Mosher AW, Ngondi JM, Nshala A, Renneker K, Rotondo LA, Stelmach R, Harding-Esch EM, Malecela MN. The Importance of Failure: How Doing Impact Surveys That Fail Saves Trachoma Programs Money. Am J Trop Med Hyg 2020; 103:2481-2487. [PMID: 33025878 PMCID: PMC7695084 DOI: 10.4269/ajtmh.20-0686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Trachoma programs use annual antibiotic mass drug administration (MDA) in evaluation units (EUs) that generally encompass 100,000–250,000 people. After one, three, or five MDA rounds, programs undertake impact surveys. Where impact survey prevalence of trachomatous inflammation—follicular (TF) in 1- to 9-year-olds is ≥ 5%, ≥ 1 additional MDA rounds are recommended before resurvey. Impact survey costs, and the proportion of impact surveys returning TF prevalence ≥ 5% (the failure rate or, less pejoratively, the MDA continuation rate), therefore influence the cost of eliminating trachoma. We modeled, for illustrative EU sizes, the financial cost of undertaking MDA with and without conducting impact surveys. As an example, we retrospectively assessed how conducting impact surveys affected costs in the United Republic of Tanzania for 2017–2018. For EUs containing 100,000 people, the median (interquartile range) cost of continuing MDA without doing impact surveys is USD 28,957 (17,581–36,197) per EU per year, whereas continuing MDA solely where indicated by impact survey results costs USD 17,564 (12,158–21,694). If the mean EU population is 100,000, then continuing MDA without impact surveys becomes advantageous in financial cost terms only when the continuation rate exceeds 71%. For the United Republic of Tanzania in 2017–2018, doing impact surveys saved enough money to provide MDA for > 1,000,000 people. Although trachoma impact surveys have a nontrivial cost, they generally save money, providing EUs have > 50,000 inhabitants, the continuation rate is not excessive, and they generate reliable data. If all EUs pass their impact surveys, then we have waited too long to do them.
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Affiliation(s)
- Anthony W Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Pamela J Hooper
- Task Force for Global Health, International Trachoma Initiative, Atlanta, Georgia
| | - Mathieu Bangert
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Upendo J Mwingira
- Neglected Tropical Disease Control Program, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | - Ana Bakhtiari
- Task Force for Global Health, International Trachoma Initiative, Atlanta, Georgia
| | | | - Christopher Fitzpatrick
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Iain Jones
- Sightsavers, Haywards Heath, United Kingdom
| | - George Kabona
- Neglected Tropical Disease Control Program, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | - Amir B Kello
- Expanded Special Project for Elimination of Neglected Tropical Diseases, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Tom Millar
- Sightsavers, Haywards Heath, United Kingdom
| | - Aryc W Mosher
- United States Agency for International Development, Washington, District of Columbia
| | | | - Andreas Nshala
- Department of International Maternal and Child Health, Faculty of Medicine and Pharmacy, University of Uppsala, Uppsala, Sweden.,IMA World Health, Dar es Salaam, United Republic of Tanzania
| | - Kristen Renneker
- Task Force for Global Health, International Trachoma Initiative, Atlanta, Georgia
| | | | | | - Emma M Harding-Esch
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mwelecele N Malecela
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Huntington MK, Bryan JP, Moon TD, Imperato PJ, McLellan SLF, Taylor WR, Schieffelin JS. Emerging Trends in Clinical Tropical Medicine Research. Am J Trop Med Hyg 2020; 101:8-11. [PMID: 31094312 PMCID: PMC6609189 DOI: 10.4269/ajtmh.19-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The American Society for Tropical Medicine and Hygiene recently inaugurated an award for the best clinical research article published in the society’s journal in the previous year. This article summarizes both the process of selecting the winner and several themes that stood out in those articles which rose to the top for consideration. Themes of note included the importance of doing clinical research outside of referral centers, the complexity that must be considered when implementing interventions, incorporation of both ends of the age spectrum into studies, and considering cost-effectiveness and opportunity cost of interventions.
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Affiliation(s)
- Mark K Huntington
- Department of Family Medicine, University of South Dakota Sanford School of Medicine, Vermillion, South Dakota
| | - Joe P Bryan
- Center for Global Health, Division for Global Health Protection, Centers for Disease Control and Prevention (retired), Atlanta, Georgia
| | - Troy D Moon
- Division of Pediatric Infectious Diseases, Vanderbilt Institute for Global Health, Nashville, Tennessee
| | | | - Susan L F McLellan
- Division of Infectious Diseases, University of Texas Medical Branch, Galveston, Texas
| | - Walter R Taylor
- Centre for Tropical Medicine and Global Health, University of Oxford, London, United Kingdom.,Mahidol Oxford Research Unit, Bangkok, Thailand
| | - John S Schieffelin
- Sections of Infectious Disease, Tulane University School of Medicine, New Orleans, Louisiana
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Biannual versus annual mass azithromycin distribution and malaria seroepidemiology among preschool children in Niger: a sub-study of a cluster randomized trial. Malar J 2019; 18:389. [PMID: 31796025 PMCID: PMC6889587 DOI: 10.1186/s12936-019-3033-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/24/2019] [Indexed: 12/02/2022] Open
Abstract
Background Biannual mass azithromycin administration to preschool children reduces all-cause mortality, but the mechanism for the effect is not understood. Azithromycin has activity against malaria parasites, and malaria is a leading cause of child mortality in the Sahel. The effect of biannual versus annual azithromycin distribution for trachoma control on serological response to merozoite surface protein 1 (MSP-119), a surrogate for malaria incidence, was evaluated among children in Niger. Methods Markers of malaria exposure were measured in two arms of a factorial randomized controlled trial designed to evaluate targeted biannual azithromycin distribution to children under 12 years of age compared to annual azithromycin to the entire community for trachoma control (N = 12 communities per arm). Communities were treated for 36 months (6 versus 3 distributions). Dried blood spots were collected at 36 months among children ages 1–5 years, and MSP-119 antibody levels were assessed using a bead-based multiplex assay to measure malaria seroprevalence. Results Antibody results were available for 991 children. MSP-119 seropositivity was 62.7% in the biannual distribution arm compared to 68.7% in the annual arm (prevalence ratio 0.91, 95% CI 0.83 to 1.00). Mean semi-quantitative antibody levels were lower in the biannual distribution arm compared to the annual arm (mean difference − 0.39, 95% CI − 0.05 to − 0.72). Conclusions Targeted biannual azithromycin distribution was associated with lower malaria seroprevalence compared to that in a population that received annual distribution. Trial Registration Clinicaltrials.gov NCT00792922
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Evans JR, Solomon AW, Kumar R, Perez Á, Singh BP, Srivastava RM, Harding‐Esch E. Antibiotics for trachoma. Cochrane Database Syst Rev 2019; 9:CD001860. [PMID: 31554017 PMCID: PMC6760986 DOI: 10.1002/14651858.cd001860.pub4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Trachoma is the world's leading infectious cause of blindness. In 1996, WHO launched the Alliance for the Global Elimination of Trachoma by the year 2020, based on the 'SAFE' strategy (surgery, antibiotics, facial cleanliness, and environmental improvement). OBJECTIVES To assess the evidence supporting the antibiotic arm of the SAFE strategy by assessing the effects of antibiotics on both active trachoma (primary objective), Chlamydia trachomatis infection of the conjunctiva, antibiotic resistance, and adverse effects (secondary objectives). SEARCH METHODS We searched relevant electronic databases and trials registers. The date of the last search was 4 January 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) that satisfied either of two criteria: (a) trials in which topical or oral administration of an antibiotic was compared to placebo or no treatment in people or communities with trachoma, (b) trials in which a topical antibiotic was compared with an oral antibiotic in people or communities with trachoma. We also included studies addressing different dosing strategies in the population. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We identified 14 studies where individuals with trachoma were randomised and 12 cluster-randomised studies. Any antibiotic versus control (individuals)Nine studies (1961 participants) randomised individuals with trachoma to antibiotic or control (no treatment or placebo). All of these studies enrolled children and young people with active trachoma. The antibiotics used in these studies included topical (oxy)tetracycline (5 studies), doxycycline (2 studies), and sulfonamides (4 studies). Four studies had more than two study arms. In general these studies were poorly reported, and it was difficult to judge risk of bias.These studies provided low-certainty evidence that people with active trachoma treated with antibiotics experienced a reduction in active trachoma at three months (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69 to 0.89; 1961 people; 9 RCTs; I2 = 73%) and 12 months (RR 0.74, 95% CI 0.55 to 1.00; 1035 people; 4 RCTs; I2 = 90%). Low-certainty evidence was available for ocular infection at three months (RR 0.81, 95% CI 0.63 to 1.04; 297 people; 4 RCTs; I2 = 0%) and 12 months (RR 0.25, 95% CI 0.08 to 0.78; 129 people; 1 RCT). None of these studies assessed antimicrobial resistance. In those studies that reported harms, no serious adverse effects were reported (low-certainty evidence).Oral versus topical antibiotics (individuals)Eight studies (1583 participants) compared oral and topical antibiotics. Only one study included people older than 21 years of age. Oral antibiotics included azithromycin (5 studies), sulfonamides (2 studies), and doxycycline (1 study). Topical antibiotics included (oxy)tetracycline (6 studies), azithromycin (1 study), and sulfonamide (1 study). These studies were poorly reported, and it was difficult to judge risk of bias.There was low-certainty evidence of little or no difference in effect between oral and topical antibiotics on active trachoma at three months (RR 0.97, 95% CI 0.81 to 1.16; 953 people; 6 RCTs; I2 = 63%) and 12 months (RR 0.93, 95% CI 0.75 to 1.15; 886 people; 5 RCTs; I2 = 56%). There was very low-certainty evidence for ocular infection at three or 12 months. Antimicrobial resistance was not assessed. In those studies that reported adverse effects, no serious adverse effects were reported; one study reported abdominal pain with azithromycin; one study reported a couple of cases of nausea with azithromycin; and one study reported three cases of reaction to sulfonamides (low-certainty evidence).Oral azithromycin versus control (communities)Four cluster-randomised studies compared antibiotic with no or delayed treatment. Data were available on active trachoma at 12 months from two studies but could not be pooled because of reporting differences. One study at low risk of bias found a reduced prevalence of active trachoma 12 months after a single dose of azithromycin in communities with a high prevalence of infection (RR 0.58, 95% CI 0.52 to 0.65; 1247 people). The other, lower quality, study in low-prevalence communities reported similar median prevalences of infection at 12 months: 9.3% in communities treated with azithromycin and 8.2% in untreated communities. We judged this moderate-certainty evidence for a reduction in active trachoma with treatment, downgrading one level for inconsistency between the two studies. Two studies reported ocular infection at 12 months and data could be pooled. There was a reduction in ocular infection (RR 0.36, 0.31 to 0.43; 2139 people) 12 months after mass treatment with a single dose compared with no treatment (moderate-certainty evidence). There was high-certainty evidence of an increased risk of resistance of Streptococcus pneumoniae, Staphylococcus aureus, and Escherichia coli to azithromycin, tetracycline, and clindamycin in communities treated with azithromycin, with approximately 5-fold risk ratios at 12 months. The evidence did not support increased resistance to penicillin or trimethoprim-sulfamethoxazole. None of the studies measured resistance to C trachomatis. No serious adverse events were reported. The main adverse effect noted for azithromycin (˜10%) was abdominal pain, vomiting, and nausea.Oral azithromycin versus topical tetracycline (communities)Three cluster-randomised studies compared oral azithromycin with topical tetracycline. The evidence was inconsistent for active trachoma and ocular infection at three and 12 months (low-certainty evidence) and was not pooled due to considerable heterogeneity. Antimicrobial resistance and adverse effects were not reported.Different dosing strategiesSix studies compared different strategies for dosing. There were: mass treatment at different dosing intervals; applying cessation or stopping rules to mass treatment; strategies to increase mass treatment coverage. There was no strong evidence to support any variation in the recommended annual mass treatment. AUTHORS' CONCLUSIONS Antibiotic treatment may reduce the risk of active trachoma and ocular infection in people infected with C trachomatis, compared to no treatment/placebo, but the size of the treatment effect in individuals is uncertain. Mass antibiotic treatment with single dose oral azithromycin reduces the prevalence of active trachoma and ocular infection in communities. There is no strong evidence to support any variation in the recommended periodicity of annual mass treatment. There is evidence of an increased risk of antibiotic resistance at 12 months in communities treated with antibiotics.
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Affiliation(s)
- Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Anthony W Solomon
- World Health OrganizationDepartment of Control of Neglected Tropical DiseasesGenevaSwitzerland
| | - Rahul Kumar
- King George's Medical UniversityDepartment of PharmacologyLucknowUPIndia226003
| | - Ángela Perez
- Health Technology Assessment InstituteDeveloping Clinical Practice GuidelinesAutopista Norte # 118‐30 Off 201BogotáColombia110111
| | - Balendra P Singh
- King George's Medical UniversityDepartment of Prosthodontics, Crowns and BridgesShahmina RoadFaculty of Dental SciencesLucknowUttar PradeshIndia226003
| | | | - Emma Harding‐Esch
- London School of Hygiene & Tropical MedicineClinical Research Department, Facullty of Infectious and Tropical DiseasesLondonUK
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9
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Amza A, Kadri B, Nassirou B, Cotter SY, Stoller NE, West SK, Bailey RL, Porco TC, Keenan JD, Lietman TM, Oldenburg CE. Community-level Association between Clinical Trachoma and Ocular Chlamydia Infection after MASS Azithromycin Distribution in a Mesoendemic Region of Niger. Ophthalmic Epidemiol 2019; 26:231-237. [PMID: 30957594 PMCID: PMC9982651 DOI: 10.1080/09286586.2019.1597129] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose: The clinical sign trachomatous inflammation - follicular (TF) is used to monitor indication for and response to mass azithromycin distribution in trachoma-endemic communities. Here, we assess the relationship between TF, trachomatous inflammation - intense (TI), and infection with ocular Chlamydia trachomatis over time during annual mass azithromycin distribution. Methods: We used data from a cluster-randomized trial of mass azithromycin distribution for trachoma control in a mesoendemic region of Niger. This study includes 24 communities that received 3 years of annual mass azithromycin distribution. TF, TI, and ocular chlamydia infection were monitored among children aged 0-5 years. We assessed the correlation between the prevalence of ocular chlamydia infection and 1) TF and 2) TI prevalence over time. Results: At baseline, ocular chlamydia prevalence was 21.2% (95% CI 14.3-28.1%), TF prevalence was 27.7% (95% CI 21.2-34.2%), and TI prevalence was 8.3% (95% CI 5.2-11.5%). The prevalence of all three measures decreased significantly over time (P < 0.001). At baseline, ocular chlamydia infection prevalence was strongly correlated with both TF (rho = 0.78, P < 0.0001) and TI (rho = 0.76, P < 0.0001). The correlation between ocular chlamydia infection and both TF and TI was weak at months 12 and 24. At 36 months, when TF prevalence had dropped below 10%, ocular chlamydia infection and TF were moderately correlated (rho = 0.70, P= 0.0002). Conclusions: Both TF and TI are good indicators of infection prevalence prior to mass azithromycin distribution. However, this relationship may be affected by repeated rounds of mass azithromycin distribution.
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Affiliation(s)
- Abdou Amza
- Programme FSS/Université Abdou Moumouni de Niamey, Programme Nationale des Soins Oculaire, Niamey, Niger
| | - Boubacar Kadri
- Programme FSS/Université Abdou Moumouni de Niamey, Programme Nationale des Soins Oculaire, Niamey, Niger
| | - Beido Nassirou
- Programme FSS/Université Abdou Moumouni de Niamey, Programme Nationale des Soins Oculaire, Niamey, Niger
| | - Sun Y Cotter
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - Nicole E. Stoller
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - Sheila K West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robin L. Bailey
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco, USA,Department of Ophthalmology, University of California, San Francisco, USA,Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, USA,Department of Ophthalmology, University of California, San Francisco, USA,Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, USA,Department of Ophthalmology, University of California, San Francisco, USA,Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, USA,Department of Ophthalmology, University of California, San Francisco, USA
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Kim JS, Oldenburg CE, Cooley G, Amza A, Kadri B, Nassirou B, Cotter SY, Stoller NE, West SK, Bailey RL, Keenan JD, Gaynor BD, Porco TC, Lietman TM, Martin DL. Community-level chlamydial serology for assessing trachoma elimination in trachoma-endemic Niger. PLoS Negl Trop Dis 2019; 13:e0007127. [PMID: 30689671 PMCID: PMC6366708 DOI: 10.1371/journal.pntd.0007127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/07/2019] [Accepted: 01/04/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Program decision-making for trachoma elimination currently relies on conjunctival clinical signs. Antibody tests may provide additional information on the epidemiology of trachoma, particularly in regions where it is disappearing or elimination targets have been met. METHODS A cluster-randomized trial of mass azithromycin distribution strategies for trachoma elimination was conducted over three years in a mesoendemic region of Niger. Dried blood spots were collected from a random sample of children aged 1-5 years in each of 24 study communities at 36 months after initiation of the intervention. A multiplex bead assay was used to test for antibodies to two Chlamydia trachomatis antigens, Pgp3 and CT694. We compared seropositivity to either antigen to clinical signs of active trachoma (trachomatous inflammation-follicular [TF] and trachomatous inflammation-intense [TI]) at the individual and cluster level, and to ocular chlamydia prevalence at the community level. RESULTS Of 988 children with antibody data, TF prevalence was 7.8% (95% CI 6.1 to 9.5) and TI prevalence was 1.6% (95% CI 0.9 to 2.6). The overall prevalence of antibody positivity to Pgp3 was 27.2% (95% CI 24.5 to 30), and to CT694 was 23.7% (95% CI 21 to 26.2). Ocular chlamydia infection prevalence was 5.2% (95% CI 2.8 to 7.6). Seropositivity to Pgp3 and/or CT694 was significantly associated with TF at the individual and community level and with ocular chlamydia infection and TI at the community level. Older children were more likely to be seropositive than younger children. CONCLUSION Seropositivity to Pgp3 and CT694 correlates with clinical signs and ocular chlamydia infection in a mesoendemic region of Niger. TRIAL REGISTRATION ClinicalTrials.gov NCT00792922.
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Affiliation(s)
- Jessica S. Kim
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
| | - Catherine E. Oldenburg
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Gretchen Cooley
- Divison of Parasitic Diseases and Malaria, Centers for Disease Prevention and Control, Atlanta, Georgia, United States of America
| | - Abdou Amza
- Programme FSS/Université Abdou Moumouni de Niamey, Programme Nationale des Soins Oculaire, Niger
| | - Boubacar Kadri
- Programme FSS/Université Abdou Moumouni de Niamey, Programme Nationale des Soins Oculaire, Niger
| | - Baido Nassirou
- Programme FSS/Université Abdou Moumouni de Niamey, Programme Nationale des Soins Oculaire, Niger
| | - Sun Yu Cotter
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
| | - Nicole E. Stoller
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
| | - Sheila K. West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Robin L. Bailey
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeremy D. Keenan
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Bruce D. Gaynor
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
| | - Travis C. Porco
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
- Institute for Global Health, University of California San Francisco, San Francisco, California, United States of America
| | - Thomas M. Lietman
- F. I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
- Institute for Global Health, University of California San Francisco, San Francisco, California, United States of America
| | - Diana L. Martin
- Divison of Parasitic Diseases and Malaria, Centers for Disease Prevention and Control, Atlanta, Georgia, United States of America
- * E-mail:
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