Abstract.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.

Background. MORDOR I found that 2 years of biannual mass azithromycin administration reduced post-neonatal childhood mortality by 18% in Niger. Over time, this benefit could increase with each distribution or wane due to antibiotic resistance. Here in MORDOR II, we treated communities in both arms for an additional year with azithromycin, resulting in a randomized comparison of the first versus the third year of treatment. Methods. MORDOR I-Niger originally randomized 594 communities to 4 biannual distributions of either azithromycin or placebo to children aged 1-59 months. In MORDOR II, all communities received 2 additional biannual azithromycin distributions. All-cause mortality was assessed during a biannual census by enumerators masked to original assignment. Results. Mean azithromycin coverage was 91.3% (SD ±7.2%) in the communities receiving the first year and 92.0% (±6.6%) in those receiving the third year of azithromycin. Mortality was 24.0 per 1,000 person-years (95% CI, 22.1—26.3) in communities randomized to the first year, and 23.3 per 1,000 person-years (95% CI, 21.4—25.5) in those randomized to the third year of treatment, with no significant difference between arms ( p =0.55). In communities originally receiving placebo, mortality decreased 13.3% (95% CI, 5.8%—20.2%, p =0.007) when treated with azithromycin. In communities continuing to receive azithromycin, the mortality reduction was not significantly different in the third year (-3.6%, 95% CI, -12.3%—4.5%, p =0.50). Conclusions. We found no evidence that the effect of mass azithromycin on childhood mortality waned in the third year of treatment. Childhood mortality fell significantly when placebo-treated communities were provided azithromycin.

BackgroundWorld 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.MethodsThis 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.ResultsA 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).ConclusionsAfter 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 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.

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