Estimation of insecticide persistence, biological activity and mosquito resistance to PermaNet® 2 long-lasting insecticidal nets over three to 32 months of use in Ethiopia.

BACKGROUND: Information is needed on the expected durability of insecticidal nets under operational conditions. The persistence of insecticidal efficacy is important to estimate the median serviceable life of nets under field conditions and to plan for net replacement. METHODS: Deltamethrin residue levels were evaluated by the proxy method of X-ray fluorescence spectrometry on 189 nets used for three to six months from nine sites, 220 nets used for 14-20 months from 11 sites, and 200 nets used for 26-32 months from ten sites in Ethiopia. A random sample of 16.5-20% of nets from each time period (total 112 of 609 nets) were tested by bioassay with susceptible mosquitoes, and nets used for 14-20 months and 26-32 months were also tested with wild caught mosquitoes. RESULTS: Mean insecticide levels estimated by X-ray fluorescence declined by 25.9% from baseline of 66.2 (SD 14.6) mg/m2 at three to six months to 44.1 (SD 21.2) mg/m2 at 14-20 months and by 30.8% to 41.1 (SD 18.9) mg/m2 at 26-32 months. More than 95% of nets retained greater than 10 mg/m2 of deltamethrin and over 79% had at least 25 mg/m2 at all time periods. By bioassay with susceptible Anopheles, mortality averaged 89.0% on 28 nets tested at three to six months, 93.3% on 44 nets at 14-20 months and 94.1% on 40 nets at 26-32 months. With wild caught mosquitoes, mortality averaged 85.4% (range 79.1 to 91.7%) at 14-20 months but had dropped significantly to 47.2% (39.8 to 54.7%) at 26-32 months. CONCLUSIONS: Insecticide residue level, as estimated by X-ray fluorescence, declined by about one third between three and six months and 14-20 months, but remained relatively stable and above minimum requirements thereafter up to 26-32 months. The insecticidal activity of PermaNet® 2.0 long-lasting insecticidal nets in the specified study area may be considered effective to susceptible mosquitoes at least for the duration indicated in this study (32 months). However, results indicated that resistance in the wild population is already rendering nets with optimum insecticide concentrations less effective in practice.

Physical durability of PermaNet 2.0 long-lasting insecticidal nets over three to 32 months of use in Ethiopia.

BACKGROUND: Ethiopia scaled up net distribution markedly starting in 2006. Information on expected net life under field conditions (physical durability and persistence of insecticidal activity) is needed to improve planning for net replacement. Standardization of physical durability assessment methods is lacking. METHODS: Permanet®2.0 long-lasting insecticidal bed nets (LLINs), available for distribution in early 2007, were collected from households at three time intervals. The number, size and location of holes were recorded for 189 nets used for three to six months from nine sites (2007) and 220 nets used for 14 to 20 months from 11 sites (2008). In 2009, a "finger/fist" sizing method classified holes in 200 nets used for 26 to 32 months from ten sites into small (<2 cm), medium (> = 2 to < =10 cm) and large (>10 cm) sizes. A proportionate hole index based on both hole number and area was derived from these size classifications. RESULTS: After three to six months, 54.5% (95% CI 47.1-61.7%) of 189 LLINs had at least one hole 0.5 cm (in the longest axis) or larger; mean holes per net was 4.4 (SD 8.4), median was 1.0 (Inter Quartile Range [IQR] 0-5) and median size was 1 cm (IQR 1-2). At 14 to 20 months, 85.5% (95% CI 80.1-89.8%) of 220 nets had at least one hole with mean 29.1 (SD 50.1) and median 12 (IQR 3-36.5) holes per net, and median size of 1 cm (IQR 1-2). At 26 to 32 months, 92.5% of 200 nets had at least one hole with a mean of 62.2 (SD 205.4) and median of 23 (IQR 6-55.5) holes per net. The mean hole index was 24.3, 169.1 and 352.8 at the three time periods respectively. Repairs were rarely observed. The majority of holes were in the lower half of the net walls. The proportion of nets in 'poor' condition (hole index >300) increased from 0% at three to six months to 30% at 26 to 32 months. CONCLUSIONS: Net damage began quickly: more than half the nets had holes by three to six months of use, with 40% of holes being larger than 2 cm. Holes continued to accumulate until 92.5% of nets had holes by 26 to 32 months of use. An almost complete lack of repairs shows the need for promoting proper use of nets and repairs, to increase LLIN longevity. Using the hole index, almost one third of the nets were classed as unusable and ineffective after two and a half years of potential use.

Baseline Prevalence of Trachoma in Refugee Settlements in Uganda: Results of 11 Population-based Surveys.

PURPOSE: There are several settlements in the Northern and Western Regions of Uganda serving refugees from South Sudan and Democratic Republic of Congo (DRC), respectively. Trachoma prevalence surveys were conducted in a number of those settlements with the aim of determining whether interventions for trachoma are required. METHODS: An evaluation unit (EU) was defined as all refugee settlements in one district. Cross-sectional population-based trachoma prevalence survey methodologies designed to adhere to World Health Organization recommendations were deployed in 11 EUs to assess prevalence of trachomatous inflammation-follicular (TF) in 1-9-year-olds and trachomatous trichiasis (TT) unknown to the health system in ≥15-year-olds. Household-level water, sanitation and hygiene coverage was also assessed in study populations. RESULTS: A total of 40,892 people were examined across 11 EUs between 2018 and 2020. The prevalence of TF in 1-9-year-olds was <5% in all EUs surveyed. The prevalence of trachomatous trichiasis (TT) unknown to the health system in ≥15-year-olds was <0.2% in 5 out of 11 EUs surveyed and ≥0.2% in the remaining 6 EUs. A high proportion of households had improved water sources, but a low proportion had improved latrines or quickly (within a 30-minute return journey) accessible water sources. CONCLUSIONS: Implementation of the antibiotic, facial cleanliness and environmental improvement components of the SAFE strategy is not needed for the purposes of trachoma's elimination as a public health problem in these refugee settlements; however, intervention with TT surgery is needed in six EUs. Since instability continues to drive displacement of people from South Sudan and DRC into Uganda, there is likely to be a high rate of new arrivals to the settlements over the coming years. These populations may therefore have trachoma surveillance needs that are distinct from the surrounding non-refugee communities.

Impact of personal protective equipment on the clarity of vision among trachoma survey graders and trichiasis surgeons in the context of COVID-19.

BACKGROUND/AIMS: The COVID-19 pandemic necessitated the use of personal protective equipment for those involved in trachoma survey grading and trichiasis surgery. We sought to determine which configuration of a face shield would be less likely to impact grading accuracy and ability to conduct trichiasis surgery. The research also included assessment of comfort, ease of cleaning and robustness. METHODS: There were three research phases. In phase 1, assessment of four potential face shield configurations was undertaken with principal trachoma graders and trichiasis surgeon trainers to decide which two options should undergo further testing. In phase 2, clarity of vision and comfort (in a classroom environment) of the two configurations were assessed compared with no face shield (control), while grading trachomatous inflammation-follicular (TF). The second phase also included the assessment of impact of the configurations while performing trichiasis surgery using a training model. In phase 3, face shield ease of use was evaluated during routine surgical programmes. RESULTS: In phase 2, 124 trachoma graders and 28 trichiasis surgeons evaluated the 2 face shield configurations selected in phase 1. TF agreement was high (kappa=0.83 and 0.82) for both configurations compared with not wearing a face shield. Comfort was reported as good by 51% and 32% of graders using the two configurations. Trichiasis skill scores were similar for both configurations. CONCLUSION: The face shield configuration that includes a cut-out for mounting the 2.5× magnifying loupes does not appear to impact the ability or comfort of trachoma graders or trichiasis surgeons to carry out their work.

Analysis of malaria surveillance data in Ethiopia: what can be learned from the Integrated Disease Surveillance and Response System?

BACKGROUND: Routine malaria surveillance data is useful for assessing incidence and trends over time, and in stratification for targeting of malaria control. The reporting completeness and potential bias of such data needs assessment. METHODS: Data on 17 malaria indicators were extracted from the Integrated Disease Surveillance and Response System database for July 2004 to June 2009 (Ethiopian calendar reporting years 1997 to 2001). Reporting units were standardized over time with 2007 census populations. The data were analysed to show reporting completeness, variation in risk by reporting unit, and incidence trends for malaria indicators. RESULTS: Reporting completeness, estimated as product of unit-month and health facility reporting, was over 80% until 2009, when it fell to 56% during a period of reorganization in the Ministry of Health. Nationally the average estimated annual incidence of reported total malaria for the calendar years 2005 to 2008 was 23.4 per 1000 persons, and of confirmed malaria was 7.6 per 1,000, with no clear decline in out-patient cases over the time period. Reported malaria in-patient admissions and deaths (averaging 6.4 per 10,000 and 2.3 per 100,000 per year respectively) declined threefold between 2005 and 2009, as did admissions and deaths reported as malaria with severe anaemia. Only 8 of 86 reporting units had average annual estimated incidence of confirmed malaria above 20 per 1,000 persons, while 26 units were consistently below five reported cases per 1,000 persons per year. CONCLUSION: The Integrated Disease Surveillance and Response System functioned well over the time period mid 2004 to the end of 2008. The data suggest that the scale up of interventions has had considerable impact on malaria in-patient cases and mortality, as reported from health centres and hospitals. These trends must be regarded as relative (over space and time) rather than absolute. The data can be used to stratify areas for improved targeting of control efforts to steadily reduce incidence. They also provide a baseline of incidence estimates against which to gauge future progress towards elimination. Inclusion of climate information over this time period and extension of the dataset to more years is needed to clarify the impact of control measures compared to natural cycles on malaria.

Evaluating Precision of a Trachomatous Trichiasis (TT) Super Survey with Modulating Sample Sizes in Tanzania.

As trachoma programs move towards eliminating trachoma as a public health problem, the number of surveys necessary to evaluate the status of trachomatous trichiasis (TT) increases. Currently, the World Health Organization endorses a district-level population-based prevalence survey for trachoma that involves a two-stage cluster design. We explored the validity of implementing this survey design in larger geographic areas to gain cost efficiencies. We evaluated the change in precision due to combining geographically contiguous and homogenous districts into single evaluation units (EUs) and modulating the sample size by running simulations on existing datasets. Preliminary findings from two opportunities in Tanzania show variability in the appropriateness in conducting this survey across larger geographies. These preliminary findings stress the importance of determining what is meant by homogeneity in terms of TT before combining multiple districts into a single EU.

Which nets are being used: factors associated with mosquito net use in Amhara, Oromia and Southern Nations, Nationalities and Peoples' Regions of Ethiopia.

BACKGROUND: There has been recent large scale-up of malaria control interventions in Ethiopia where transmission is unstable. While household ownership of long-lasting insecticidal nets (LLIN) has increased greatly, there are concerns about inadequate net use. This study aimed to investigate factors associated with net use at two time points, before and after mass distribution of nets. METHODS: Two cross sectional surveys were carried out in 2006 and 2007 in Amhara, Oromia and SNNP regions. The latter was a sub-sample of the national Malaria Indicator Survey (MIS 3R). Each survey wave used multi-stage cluster random sampling with 25 households per cluster (224 clusters with 5,730 households in Baseline 2006 and 245 clusters with 5,910 households in MIS 3R 2007). Net ownership was assessed by visual inspection while net utilization was reported as use of the net the previous night. This net level analysis was restricted to households owning at least one net of any type. Logistic regression models of association between net use and explanatory variables including net type, age, condition, cost and other household characteristics were undertaken using generalized linear latent and mixed models (GLLAMM). RESULTS: A total of 3,784 nets in 2,430 households were included in the baseline 2006 analysis while the MIS 3R 2007 analysis comprised 5,413 nets in 3,328 households. The proportion of nets used the previous night decreased from 85.1% to 56.0% between baseline 2006 and MIS 3R 2007, respectively. Factors independently associated with increased proportion of nets used were: LLIN net type (at baseline 2006); indoor residual spraying (at MIS 3R 2007); and increasing wealth index at both surveys. At both baseline 2006 and MIS 3R 2007, reduced proportion of nets used was independently associated with increasing net age, increasing damage of nets, increasing household net density, and increasing altitude (>2,000 m). CONCLUSION: This study identified modifiable factors affecting use of nets that were consistent across both surveys. While net replacement remains important, the findings suggest that: more education about use and care of nets; making nets more resistant to damage; and encouraging net mending are likely to maximize the huge investment in scale up of net ownership by ensuring they are used. Without this step, the widespread benefits of LLIN cannot be realized.

Factors associated with mosquito net use by individuals in households owning nets in Ethiopia.

BACKGROUND: Ownership of insecticidal mosquito nets has dramatically increased in Ethiopia since 2006, but the proportion of persons with access to such nets who use them has declined. It is important to understand individual level net use factors in the context of the home to modify programmes so as to maximize net use. METHODS: Generalized linear latent and mixed models (GLLAMM) were used to investigate net use using individual level data from people living in net-owning households from two surveys in Ethiopia: baseline 2006 included 12,678 individuals from 2,468 households and a sub-sample of the Malaria Indicator Survey (MIS) in 2007 included 14,663 individuals from 3,353 households. Individual factors (age, sex, pregnancy); net factors (condition, age, net density); household factors (number of rooms [2006] or sleeping spaces [2007], IRS, women's knowledge and school attendance [2007 only], wealth, altitude); and cluster level factors (rural or urban) were investigated in univariate and multi-variable models for each survey. RESULTS: In 2006, increased net use was associated with: age 25-49 years (adjusted (a) OR = 1.4, 95% confidence interval (CI) 1.2-1.7) compared to children U5; female gender (aOR = 1.4; 95% CI 1.2-1.5); fewer nets with holes (Ptrend = 0.002); and increasing net density (Ptrend < 0.001). Reduced net use was associated with: age 5-24 years (aOR = 0.2; 95% CI 0.2-0.3). In 2007, increased net use was associated with: female gender (aOR = 1.3; 95% CI 1.1-1.6); fewer nets with holes (aOR [all nets in HH good] = 1.6; 95% CI 1.2-2.1); increasing net density (Ptrend < 0.001); increased women's malaria knowledge (Ptrend < 0.001); and urban clusters (aOR = 2.5; 95% CI 1.5-4.1). Reduced net use was associated with: age 5-24 years (aOR = 0.3; 95% CI 0.2-0.4); number of sleeping spaces (aOR [per additional space] = 0.6, 95% CI 0.5-0.7); more old nets (aOR [all nets in HH older than 12 months] = 0.5; 95% CI 0.3-0.7); and increasing household altitude (Ptrend < 0.001). CONCLUSION: In both surveys, net use was more likely by women, if nets had fewer holes and were at higher net per person density within households. School-age children and young adults were much less likely to use a net. Increasing availability of nets within households (i.e. increasing net density), and improving net condition while focusing on education and promotion of net use, especially in school-age children and young adults in rural areas, are crucial areas for intervention to ensure maximum net use and consequent reduction of malaria transmission.

The Importance of Failure: How Doing Impact Surveys That Fail Saves Trachoma Programs Money.

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.

The costs of monitoring trachoma elimination: Impact, surveillance, and trachomatous trichiasis (TT)-only surveys.

BACKGROUND: Although trachoma causes more cases of preventable blindness than any other infectious disease, a combination of strategies is reducing its global prevalence. As a district moves toward eliminating trachoma as a public health problem, national programs conduct trachoma impact surveys (TIS) to assess whether to stop preventative interventions and trachoma surveillance surveys (TSS) to determine whether the prevalence of active trachoma has rebounded after interventions have halted. In some contexts, programs also conduct trachomatous trichiasis (TT)-only surveys. A few costing studies of trachoma prevalence surveys exist, but none examine TIS, TSS, or TT-only surveys. METHODOLOGY/PRINCIPAL FINDINGS: We assessed the incremental financial cost to the national program of TIS, TSS, and TT-only surveys, which are standardized cluster-sampled prevalence surveys. We conducted a retrospective review of expenditures and grant disbursements for TIS and TSS in 322 evaluation units in 11 countries between 2011 and 2018. We also assessed the costs of three pilot and five standard TT-only surveys in four countries between 2017 and 2018. The median cost of TIS and TSS was $8,298 per evaluation unit [interquartile range (IQR): $6,532-$10,111, 2017 USD]. Based on a linear regression with bootstrapped confidence intervals, after controlling for country, costs per survey did not change significantly over time but did decline by $83 per survey implemented in a single round (95% CI: -$108 --$63). Of total costs, 80% went to survey fieldwork; of that, 58% went towards per diems and 38% towards travel. TT-only surveys cost a median of $9,707 (IQR: $8,537-$11,635); within a given country, they cost slightly more (106% [IQR: 94%-136%]) than TIS and TSS. CONCLUSIONS/SIGNIFICANCE: The World Health Organization requires trachoma prevalence estimates for validating the elimination of trachoma as a public health problem. This study will help programs improve their planning as they assemble resources for that effort.

Evaluation of light microscopy and rapid diagnostic test for the detection of malaria under operational field conditions: a household survey in Ethiopia.

BACKGROUND: In most resource-poor settings, malaria is usually diagnosed based on clinical signs and symptoms and not by detection of parasites in the blood using microscopy or rapid diagnostic tests (RDT). In population-based malaria surveys, accurate diagnosis is important: microscopy provides the gold standard, whilst RDTs allow immediate findings and treatment. The concordance between RDTs and microscopy in low or unstable transmission areas has not been evaluated. OBJECTIVES: This study aimed to estimate the prevalence of malaria parasites in randomly selected malarious areas of Amhara, Oromia, and Southern Nations, Nationalities and Peoples' (SNNP) regions of Ethiopia, using microscopy and RDT, and to investigate the agreement between microscopy and RDT under field conditions. METHODS: A population-based survey was conducted in 224 randomly selected clusters of 25 households each in Amhara, Oromia and SNNP regions, between December 2006 and February 2007. Fingerpick blood samples from all persons living in even-numbered households were tested using two methods: light microscopy of Giemsa-stained blood slides; and RDT (ParaScreen device for Pan/Pf). RESULTS: A total of 13,960 people were eligible for malaria parasite testing of whom 11,504 (82%) were included in the analysis. Overall slide positivity rate was 4.1% (95% confidence interval [CI] 3.4-5.0%) while ParaScreen RDT was positive in 3.3% (95% CI 2.6-4.1%) of those tested. Considering microscopy as the gold standard, ParaScreen RDT exhibited high specificity (98.5%; 95% CI 98.3-98.7) and moderate sensitivity (47.5%; 95% CI 42.8-52.2) with a positive predictive value of 56.8% (95% CI 51.7-61.9) and negative predictive value of 97.6% (95% CI 97.6-98.1%) under field conditions. CONCLUSION: Blood slide microscopy remains the preferred option for population-based prevalence surveys of malaria parasitaemia. The level of agreement between microscopy and RDT warrants further investigation in different transmission settings and in the clinical situation.

Risk factors for active trachoma in children and trichiasis in adults: a household survey in Amhara Regional State, Ethiopia.

Identification of risk factors is essential for planning and implementing effective trachoma control programmes. We aimed to investigate risk factors for active trachoma and trichiasis in Amhara Regional State, Ethiopia. A survey was undertaken and eligible participants (children aged 1-9 years and adults aged 15 years and above) examined for trachoma. Risk factors were assessed through interviews and observations. Using ordinal logistic regression, associations between signs of active trachoma in children and potential risk factors were explored. Associations between trichiasis in adults and potential risk factors were investigated using conventional logistic regression. A total of 5427 children from 2845 households and 9098 adults from 4039 households were included in the analysis. Ocular discharge [odds ratio (OR)=5.9; 95% CI 4.8-7.2], nasal discharge (OR=1.6; 95% CI 1.3-1.9), thatch roof in household (OR=1.3; 95% CI 1.0-1.5), no electricity in household (OR=2.4; 95% CI 1.3-4.3) and increasing altitude (Ptrend<0.001) were independently associated with severity of active trachoma. Trichiasis was associated with increasing age (ORper 5 year increase=1.5; 95% CI 1.4-1.7), female gender (OR=4.5; 95% CI 3.5-5.8), increasing prevalence of active trachoma in children (Ptrend=0.003) and increasing altitude (Ptrend=0.015).

Malaria prevalence and mosquito net coverage in Oromia and SNNPR regions of Ethiopia.

BACKGROUND: Malaria transmission in Ethiopia is unstable and seasonal, with the majority of the country's population living in malaria-prone areas. Results from DHS 2005 indicate that the coverage of key malaria interventions was low. The government of Ethiopia has set the national goal of full population coverage with a mean of 2 long-lasting insecticidal nets (LLINs) per household through distribution of about 20 million LLIN by the end of 2007. The aim of this study was to generate baseline information on malaria parasite prevalence and coverage of key malaria control interventions in Oromia and SNNPR and to relate the prevalence survey findings to routine surveillance data just before further mass distribution of LLINs. METHODS: A 64 cluster malaria survey was conducted in January 2007 using a multi-stage cluster random sampling design. Using Malaria Indicator Survey Household Questionnaire modified for the local conditions as well as peripheral blood microscopy and rapid diagnostic tests, the survey assessed net ownership and use and malaria parasite prevalence in Oromia and SNNPR regions of Ethiopia. Routine surveillance data on malaria for the survey time period was obtained for comparison with prevalence survey results. RESULTS: Overall, 47.5% (95% confidence interval (CI) 33.5-61.9%) of households had at least one net, and 35.1% (95% CI 23.1-49.4%) had at least one LLIN. There was no difference in net ownership or net utilization between the regions. Malaria parasite prevalence was 2.4% (95% CI 1.6-3.5%) overall, but differed markedly between the two regions: Oromia, 0.9% (95% CI 0.5-1.6); SNNPR, 5.4% (95% CI 3.4-8.5), p < 0.001. This difference between the two regions was also reflected in the routine surveillance data. CONCLUSION: Household net ownership exhibited nearly ten-fold increase compared to the results of Demographic and Health Survey 2005 when fewer than 5% of households in these two regions owned any nets. The results of the survey as well as the routine surveillance data demonstrated that malaria continues to be a significant public health challenge in these regions-and more prevalent in SNNPR than in Oromia.

Integrated Healthcare Delivery: A Qualitative Research Approach to Identifying and Harmonizing Perspectives of Integrated Neglected Tropical Disease Programs.

BACKGROUND: While some evidence supports the beneficial effects of integrating neglected tropical disease (NTD) programs to optimize coverage and reduce costs, there is minimal information regarding when or how to effectively operationalize program integration. The lack of systematic analyses of integration experiences and of integration processes may act as an impediment to achieving more effective NTD programming. We aimed to learn about the experiences of NTD stakeholders and their perceptions of integration. METHODOLOGY: We evaluated differences in the definitions, roles, perceived effectiveness, and implementation experiences of integrated NTD programs among a variety of NTD stakeholder groups, including multilateral organizations, funding partners, implementation partners, national Ministry of Health (MOH) teams, district MOH teams, volunteer rural health workers, and community members participating in NTD campaigns. Semi-structured key informant interviews were conducted. Coding of themes involved a mix of applying in-vivo open coding and a priori thematic coding from a start list. FINDINGS: In total, 41 interviews were conducted. Salient themes varied by stakeholder, however dominant themes on integration included: significant variations in definitions, differential effectiveness of specific integrated NTD activities, community member perceptions of NTD programs, the influence of funders, perceived facilitators, perceived barriers, and the effects of integration on health system strength. In general, stakeholder groups provided unique perspectives, rather than contrarian points of view, on the same topics. The stakeholders identified more advantages to integration than disadvantages, however there are a number of both unique facilitators and challenges to integration from the perspective of each stakeholder group. CONCLUSIONS: Qualitative data suggest several structural, process, and technical opportunities that could be addressed to promote more effective and efficient integrated NTD elimination programs. We highlight a set of ten recommendations that may address stakeholder concerns and perceptions regarding these key opportunities. For example, public health stakeholders should embrace a broader perspective of community-based health needs, including and beyond NTDs, and available platforms for addressing those needs.

Trachoma prevalence in Niger: results of 31 district-level surveys.

BACKGROUND: The leading cause of preventable blindness worldwide is trachoma, a condition caused by an infection of the inner eyelid. In Niger, a landlocked republic in Western Africa, surveys in 1988-89 identified trachoma as endemic in all but one region and, as a result, there is a National Prevention of Blindness Program plan to eliminate trachoma by 2015. METHODS: Thirty-one districts in eastern and western Niger were surveyed for trachoma prevalence from May 2009 to March 2012 as part of routine program impact evaluations. Prevalence surveys were implemented independently in each district using a two-stage cluster random design. Probability proportional to size was used to randomly select villages and 25 households were selected in each cluster. The prevalence of trachoma of clinical grade trachomatous follicular (TF) was estimated in children aged 1-9 years, and the prevalence of blinding trachoma, trachomatous trichiasis (TT), was measured in adults aged ≥15 years. RESULTS: A total of 14 211 households was surveyed; 58 617 individuals were evaluated for clinical signs of trachoma, of whom 27 087 were children aged 1-9 years. District-wide implementation of the full SAFE strategy is warranted in 16 districts where TF prevalence exceeds 10% and targeted implementation of the SAFE strategy (surgery for trichiasis; antibiotic therapy to control transmission; facial cleanliness for hygiene promotion; environmental change for improvements in access to water and sanitation) is recommended in the remaining 15 districts. The prevalence of TT among adults exceeded 1% in nine districts, suggesting that surgical services to treat TT should be implemented district-wide. CONCLUSIONS: These results establish the need for continued SAFE strategy implementation throughout Niger.

'A living death': a qualitative assessment of quality of life among women with trichiasis in rural Niger.

BACKGROUND: Prior to blindness, trachoma is thought to profoundly affect women's abilities to lead normal lives, but supporting evidence is lacking. To better understand the effects of trichiasis, we asked women to define quality of life, how trichiasis affects this idea and their perceptions of eyelid surgery. METHODS: Operated and unoperated women were purposively selected for in-depth interviews. These were audio-recorded and transcribed, and codes were identified and applied to the transcripts. Overarching themes, commonalities and differences were identified and matched to quotations. RESULTS: Twenty-three women were interviewed. Quality of life was defined as health, security, family, social status and religious participation. Trichiasis caused severe pain and loss of health, leading to loss of security. This affected social, economic and religious activities and caused burden on their families. Surgery improved quality of life, even in cases of surgical failure or recurrent disease. CONCLUSIONS: Trichiasis disables most women, even those reporting fewer or less-severe symptoms. While women in rural Niger often live in extreme poverty, trichiasis exacerbates the situation, making women unable to work and undermining their social status. It adds to family burden, as women lose the ability to meaningfully contribute to the household and require additional family resources for their care.

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.

Monitoring of mass distribution interventions for trachoma in Plateau State, Nigeria.

Mass drug administration (MDA) with antibiotics is a key component of the SAFE strategy for trachoma control. Guidelines recommend that where MDA is warranted the whole population be targeted with 80% considered the minimum acceptable coverage. In other countries, MDA is usually conducted by salaried Ministry of Health personnel (MOH). In Plateau State, Nigeria, the existing network of volunteer Community Directed Distributors (CDD) was used for the first trachoma MDA. We conducted a population-based cluster random survey (CRS) of MDA participation to determine the true coverage and compared this to coverage reported from CDD registers. We surveyed 1,791 people from 352 randomly selected households in 24 clusters in three districts in Plateau State in January 2011, following the implementation of MDA. Households were enumerated and all individuals present were asked about MDA participation. Household heads were questioned about household-level characteristics and predictors of participation. Individual responses were compared with the CDD registers. MDA coverage was estimated as 60.3% (95% CI 47.9-73.8%) by the survey compared with 75.8% from administrative program reports. CDD registration books for comparison with responses were available in 19 of the 24 clusters; there was a match for 658/682 (96%) of verifiable responses. CDD registers did not list 481 (41.3%) of the individuals surveyed. Gender and age were not associated with individual participation. Overall MDA coverage was lower than the minimum 80% target. The observed discrepancy between the administrative coverage estimate from program reports and the CRS was largely due to identification of communities missed by the MDA and not reported in the registers. CRS for evaluation of MDA provides a useful additional monitoring tool to CDD registers. These data support modification of distributor training and MDA delivery to increase coverage in subsequent rounds of MDA.

Trachoma among children in community surveys from four African countries and implications of using school surveys for evaluating prevalence.

BACKGROUND: School surveys provide a convenient platform to obtain large child cohorts from multiple communities and are widely used as a proxy to determine community prevalence of neglected tropical diseases. The purpose of this study was to compare trachoma prevalence between preschool- and school-aged children and children who attend and do not attend school. METHODS: We analysed data from community-based trachoma surveys conducted from 2008-2011 in Ethiopia, Mali, Niger and Nigeria. The surveys utilised a cross-sectional, randomised cluster design. Individual-level data on school attendance was collected. RESULTS: Overall, 75 864 children aged 1-15 years from 2100 communities were included in the analysis. The prevalence of trachomatous inflammation follicular (TF) among these children in surveyed districts was 19.1% (95% CI 17.9-20.2%) in Ethiopia, 6.2% (95% CI 5.4-6.9%) in Niger, 4.6% (95% CI 4.2-4.9%) in Mali and 4.2% (95% CI 3.5-4.9%) in Nigeria. Controlling for age, sex and clustering, the OR of TF for school-attendees compared to non-attendees was 0.64 (95% CI 0.56-0.73) in Ethiopia, 0.67 (95% CI 0.56-0.80) in Mali, 1.03 (95% CI 0.81-1.16) in Niger and 1.06, (95% CI 0.65-1.73) in Nigeria. CONCLUSION: Estimating the prevalence of trachoma through examination of only school-going children risks underestimating the true prevalence.

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.