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.

Changes in reproductive courtship behaviors of adult American kestrels (Falco sparverius) exposed to environmentally relevant levels of the polybrominated diphenyl ether mixture, DE-71.

Polybrominated diphenyl ethers (PBDEs) are increasing in biota. Here, captive adult American kestrels were exposed daily by diet to safflower oil (controls), or one of two levels of a pentaBDE technical formulation, DE-71 (0.3 or 1.6 ppm), for approximately 75 days, commencing 21 days before breeding. This exposure resulted in eggs having PBDE concentrations similar (low exposure) or within the same order of magnitude (high exposure) reported for wild American kestrels and gulls in the Great Lakes. Compared to controls, kestrels in both exposure groups copulated less, spent less time in their nest boxes, and participated in fewer pair-bonding behaviors. Furthermore, the timing of these behaviors, which is important to creating and maintaining the pair-bond, also differed significantly from the controls. The females in the low-exposure group made fewer compatible trilling calls and ate less frequently. These behavioral changes were compounded by increasing exposure to DE-71 during the 9-day courtship period immediately preceding egg laying, a standard measure of the kestrel courtship period. The birds in the high-exposure group made more food transfers, excited "klee" calls, and copulations, the latter only when compared to the low-exposure birds, whereas the low-exposure males performed fewer pair-bonding behaviors. This study demonstrates that the exposure of kestrels to environmentally relevant levels of DE-71 modifies the quality of the pair-bond, affects the reproductive behavior of both sexes, and occurs when birds are exposed for a short period as adults. In addition, these behavioral effects are consistent with the observed reproductive changes in these birds.