Adisu Abebe

: Ethiopia accounts for 59% of the global trachoma burden. To eliminate trachoma as a public health problem by 2030, modified mass drug administration (MDA) strategies have been proposed, including more frequent than annual MDA. In the present study, the cost of the “child MDA” (CMDA) strategy, defined as an initial community-wide MDA treatment followed by another treatment targeting children aged 6 months to 9 years, was estimated in the Lasta and Wadilla districts, Amhara, Ethiopia. A micro-costing analysis was conducted from a payer perspective, documenting the total financial and economic cost, cost per person treated, and cost per treatment. The cost per person treated was calculated by dividing the total cost by the total number of people treated during the community-wide MDA distribution. The cost per treatment was calculated by dividing the total cost by the total number of treatments distributed overall. The total financial cost of implementing the CMDA strategy in Lasta and Wadilla was $106,427, corresponding to a financial cost per person treated of $0.41 and a financial cost per treatment of $0.32. In Lasta, 168,175 treatments were distributed at a financial cost of $61,978, corresponding to a cost per person of $0.48 and a cost per treatment of $0.37. In Wadilla, 169,248 treatments were distributed at a financial cost of $44,449, corresponding to a cost per person of $0.34 and a cost per treatment of $0.26. This information is useful to stakeholders considering the CMDA strategy in similar contexts and may contribute to future cost-effectiveness analyses of the strategy.

: There have been significant reductions in the burden of trachoma worldwide. However, some districts have experienced persistently high trachoma prevalence despite many years of intervention. Here, we report the epidemiology of trachoma in Merhabete, Ethiopia, a district in the Amhara Region that has been receiving azithromycin mass drug administration (MDA) since 2009. Data were obtained from the baseline survey of a cluster randomized trial evaluating targeted treatment strategies for trachoma elimination. An enumerative census was conducted in February 2022 to generate lists of children aged 6 months to 9 years in 80 sentinel communities participating in the trial. All children in the sentinel communities who were included in the census were examined. Field grades and conjunctival swabs were collected to assess active trachoma (based on clinical assessment) and ocular chlamydia (based on polymerase chain reaction to identify Chlamydia trachomatis). A total of 5,935 children were examined in 80 communities. The prevalence of trachomatous inflammation—follicular (TF) was 46.6%, trachomatous inflammation—intense (TI) was 17.5%, and ocular chlamydia was 28.0%. The correlation between TF and ocular chlamydia (correlation coefficient 0.54, 95% CI 0.34–0.70) was similar to the correlation between TI and ocular chlamydia (correlation coefficient 0.49, 95% CI 0.30–0.65). The prevalence of ocular chlamydia remained high in this district, which had received more than 10 rounds of azithromycin MDA. Ocular chlamydia was moderately correlated with both TF and TI. Intensive interventions may be required to eliminate trachoma in settings with persistently high ocular chlamydia prevalence despite many years of intervention.

Trachoma recrudescence is a serious concern for trachoma control programs. Programs define recrudescence as the return of trachomatous inflammation-follicular (TF) prevalence above elimination threshold (≥5%) on district-level trachoma surveillance surveys (TSSs). This study aimed to determine potential correlates of trachoma recrudescence within a historically highly endemic region. Between 2015 and 2021, population-based TSSs were conducted in 51 districts of Amhara, Ethiopia. District estimates were calculated accounting for multistage design; logistic regression was used to estimate the association of key correlates with recrudescence at the district level. Among the 51 districts, 17 (33%) were recrudescent. Correlates of recrudescence included indicators of historic trachoma burden, such as higher trachomatous inflammation-intense (TI) prevalence (odds ratio [OR]: 2.6, CI: 1.4–5.3) and higher Chlamydia trachomatis (Ct) infection prevalence (OR: 2.9, CI: 1.1–9.9) at the first recorded impact survey. The increased prevalence of children with clean faces (OR: 0.4, CI: 0.21–1.0) and the increased prevalence of travel time to a water source ≤ 30 min (OR: 0.5, CI: 0.2–1.1) at the TSS were associated with a protective effect from recrudescence. Data on historical trachoma burden as well as current water and sanitation conditions may help programs predict where recrudescence is more likely to occur and thus help programs sustain elimination as a public health problem.

: Although trachoma mass drug administration (MDA) programs target ocular Chlamydia trachomatis, the global trachoma control program does not monitor infection as a measure of impact but instead relies on monitoring clinical indicators. This study aimed to monitor the prevalence of ocular C. trachomatis among a population-based sample of children ages 1–5 years throughout Amhara, Ethiopia, a region that has received approximately 8 years of annual MDA as part of trachoma control. Between 2014 and 2021, trachoma impact surveys and surveillance surveys were conducted in all 156 districts of Amhara using a multistage cluster randomized methodology. Certified graders assessed individuals ages ≥ 1 year for trachomatous inflammation-follicular (TF), and a random subset of children ages 1–5 years also provided a conjunctival swab. Polymerase chain reaction was used to test for C. trachomatis. A total of 28,410 conjunctival swabs were collected from children ages 1–5 years across Amhara. The regional C. trachomatis infection prevalence was 4.7% (95% uncertainty interval: 4.3–5.1%). Infection was detected in all 10 zones of the region and ranged from 0.2% in Awi Zone to 11.9% in Waghemra Zone. Infection was detected in 17 (26%) districts with a TF prevalence < 10% and in 7 (21%) districts with a TF prevalence < 5%. Through programmatic monitoring of C. trachomatis infection, this study demonstrated that considerable infection remained throughout Amhara despite approximately 8 years of trachoma interventions and that enhanced interventions such as more frequent than annual MDA will be needed if elimination thresholds are to be reached.

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.