Abstract
BackgroundAn important component of the World Health Organization's comprehensive trachoma elimination strategy is the provision of repeated annual mass azithromycin distributions, which are directed at reducing the burden of ocular chlamydia. Knowledge of characteristics associated with infection after mass antibiotic treatments could allow trachoma programs to focus resources to those most likely to be infected with ocular chlamydia.Methodology/Principal FindingsWe monitored 12 communities in rural Ethiopia that had received 3 annual mass azithromycin treatments as part of a cluster-randomized trial for trachoma. One year after the third treatment, a random sample of children from each village received conjunctival examination for follicular trachomatous inflammation (TF) and intense trachomatous inflammation (TI), conjunctival swabbing for chlamydial RNA and DNA, and a household survey. The primary outcome for this study was RNA evidence of ocular chlamydia, which we detected in 41 of 573 swabbed children (7.2%, 95%CI 2.7–17.8). In multivariate mixed effects logistic regression models, ocular chlamydial RNA was significantly associated with ocular discharge (OR 2.82, 95%CI 1.07–7.42), missing the most recent mass azithromycin treatment (OR 2.49, 95%CI 1.02–6.05), having a sibling with ocular chlamydia (OR 4.44, 95%CI 1.60–12.29), and above-median community population (OR 7.81, 95%CI 1.56–39.09). Ocular chlamydial infection was also independently associated with TF (OR 3.42, 95%CI 1.56–7.49) and TI (OR 5.39, 95%CI 2.43–11.98).Conclusions/SignificanceIn areas with highly prevalent trachoma treated with multiple rounds of mass azithromycin, trachoma programs could consider continuing mass azithromycin treatments in households that have missed prior mass antibiotic treatments, in households with clinically active trachoma, and in larger communities.
Highlights
As part of the SAFE strategy (Surgery for trichiasis, Antibiotics, Facial hygiene promotion, and Environmental improvements), the World Health Organization recommends repeated annual mass antibiotic distributions for trachoma, usually with oral azithromycin, followed by reassessment after at least 3 years of SAFE [1]
The World Health Organization recommends at least 3 rounds of annual mass antibiotic distributions in areas with trachoma, with further mass treatments based on the prevalence of trachoma
We found that children were more likely to be infected with ocular chlamydia if they had ocular inflammatory signs or ocular discharge, or if they had missed the preceding antibiotic treatment, had an infected sibling, or came from a larger community
Summary
As part of the SAFE strategy (Surgery for trichiasis, Antibiotics, Facial hygiene promotion, and Environmental improvements), the World Health Organization recommends repeated annual mass antibiotic distributions for trachoma, usually with oral azithromycin, followed by reassessment after at least 3 years of SAFE [1]. In areas with highly prevalent trachoma, three treatments are unlikely to be sufficient to eliminate the causative agent, Chlamydia trachomatis [2,3]. In these areas with highly prevalent disease, re-infection rapidly occurs, even after ocular chlamydia has been brought to very low levels with repeated mass azithromycin treatments [4]. An important component of the World Health Organization’s comprehensive trachoma elimination strategy is the provision of repeated annual mass azithromycin distributions, which are directed at reducing the burden of ocular chlamydia. Knowledge of characteristics associated with infection after mass antibiotic treatments could allow trachoma programs to focus resources to those most likely to be infected with ocular chlamydia
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