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Background The International Trachoma Initiative (ITI) provides azithromycin for mass drug administration (MDA) to eliminate trachoma as a public health problem. Azithromycin is given as tablets for adults and powder for oral suspension (POS) is recommended for children aged Methods MDA was observed in three regions of Ethiopia and data were collected on azithromycin administration and ASEs. Results A total of 6477 azithromycin administrations were observed; 97.9% of children received the exact recommended dose. Of children aged 6 mo to Conclusions There is a high level of adherence to the revised azithromycin dosing guidelines and low incidence of choking and ASEs.

This study analyzed the determinants of rural households’ food security in the Kallu district of the Amhara region, Northern Ethiopia. The study used primary data collected from 395 randomly selected rural households. The study employed descriptive statistics and a binary logit model to estimate the status and determinants of smallholders’ food security, respectively. Of the total sample households, 47.30% are food insecure. The binary logit model results showed that sex and education level of the household head, livestock ownership, credit access, and technology adoption have positive and significant effects on food security, while age and market distance are negatively associated with the probability to be food secure. The results suggest that improving access to marketing and financial services will contribute to improving the food security status of smallholders.

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.

To investigate, in Amhara, Ethiopia, the association between prevalence of active trachoma among children aged 1-9 years and community sanitation usage.Between 2011 and 2014, prevalence of trachoma and household pit latrine usage were measured in five population-based cross-sectional surveys. Data on observed indicators of latrine use were aggregated into a measure of community sanitation usage calculated as the proportion of households with a latrine in use. All household members were examined for clinical signs, i.e. trachomatous inflammation, follicular and/or intense, indicative of active trachoma. Multilevel logistic regression was used to estimate prevalence odds ratios (OR) and 95% confidence intervals (CI), adjusting for community, household and individual factors, and to evaluate modification by household latrine use and water access.In surveyed areas, prevalence of active trachoma among children was estimated to be 29% (95% CI: 28-30) and mean community sanitation usage was 47% (95% CI: 45-48). Despite significant modification (p0.0001), no pattern in stratified ORs was detected. Summarizing across strata, community sanitation usage values of 60 to 80% and ≥ 80% were associated with lower prevalence odds of active trachoma, compared with community sanitation usage of 20% (OR: 0.76; 95% CI: 0.57-1.03 and OR: 0.67; 95% CI: 0.48-0.95, respectively).In Amhara, Ethiopia, a negative correlation was observed between community sanitation usage and prevalence of active trachoma among children, highlighting the need for continued efforts to encourage higher levels of sanitation usage and to support sustained use throughout the community, not simply at the household level.Étudier dans la région Amhara, en Éthiopie, l'association entre la prévalence du trachome actif chez les enfants âgés de 1 à 9 ans et l'utilisation d'installations d'assainissement collectif.Entre 2011 et 2014, la prévalence du trachome et l'utilisation de latrines à fosse domestiques ont été mesurées dans le cadre de cinq enquêtes transversales menées auprès de la population. Les données sur les indicateurs observés concernant l'utilisation de latrines ont été regroupées dans une mesure de l'utilisation des installations d'assainissement collectif exprimée comme la proportion de ménages utilisant des latrines. Tous les membres des ménages ont fait l'objet d'un examen destiné à détecter les signes cliniques, c'est-à-dire une inflammation trachomateuse folliculaire et/ou intense, révélateurs d'un trachome actif. Une régression logistique à plusieurs niveaux a été utilisée pour estimer le rapport de cote (RC) de prévalence ainsi que les intervalles de confiance (IC) à 95%, en tenant compte de facteurs liés à la communauté, aux ménages et aux individus, et pour évaluer les variations induites par l'utilisation de latrines domestiques et un accès à l'eau.Dans les zones étudiées, la prévalence du trachome actif chez les enfants a été estimée à 29% (IC à 95%: 28–30) et l'utilisation moyenne des installations d'assainissement collectif à 47% (IC à 95%: 45–48). Malgré des variations considérables (p 0,0001), aucune tendance liée aux RC stratifiés ne s'est dégagée. Pour résumer en tenant compte des différentes strates, lorsque les valeurs relatives à l'utilisation des installations d'assainissement collectif étaient comprises entre 60 et 80% ou ≥ 80%, le rapport de cote de prévalence du trachome actif était plus faible que lorsque les valeurs relatives à l'utilisation des installations d'assainissement collectif étaient 20% (RC: 0,76; IC à 95%: 0,57–1,03 et RC: 0,67; IC à 95%: 0,48–0,95, respectivement).Dans la région Amhara de l'Éthiopie, une corrélation négative a été observée entre l'utilisation d'installations d'assainissement collectif et la prévalence du trachome actif chez les enfants, soulignant la nécessité de poursuivre les efforts pour encourager l'utilisation d'installations d'assainissement et promouvoir une utilisation durable dans l'ensemble de la population, et non seulement au niveau des ménages.Investigar, en Amhara, Etiopía, la relación entre la prevalencia del tracoma activo en niños de entre 1 y 9 años y el uso comunitario del saneamiento.Entre 2011 y 2014, se midieron la prevalencia del tracoma y el uso doméstico de las letrinas de pozo en cinco encuestas transversales basadas en la población. Los datos sobre los indicadores observados del uso de letrinas se agregaron en una medida del uso del saneamiento comunitario calculado como el porcentaje de hogares con una letrina en uso. Se examinó a todos los miembros del hogar en busca de síntomas clínicos, es decir, inflamación tracomatosa, folicular y/o intensa, indicio de tracoma activo. Se utilizó una regresión logística de varios niveles para estimar la prevalencia de los cocientes de posibilidades (CP) y los intervalos de confianza (IC) del 95%, ajustándose a factores comunitarios, domésticos e individuales, y para evaluar la modificación por uso de letrinas y acceso al agua en los hogares.En las zonas encuestadas, se estimó que la prevalencia del tracoma activo en niños era del 29% (IC del 95%: 28–30) y que el uso comunitario del saneamiento era del 47% (IC del 95%: 45–48). A pesar de una importante modificación (p0,0001), no se detectó ningún patrón en los CP estratificados. Como resumen de los estratos, los valores de uso comunitario del saneamiento del 60 al 80% y ≥ 80% se relacionaron con una menor prevalencia de tracoma activo, en comparación con un uso comunitario del saneamiento de 20% (CP: 0,76; IC del 95%: 0,57–1,03 y CP: 0,67; IC del 95%: 0,48-0,95, respectivamente).En Amhara, Etiopía, se observó una correlación negativa entre el uso comunitario del saneamiento y la prevalencia del tracoma activo en niños, destacando la necesidad de unos esfuerzos continuos por fomentar unos mayores niveles de uso del saneamiento y para respaldar el uso constante en toda la comunidad, no únicamente en los hogares.التحقيق في العلاقة بين انتشار التراخوما النشطة بين الأطفال ممن تتراوح أعمارهم من سنة إلى 9 سنوات واستخدام المرافق الصحية المجتمعية في أمهرة بإثيوبيا.تم قياس انتشار التراخوما واستخدام المرحاض الحفري المنزلي في خمسة استطلاعات رأي شملت قطاعات متعددة وقائمة على السكان في الفترة ما بين سنة 2011 و2014. وتم تجميع البيانات المتعلقة بالمؤشرات الملحوظة لاستخدام المرحاض للخروج بمقياس لمدى استخدام المرافق الصحية المجتمعية المحتسب كنسبة العوائل التي تستخدم المرحاض. وقد تم فحص جميع أفراد الأسرة بحثًا عن علامات سريرية، أي التهاب تراخومي، أو مسامي، أو حاد، أو مؤشرات تدل على الإصابة بحالة من التراخوما النشطة. وتم استخدام التحوف اللوجيستي متعدد المراحل لتقدير نسب احتمالات الانتشار (OR) ونسب أرجحية تبلغ ‏95‏% (CI)، مع تعديلها حسب العوامل المجتمعية والفردية والأسرية، وتقييم التعديل حسب استخدام العوائل للمراحيض وتوفُّر الماء لديهم.في مناطق الاستطلاع، تم تقدير انتشار التراخوما النشطة بين الأطفال بنسبة ‏29% (95‏% كمقدار لنسبة الأرجحية: 28 – 30) وتقدير متوسط استخدام المرافق الصحية المجتمعية بنسبة 47% (95% كمقدار لنسبة الأرجحية: 45–48). وبالرغم من التعديل الكبير (بمعدل احتمال0.0001)، لم يتم الكشف عن نمط معين في نسب احتمالات الانتشار المطبقة. ومن خلال تلخيص البيانات عبر الشرائح المختلفة، فقد تم ربط نسب استخدام المرافق الصحية المجتمعية التي تتراوح من 60 إلى80‏% و≤ 80‏% باحتمالات منخفضة لانتشار التراخوما، مقارنة باستخدام المرافق الصحية المجتمع بنسبة20‏% (احتمالات الانتشار: 0.76؛ 95‏% كمقدار لنسبة الأرجحية: 0.57 – 1.03 ونسبة انتشار: 0.67؛ ‏95% كمقدار لنسبة الأرجحية: 0.48 – 0.95، على التوالي).في أمهرة بإثيوبيا، لوحظ وجود ارتباط سلبي بين استخدام المرافق الصحية المجتمعية وانتشار التراخوما النشطة بين الأطفال، مع تسليط الضوء على الحاجة إلى مجهودات مستمرة لتشجيع المستويات الأعلى من استخدام المرافق الصحية، ودعم الاستخدام المستمر عبر المجتمع، وليس على مستوى الأُسرة فحسب.旨在调查埃塞俄比亚阿姆哈拉地区 1 到 9 岁儿童活动性沙眼患病率与社区卫生设施使用情况之间的联系。.2011 年至 2014 年间，五项基于人口的横断面调查对沙眼患病率和家用蹲厕使用情况进行了衡量。 我们汇总了观察到的厕所使用指标数据作为社区卫生设施使用情况的量测指标，按照使用厕所家庭的比例进行计算。 检查了所有家庭成员的临床症状，例如沙眼性炎症、滤泡性和/或严重指示性活动性沙眼。 我们采用多级逻辑回归模型估算了患病率比值比 (OR) 和 95% 置信区间 (CI)，调整了社区、家庭和个人因素，以评估通过家用厕所使用和供水情况进行的整改。.在调查地区，儿童活动性沙眼患病率估计值为 29% (95% CI: 28–30)，社区卫生设施使用率的平均值为 47% (95% CI: 45–48). 除重大调整项目 (p 0.0001) 以外，未发现分层比值比的模式。 汇总横断面数据得出，与社区卫生设施使用率低于 20% 的情况相比，社区卫生设施使用率在 60% 到 80% 之间和 80% 及以上的情况与较低的活动性沙眼患病率有关联（分别为 OR: 0.76; 95% CI: 0.57–1.03 和 OR: 0.67; 95% CI: 0.48–0.95）。.我们在埃塞俄比亚阿姆哈拉地区观察到，社区卫生设施使用率与儿童活动性沙眼患病率呈负相关，突出了需要继续努力促进更高水平的卫生设施使用率并支持在整个社会的持续使用，而不仅限于家庭层面上。.Изучить в регионе Амхара, Эфиопия, связь между распространенностью активной трахомы среди детей в возрасте 1–9 лет и общинным использованием санитарно-гигиенических удобств.В период с 2011 по 2014 год в ходе пяти поперечно-секционных обследований популяционного масштаба была изучена распространенность трахомы и использования ямного туалета домашними хозяйствами. Данные по наблюдаемым показателям использования ямных туалетов были объединены, чтобы получить масштаб общинного использования санитарно-гигиенических удобств, выраженный долей домашних хозяйств, в которых используются ямные туалеты. Все члены семей были обследованы на предмет клинических признаков, т. е. трахоматозного воспаления, фолликулярного и (или) интенсивного, указывающего на активную трахому. Многоуровневая логистическая регрессия была использована для оценки отношений шансов (ОШ) и 95%-х доверительных интервалов (ДИ) распространенности с учетом общинных, бытовых и индивидуальных факторов, а также для оценки влияния использования ямного туалета и доступа к воде в домашнем хозяйстве.В обследованных районах распространенность активной трахомы среди детей оценивалась как 29% (95%-й ДИ: 28–30) и среднее значение использования санитарии общиной составляло 47% (95%-й ДИ: 45–48). Несмотря на значительное влияние (р 0,0001), не было обнаружено никакой закономерности в стратифицированных ОШ. Подводя итог по стратам, можно отметить, что там, где показатели использования санитарно-гигиенических удобств общиной составляли от 60 до80% и ≥ 80%, наблюдалась более низкая вероятность распространенности активной трахомы по сравнению со стратой, где показатель использования санитарно-гигиенических удобств общиной составил менее 20% (ОШ: 0,76; 95%-й ДИ: 0,57–1,03 и ОШ: 0,67; 95%-й ДИ: 0,48–0,95 соответственно).В регионе Амхара, Эфиопия, наблюдалась отрицательная корреляция между общинным использованием санитарно-гигиенических удобств и распространенностью активной трахомы среди детей, что указывает на необходимость в непрекращающихся мерах по стимулированию более высокого уровня использования санитарно-гигиенических удобств и поддержке постоянного использования всей общиной, а не только на уровне домашнего хозяйства.

Supplementary information. Table S1. Estimated measures of association of household ownership of a latrine in use with prevalence of Ascaris lumbricoides infection, using conditional logistic regression and mixed regression with and without individual sampling weights. Table S2. Number of clusters (n) contributing to each stratum-specific analysis out of the total number of clusters within that stratum of community sanitation usage (N) and correlation between cluster-specific odds ratios of association of household ownership of a latrine in use with prevalence of Ascaris lumbricoides infection and respective sampling weight by strata of community sanitation usage. (DOCX 24Â kb)

Supplementary information. Table S1. Estimated measures of association of household ownership of a latrine in use with prevalence of Ascaris lumbricoides infection, using conditional logistic regression and mixed regression with and without individual sampling weights. Table S2. Number of clusters (n) contributing to each stratum-specific analysis out of the total number of clusters within that stratum of community sanitation usage (N) and correlation between cluster-specific odds ratios of association of household ownership of a latrine in use with prevalence of Ascaris lumbricoides infection and respective sampling weight by strata of community sanitation usage. (DOCX 24Â kb)

Background Globally, in 2010, approximately 1.5 billion people were infected with at least one species of soil-transmitted helminth (STH), Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale and Necator americanus). Infection occurs through ingestion or contact (hookworm) with eggs or larvae in the environment from fecal contamination. To control these infections, the World Health Organization recommends periodic mass treatment of at-risk populations with deworming drugs. Prevention of these infections typically relies on improved excreta containment and disposal. Most evidence of the relationship between sanitation and STH has focused on household-level access or usage, rather than community-level sanitation usage. We examined the association between the proportion of households in a community with latrines in use and prevalence of STH infections among school-aged children. Methods Data on STH prevalence and household latrine usage were obtained during four population-based, cross-sectional surveys conducted between 2011 and 2014 in Amhara, Ethiopia. Multilevel regression was used to estimate the association between the proportion of households in the community with latrines in use and presence of STH infection, indicated by > 0 eggs in stool samples from children 6–15 years old. Results Prevalence of STH infection was estimated as 22% (95% CI: 20–24%), 14% (95% CI: 13–16%), and 4% (95% CI: 4–5%) for hookworm, A. lumbricoides, and T. trichiura, respectively. Adjusting for individual, household, and community characteristics, hookworm prevalence was not associated with community sanitation usage. Trichuris trichuria prevalence was higher in communities with sanitation usage ≥ 60% versus sanitation usage

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.; 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.; 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.; Estimating the prevalence of trachoma through examination of only school-going children risks underestimating the true prevalence.

This study developed and validated a model for predicting the probability that communities in Amhara Region, Ethiopia, have low sanitation coverage, based on environmental and sociodemographic conditions. Community sanitation coverage was measured between 2011 and 2014 through trachoma control program evaluation surveys. Information on environmental and sociodemographic conditions was obtained from available data sources and linked with community data using a geographic information system. Logistic regression was used to identify predictors of low community sanitation coverage (< 20% versus ≥ 20%). The selected model was geographically and temporally validated. Model-predicted probabilities of low community sanitation coverage were mapped. Among 1,502 communities, 344 (22.90%) had coverage below 20%. The selected model included measures for high topsoil gravel content, an indicator for low-lying land, population density, altitude, and rainfall and had reasonable predictive discrimination (area under the curve = 0.75, 95% confidential interval = 0.72, 0.78). Measures of soil stability were strongly associated with low community sanitation coverage, controlling for community wealth, and other factors. A model using available environmental and sociodemographic data predicted low community sanitation coverage for areas across Amhara Region with fair discrimination. This approach could assist sanitation programs and trachoma control programs, scaling up or in hyperendemic areas, to target vulnerable areas with additional activities or alternate technologies.

The SAFE strategy for trachoma control includes Surgery, Antibiotic distribution, Facial cleanliness and Environmental improvements, including promotion of latrine construction. In this study, household latrine coverage was estimated in order to evaluate SAFE implementation in a district of Ethiopia where reported coverage in rural areas was 97%. Characteristics of latrine adopters and non-adopters were explored. Interviews were conducted in 442 households selected at random in a multistage cluster sample. Overall, estimated household latrine coverage was 56.2% (95% CI 37.5-74.8%) and in rural areas coverage was 67.7% (95% CI 59.6-75.7%). Previously owning a latrine was reported by 12.7% (95% CI 8.9-16.5%) of respondents, of which 32.0% (95% CI 15.9-48.2%) had built a replacement. Latrine adopters were more likely to be male (P 0.0001), to report their primary occupation as agriculture (P 0.0001), have more than five residents in their household (P = 0.004) and live in a rural area (P 0.0001). Respondents who were advised by a health extension worker (P 0.0001) or development agent (P 0.0001) were more likely to have built a latrine. Household latrine coverage has increased from the 2007 zonal estimate (8.9%), but was lower than that reported. Latrine promotion should include emphasis on rebuilding latrines. More support may be needed by small households as well as those with a female head if universal latrine access is to be achieved in Kewot.

We assessed malaria infection in relation to age, altitude, rainfall, socio-economic factors and coverage of control measures in a representative sample of 11437 people in Amhara, Oromia and SNNP regions of Ethiopia in December 2006-January 2007. Surveys were conducted in 224 randomly selected clusters of 25 households (overall sample of 27884 people in 5708 households). In 11538 blood slides examined from alternate households (83% of those eligible), malaria prevalence in people of all ages was 4.1% (95% CI 3.4-4.9), with 56.5% of infections being Plasmodium falciparum. At least one mosquito net or one long-lasting insecticidal net (LLIN) was present in 37.0% (95% CI 31.1-43.3) and 19.6% (95% CI 15.5-24.5) of households, respectively. In multivariate analysis (n=11437; 82% of those eligible), significant protective factors were: number of LLINs per household (odds ratio [OR] (per additional net)=0.60; 95% CI 0.40-0.89), living at higher altitude (OR (per 100 m)=0.95; 95% CI 0.90-1.00) and household wealth (OR (per unit increase in asset index)=0.79; 95% CI 0.66-0.94). Malaria prevalence was positively associated with peak monthly rainfall in the year before the survey (OR (per additional 10 mm rain)=1.10; 95% CI 1.03-1.18). People living above 2000 m and people of all ages are still at significant risk of malaria infection.

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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., Author Summary Trachoma, the leading cause of preventable blindness, is targeted for “elimination as a public health problem” by the year 2020. National programs are implementing the recommended strategy of surgery, antibiotics, facial cleanliness, and environmental improvements (SAFE) to meet this target. Many programs are currently facing the decision of when to scale down interventions, particularly mass drug administration (MDA) of azithromycin. We implemented large population-based surveys in two different zones of the Amhara National Regional State of Ethiopia. Rather than conducting an impact assessment first at the district level, followed by additional sub-district-level surveys, we took a novel approach to measure the prevalence of trachoma at sub-district level to be able to make an immediate decision of whether to stop MDA. Over 72,000 people in 714 communities in 72 sub-districts were examined for clinical signs of trachoma. We identified only six sub-districts that met criteria for being able to stop MDA. Our work demonstrates that determining the prevalence of trachoma at sub-district level is feasible but requires significant resources. In this hyper-endemic setting, sub-district-level surveys were not needed in the majority of districts. Overall, the clinical data suggest some decline in trachoma within these areas since the SAFE strategy was implemented.

BackgroundLarge cross-sectional household surveys are common for measuring indicators of neglected tropical disease control programs. As an alternative to standard paper-based data collection, we utilized novel paperless technology to collect data electronically from over 12,000 households in Ethiopia.MethodologyWe conducted a needs assessment to design an Android-based electronic data collection and management system. We then evaluated the system by reporting results of a pilot trial and from comparisons of two, large-scale surveys; one with traditional paper questionnaires and the other with tablet computers, including accuracy, person-time days, and costs incurred.Principle findingsThe electronic data collection system met core functions in household surveys and overcame constraints identified in the needs assessment. Pilot data recorders took 264 (standard deviation (SD) 152 sec) and 260 sec (SD 122 sec) per person registered to complete household surveys using paper and tablets, respectively (P = 0.77). Data recorders felt a lack of connection with the interviewee during the first days using electronic devices, but preferred to collect data electronically in future surveys. Electronic data collection saved time by giving results immediately, obviating the need for double data entry and cross-correcting. The proportion of identified data entry errors in disease classification did not differ between the two data collection methods. Geographic coordinates collected using the tablets were more accurate than coordinates transcribed on a paper form. Costs of the equipment required for electronic data collection was approximately the same cost incurred for data entry of questionnaires, whereas repeated use of the electronic equipment may increase cost savings.Conclusions/significanceConducting a needs assessment and pilot testing allowed the design to specifically match the functionality required for surveys. Electronic data collection using an Android-based technology was suitable for a large-scale health survey, saved time, provided more accurate geo-coordinates, and was preferred by recorders over standard paper-based questionnaires.

The WHO recommends the SAFE (surgery, antibiotics, facial cleanliness and environmental improvement) strategy for trachoma control. We aimed to investigate the association between active trachoma and community intervention with antibiotics, facial cleanliness, environmental improvement (A,F,E) components of SAFE in five trachoma hyperendemic districts of Amhara region, Ethiopia.Cluster random surveys were undertaken to evaluate SAFE following 3 years of interventions. Children aged 1-9 years were examined for trachoma signs using the WHO simplified grading system and structured questionnaires used to assess uptake of A, F and E. Active trachoma signs (trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (TI)) were used to derive an ordinal severity score where TI was considered more severe than TF. Associations between active trachoma and potential factors were investigated using ordinal logistic multilevel regression models.A total of 1813 children aged 1-9 years were included in the analysis. Factors independently associated with reduced odds of active trachoma signs were: number of times treated with azithromycin (p-trend=0.026); months since last mass azithromycin distribution (p-trend0.001); clean face (OR=0.6; 95% CI 0.5 to 0.8); and household pit latrine (OR=0.8; 95% CI 0.7 to 0.9).These findings are important, since they make the case for continued implementing the A,F,E interventions simultaneously, and suggest appropriate timing of SAFE evaluations within 6-12 months after the last mass azithromycin distribution.

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., Author Summary Part of the SAFE strategy (surgery, antibiotics, facial cleanliness, and environmental improvement) to eliminate blinding trachoma involves improving access to, and use of, water and sanitation. We combined the assessment of parasitic worm and intestinal protozoa infections with surveys of trachoma in an area of Ethiopia where the SAFE strategy, together with enhanced outreach services and the health extension program, had been implemented for more than 5 years. We compared our findings with results from a survey conducted in the mid-1990s. We documented significant increases in household access and use of latrines and clean water: the F and E components of the SAFE strategy as promoted by the health extension program. We found considerably lower levels of parasitic worm infections than those reported previously. Moreover, we documented, for the first time in this zone, pathogenic intestinal protozoa infections, which indicate poor water quality and unhygienic water collection and storage practices in the communities surveyed. A plausible hypothesis for the decline in parasitic worm infections might be the combined impact of ongoing simultaneous health programs: SAFE strategy for trachoma control alongside the health extension program and regular deworming of preschool-aged children.

BackgroundDiagnostic tests are recommended for suspected malaria cases before treatment, but comparative performance of microscopy and rapid diagnostic tests (RDTs) at rural health centers has rarely been studied compared to independent expert microscopy.MethodsParticipants (N = 1997) with presumptive malaria were recruited from ten health centers with a range of transmission intensities in Amhara Regional State, Northwest Ethiopia during October to December 2007. Microscopy and ParaScreen Pan/Pf® RDT were done immediately by health center technicians. Blood slides were re-examined later at a central laboratory by independent expert microscopists.ResultsOf 1,997 febrile patients, 475 (23.8%) were positive by expert microscopists, with 57.7% P. falciparum, 24.6% P. vivax and 17.7% mixed infections. Sensitivity of health center microscopists for any malaria species was >90% in five health centers (four of which had the highest prevalence), >70% in nine centers and 44% in one site with lowest prevalence. Specificity for health center microscopy was very good (>95%) in all centers. For ParaScreen RDT, sensitivity was ≥90% in three centers, ≥70% in six and ConclusionsHealth center microscopists performed well in nine of the ten health centers; while for ParaScreen RDT they performed well in only six centers. Overall the accuracy of local microscopy exceeded that of RDT for all outcomes. This study supports the introduction of RDTs only if accompanied by appropriate training, frequent supervision and quality control at all levels. Deficiencies in RDT use at some health centers must be rectified before universal replacement of good routine microscopy with RDTs. Maintenance and strengthening of good quality microscopy remains a priority at health center level.

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.