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Summary Background Few studies have been done of patterns of treatment during mass drug administration (MDA) to control neglected tropical diseases. We used routinely collected individual-level treatment records that had been collated for the Tuangamize Minyoo Kenya Imarisha Afya (Swahili for Eradicate Worms in Kenya for Better Health [TUMIKIA]) trial, done in coastal Kenya from 2015 to 2017. In this analysis we estimate the extent of and factors associated with the same individuals not being treated over multiple rounds of MDA, which we term systematic non-treatment. Methods We linked the baseline population of the TUMIKIA trial randomly assigned to receive biannual community-wide MDA for soil-transmitted helminthiasis to longitudinal records on receipt of treatment in any of the four treatment rounds of the study. We fitted logistic regression models to estimate the association of non-treatment in a given round with non-treatment in the previous round, controlling for identified predictors of non-treatment. We also used multinomial logistic regression to identify factors associated with part or no treatment versus complete treatment. Findings 36 327 participants were included in our analysis: 16 236 children aged 2–14 years and 20 091 adults aged 15 years or older. The odds of having no treatment recorded was higher if a participant was not treated during the previous round of MDA (adjusted odds ratio [OR] 3·60, 95% CI 3·08–4·20 for children and 5·58, 5·01–6·21 for adults). For children, school attendance and rural residence reduced the odds of receiving part or no treatment, whereas odds were increased by least poor socioeconomic status and living in an urban or periurban household. Women had higher odds than men of receiving part or no treatment. However, when those with pregnancy or childbirth in the previous 2 weeks were excluded, women became more likely to receive complete treatment. Adults aged 20–25 years were the age group with the highest odds of receiving part (OR 1·41, 95% CI 1·22–1·63) or no treatment (OR 1·81, 95% CI 1·53–2·14). Interpretation Non-treatment was associated with specific sociodemographic groups and characteristics and did not occcur at random. This finding has important implications for MDA programme effectiveness, the relevance of which will intensify as disease prevalence decreases and infections become increasingly clustered. Funding Bill & Melinda Gates Foundation, Joint Global Health Trials Scheme of the Medical Research Council, UK Department for International Development, Wellcome Trust, Children's Investment Fund Foundation, and London Centre for Neglected Tropical Diseases.

Many sanitation interventions suffer from poor sustainability. Failure to maintain or replace toilet facilities risks exposing communities to environmental pathogens, yet little is known about the factors that drive sustained access beyond project life spans. Using data from a cohort of 1666 households in Kwale County, Kenya, we investigated the factors associated with changes in sanitation access between 2015 and 2017. Sanitation access is defined as access to an improved or unimproved facility within the household compound that is functional and in use. A range of contextual, psychosocial, and technological covariates were included in logistic regression models to estimate their associations with (1) the odds of sustaining sanitation access and (2) the odds of gaining sanitation access. Over two years, 28.3% households sustained sanitation access, 4.7% lost access, 17.7% gained access, and 49.2% remained without access. Factors associated with increased odds of households sustaining sanitation access included not sharing the facility and presence of a solid washable slab. Factors associated with increased odds of households gaining sanitation access included a head with at least secondary school education, level of coarse soil fragments, and higher local sanitation coverage. Results from this study can be used by sanitation programs to improve the rates of initial and sustained adoption of sanitation.

Background: Success of mass drug administration (MDA) for control of neglected tropical diseases depends on treatment coverage and patterns across rounds. There has been limited opportunity to explore these features within programmes at scale. Here we use routinely-collected individual-level treatment records collated for the TUMIKIA trial, conducted in coastal Kenya from 2015-2017, to estimate the extent of -- and factors associated with -- systematic non-treatment in the targeted population. Methods: The trial baseline population (N=36327) was linked with treatment records from four rounds of biannual community-wide MDA for soil-transmitted helminthiasis. We fit logistic regression models to estimate the association of non-treatment with treatment status during the previous round, controlling for identified predictors of non-treatment, and used multinomial logistic regression to identify factors associated with partial or no treatment versus complete treatment. Findings: Children aged 2-14 years and individuals aged 15+ years were more likely to remain untreated if they were not treated during the previous MDA. For children, school attendance and rural residence were protective against receiving partial and no treatment. Women were more likely than men to receive partial and no treatment, unless periods of pregnancy and recent childbirth were excluded; then, women more likely received complete treatment. Adults aged 20-25 years were most likely to receive partial or no treatment. Interpretation: We identified eligible populations who received incomplete treatment across multiple MDA rounds and found that this non-treatment did not occur at random. This finding has important implications for MDA programme effectiveness and will be increasingly important as prevalence reaches low levels. Funding Statement: Funding for TUMIKIA was received from the Bill & Melinda Gates Foundation, the Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, the Wellcome Trust, and the Children’s Investment Fund Foundation. This analysis was supported by the London Centre for Neglected Tropical Diseases. SK is supported by THRiVE-2, a DELTAS Africa grant # DEL-15-011 from Wellcome Trust grant # 107742/Z/15/Z and the UK government. Declaration of Interests: RMA was a non-executive director of GlaxoSmithKline during the TUMIKIA trial. GlaxoSmithKline had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. SJB is currently employed by the Bill & Melinda Gates Foundation (BMGF) but was employed by the London School of Hygiene & Tropical Medicine when TUMIKIA was designed and commenced. GlaxoSmithKline and BMGF played no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. All other authors declare no competing interests. Ethics Approval Statement: The TUMIKIA trial protocol, including measurement of treatment coverage and adherence using routine and household survey data, was approved by the Kenya Medical Research Institute and National Ethics Review Committee (SSC Number 2826) and the London School of Hygiene & Tropical Medicine (LSHTM) Ethics Committee (7177). Written informed consent was sought from the household head or adult answering the household-level questionnaire. All information and consent procedures were conducted in Kiswahili.