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Aragie S, Tadesse W, Dagnew A, Hailu D, Dubie M, Wittberg DM, Melo JS, Haile M, Zeru T, Freeman MC, Nash SD, Callahan EK, Tadesse Z, Arnold BF, Porco TC, Lietman TM, Keenan JD. Changing hygiene behaviours: a cluster-randomized trial, Ethiopia. Bull World Health Organ 2021; 99:762-772A. [PMID: 34737469 PMCID: PMC8542271 DOI: 10.2471/blt.21.285915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether a water, sanitation and hygiene intervention could change hygiene behaviours thought to be important for trachoma control. METHODS We conducted a cluster-randomized trial in rural Ethiopia from 9 November 2015 to 5 March 2019. We randomized 20 clusters to an intervention consisting of water and sanitation infrastructure and hygiene promotion and 20 clusters to no intervention. All intervention clusters received a primary-school hygiene curriculum, community water point, household wash station, household soap and home visits from hygiene promotion workers. We assessed intervention fidelity through annual household surveys. FINDINGS Over the 3 years, more wash stations, soap and latrines were seen at households in the intervention clusters than the control clusters: risk difference 47 percentage points (95% confidence interval, CI: 41-53) for wash stations, 18 percentage points (95% CI: 12-24) for soap and 12 percentage points (95% CI: 5-19) for latrines. A greater proportion of people in intervention clusters reported washing their faces with soap (e.g. risk difference 21 percentage points; 95% CI: 15-27 for 0-5 year-old children) and using a latrine (e.g. risk difference 9 percentage points; 95% CI: 2-15 for 6-9 year-old children). Differences between the intervention and control arms were not statistically significant for many indicators until the programme had been implemented for at least a year; they did not decline during later study visits. CONCLUSION The community- and school-based intervention was associated with improved hygiene access and behaviours, although changes in behaviour were slow and required several years of the intervention.
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Affiliation(s)
| | | | - Adane Dagnew
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | | | - Melese Dubie
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | - Dionna M Wittberg
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Jason S Melo
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | | | - Taye Zeru
- Amhara Public Health Institute, Bahir Dar, Ethiopia
| | | | | | | | | | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Travis C Porco
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
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Melo JS, Aragie S, Chernet A, Tadesse Z, Dagnew A, Hailu D, Haile M, Zeru T, Wittberg DM, Nash SD, Callahan EK, Arnold BF, Porco TC, Lietman TM, Keenan JD. Targeted Antibiotics for Trachoma: A Cluster-Randomized Trial. Clin Infect Dis 2021; 73:979-986. [PMID: 33674869 DOI: 10.1093/cid/ciab193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current guidelines recommend community-wide mass azithromycin for trachoma, but a targeted treatment strategy could reduce the volume of antibiotics required. METHODS In total, 48 Ethiopian communities were randomized to mass, targeted, or delayed azithromycin distributions. In the targeted arm, only children aged 6 months to 5 years with evidence of ocular chlamydia received azithromycin, distributed thrice over the following year. The primary outcome was ocular chlamydia at months 12 and 24, comparing the targeted and delayed arms (0-5 year-olds, superiority analysis) and the targeted and mass azithromycin arms (8-12 year-olds, noninferiority analysis, 10% noninferiority margin). RESULTS At baseline, the mean prevalence of ocular chlamydia in the 3 arms ranged from 7% to 9% among 0-5 year-olds and from 3% to 9% among 8-12 year-olds. Averaged across months 12-24, the mean prevalence of ocular chlamydia among 0-5 year-olds was 16.7% (95% confidence interval [CI]: 9.0%-24.4%) in the targeted arm and 22.3% (95% CI: 11.1%-33.6%) in the delayed arm (P = .61). The final mean prevalence of ocular chlamydia among 8-12 year-olds was 13.5% (95% CI: 7.9%-19.1%) in the targeted arm and 5.5% (95% CI: 0.3%-10.7%) in the mass treatment arm (adjusted risk difference 8.5 percentage points [pp] higher in the targeted arm, 95% CI: 0.9 pp-16.1 pp higher). CONCLUSIONS Antibiotic treatments targeted to infected preschool children did not result in significantly less ocular chlamydia infections compared with untreated communities and did not meet noninferiority criteria relative to mass azithromycin distributions. Targeted approaches may require treatment of a broader segment of the population in areas with hyperendemic trachoma.
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Affiliation(s)
- Jason S Melo
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | | | | | | | - Adane Dagnew
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | | | | | - Tàye Zeru
- Amhara Public Health Institute, Bahir Dar, Ethiopia
| | - Dionna M Wittberg
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | | | | | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Institute for Global Health, University of California San Francisco, San Francisco, California, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
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Gwyn S, Aragie S, Wittberg DM, Melo JS, Dagnew A, Hailu D, Tadesse Z, Haile M, Zeru T, Nash SD, Arnold BF, Martin DL, Keenan JD. Precision of Serologic Testing from Dried Blood Spots Using a Multiplex Bead Assay. Am J Trop Med Hyg 2021; 105:822-827. [PMID: 34255738 DOI: 10.4269/ajtmh.21-0140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/16/2021] [Indexed: 11/07/2022] Open
Abstract
Multiplex bead assays (MBAs) for serologic testing have become more prevalent in public health surveys, but few studies have assessed their test performance. As part of a trachoma study conducted in a rural part of Ethiopia in 2016, dried blood spots (DBS) were collected from a random sample of 393 children aged 0 to 9 years, with at least two separate 6-mm DBS collected on a filter card. Samples eluted from DBS were processed using an MBA on the Luminex platform for antibodies against 13 antigens of nine infectious organisms: Chlamydia trachomatis, Vibrio cholera, enterotoxigenic Escherichia coli, Cryptosporidium parvum, Entamoeba histolytica, Camplyobacter jejuni, Salmonella typhimurium Group B, Salmonella enteritidis Group D, and Giardia lamblia. Two separate DBS from each child were processed. The first DBS was run a single time, with the MBA set to read 100 beads per well. The second DBS was run twice, first at 100 beads per well and then at 50 beads per well. Results were expressed as the median fluorescence intensity minus background (MFI-BG), and classified as seropositive or seronegative according to external standards. Agreement between the three runs was high, with intraclass correlation coefficients of > 0.85 for the two Salmonella antibody responses and > 0.95 for the other 11 antibody responses. Agreement was also high for the dichotomous seropositivity indicators, with Cohen's kappa statistics exceeding 0.87 for each antibody assay. These results suggest that serologic testing on the Luminex platform had strong test performance characteristics for analyzing antibodies using DBS.
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Affiliation(s)
- Sarah Gwyn
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Dionna M Wittberg
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Jason S Melo
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Adane Dagnew
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | | | | | | | - Taye Zeru
- Amhara Regional Health Bureau, Bahir Dar, Ethiopia
| | | | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Diana L Martin
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, California
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Aiemjoy K, Aragie S, Gebresillasie S, Fry DM, Dagnew A, Hailu D, Chanyalew M, Tadesse Z, Stewart A, Callahan K, Freeman M, Neuhaus J, Arnold BF, Keenan JD. Defining Diarrhea: A Population-Based Validation Study of Caregiver-Reported Stool Consistency in the Amhara Region of Ethiopia. Am J Trop Med Hyg 2018; 98:1013-1020. [PMID: 29488457 PMCID: PMC5928832 DOI: 10.4269/ajtmh.17-0806] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Diarrhea is a leading cause of death among children aged less than five years globally. Most studies of pediatric diarrhea rely on caregiver-reported stool consistency and frequency to define the disease. Research on the validity of caregiver-reported diarrhea is sparse. We collected stool samples from 2,398 children participating in two clinical trials in the Amhara region of Ethiopia. The consistency of each stool sample was graded by the child's caregiver and two trained laboratory technicians according to an illustrated stool consistency scale. We assessed the reliability of graded stool consistency among the technicians, and then compared the caregiver's grade with the technician's grade. We also tested if the illustrated stool consistency scale could improve the validity of caregiver's report. The weighted kappa measuring the agreement between the two laboratory technicians reached 0.90 after 500 stool samples were graded. The sensitivity of caregiver-reported loose or watery stool was 15.5% (95% confidence interval [CI]: 9.7, 24.2) and the specificity was 98.4% (95% CI 97.1, 99.1). With the illustrated scale, the sensitivity was 68.5% (95% CI: 58.5, 77.1) and the specificity was 86.1% (95% CI: 79.3, 90.9). The results indicate that caregiver-reported stool consistency using the terms "loose or watery" does not accurately describe stool consistency as graded by trained laboratory technicians. Given the predominance of using caregiver-reported stool consistency to define diarrheal disease, the low sensitivity identified in this study suggests that the burden of diarrheal disease may be underestimated and intervention effects could be biased. The illustrated scale is a potential low-lost tool to improve the validity of caregiver-reported stool consistency.
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Affiliation(s)
- Kristen Aiemjoy
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | | | | | - Dionna M Fry
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Adane Dagnew
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | | | | | | | | | | | - Mathew Freeman
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - John Neuhaus
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Benjamin F Arnold
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
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