Community mass treatment with azithromycin for trachoma: Factors associated with change in participation of children from the first to the second round.

BACKGROUND: Mass drug administration (MDA) with azithromycin is an important part of trachoma control programs. Maintaining high participation among children is challenging. AIM: We assessed factors identifying households with a child who changed participation from the first MDA to the second MDA compared to households where all children participated at both MDAs. METHODS: Two case-control comparisons were conducted in 11 Tanzanian communities, which underwent MDA in 2008 and 2009. The first case group (n=165) was a random sample of households with a child who changed from a 2008 non-participant to a 2009 participant (delayed participant). The second case group (n=165) was a random sample of households with a child who went from a 2008 participant to a 2009 non-participant (change to non-participant). Controls (n=330) were a random sample of households where all children participated in both rounds. Risk factors were assessed using questionnaires asked of children's guardians. Logistic models with a random-intercept were used to estimate odds ratios and 95% confidence intervals. RESULTS: Households with delayed participation were more likely to be in communities with fewer treatment days (OR=2.98, 95% CI=1.80-4.92) and assigned to Community Treatment Assistants (CTA) with a wide area to cover (OR=1.88, 95% CI=1.09-3.23). Households with change to non-participation were more likely to live further from the distribution site (OR=3.17, 95% CI=1.19-8.46), have the guardian born outside the village with short-term residency (OR=2.64, 95% CI=1.32-5.31), and be assigned to a male CTA (OR=1.75, 95% CI=1.08-2.83). CONCLUSIONS: Factors related to program accessibility were associated with delayed participation and maintaining participation.

Azithromycin mass treatment for trachoma control: risk factors for non-participation of children in two treatment rounds.

BACKGROUND: Persistent non-participation of children in mass drug administration (MDAs) for trachoma may reduce program impact. Risk factors that identify families where participation is a problem or program characteristics that foster non-participation are poorly understood. We examined risk factors for households with at least one child who did not participate in two MDAs compared to households where all children participated in both MDAs. METHODS/PRINCIPAL FINDINGS: We conducted a case control study in 28 Tanzanian communities. Cases included all 152 households with at least one child who did not participate in the 2008 and 2009 MDAs with azithromycin. Controls consisted of a random sample of 460 households where all children participated in both MDAs. A questionnaire was asked of all families. Random-intercept logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs), control for clustering, and adjust for community size. In total, 140 case households and 452 control households were included in the analyses. Compared to controls, guardians in case households had higher odds of reporting excellent health (OR 4.12 (CI 95% 1.57-10.86)), reporting a burden due to family health (OR 3.15 (95% CI 1.35-7.35)), reduced ability to rely on others for assistance (OR 1.66 (95% CI 1.01-2.75)), being in a two (versus five) days distribution program (OR 3.31 (95% CI 1.68-6.50)) and living in a community with < 2 community treatment assistants (CTAs)/1000 residents (OR 2.07 (95% CI 1.04-4.12). Furthermore, case households were more likely to have more children, younger guardians, unfamiliarity with CTAs, and CTAs with more travel time to their assigned households (p-values < 0.05). CONCLUSIONS/SIGNIFICANCE: Compared to full participation households, households with persistent non-participation had a higher burden of familial responsibility and seemed less connected in the community. Additional distribution days and lessening CTAs' travel time to their furthest assigned households may prevent non-participation.

Mass treatment with azithromycin for trachoma control: participation clusters in households.

BACKGROUND: Mass treatment to trachoma endemic communities is a critical part of the World Health Organization SAFE strategy. However, non-participation may not be at random, affecting coverage surveys and effectiveness if infection is differential. METHODOLOGY/PRINCIPAL FINDINGS: As part of the Partnership for Rapid Elimination of Trachoma (PRET), 32 communities in Tanzania, and 48 in The Gambia had a detailed census taken followed by mass treatment with azithromycin. The target coverage in each community was >80% of children ages <10 years. Community treatment assistants observed treatment and recorded compliance, thus coverage at the community, household, and individual level could be determined. Within each community, we determined the actual proportions of households where all, some, or none of the children were treated. Assuming the coverage in children <10 years of the community was as observed and non-participation was at random, we did 500 simulations to derive expected proportions of households where all, some, or none of the children were treated. Clustering of household treatment was detected comparing greater-than-expected proportions of households where none or all of children were treated, and the intraclass correlation (ICC) was calculated. Tanzanian and Gambian mass treatment coverages for children <10 years of age ranged from 82-100% and 62-99%, respectively. Clustering of households where all children were treated or no children were treated was greater than expected. Compared to model simulations, all Tanzanian communities and 44 of 48 (91.7%) Gambian communities had significantly higher proportions of households where all children were treated. Furthermore, 30 of 32 (93.8%) Tanzanian communities and 34 of 48 (70.8%) Gambian communities had a significantly elevated proportion of households compared to the expected proportion where no children were treated. The ICC for Tanzania was 0.77 (95% CI 0.74-0.81) and for The Gambia was 0.55 (95% CI 0.51-0.59). CONCLUSIONS/SIGNIFICANCE: In programs aiming for high coverage, complete compliance or non-compliance with mass treatment clusters within households. Non-compliance cannot be assumed to be at random.