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Estimation of effects of community intervention with Antibiotics, Facial cleanliness, and Environmental improvement (A,F,E) in five districts of Ethiopia hyperendemic for trachoma
  1. Jeremiah Ngondi1,2,
  2. Teshome Gebre3,
  3. Estifanos B Shargie3,
  4. Liknaw Adamu4,
  5. Tesfaye Teferi3,
  6. Mulat Zerihun3,
  7. Berhan Ayele3,
  8. Jonathan D King2,
  9. Elizabeth A Cromwell2,
  10. Paul M Emerson2
  1. 1Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK
  2. 2The Carter Center, Atlanta, Georgia, USA
  3. 3The Carter Center, Woreda, Kebele, Addis Ababa, Ethiopia
  4. 4Ministry of Health, Prevention of Blindness Team, Addis Ababa, Ethiopia
  1. Correspondence to Dr Jeremiah Ngondi, Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Robinson Way, Cambridge, CB2 0SR, UK; jn250{at}


Aims 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.

Methods 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.

Results 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-trend<0.001); 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).

Conclusion 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.

  • Trachoma control
  • evaluation
  • SAFE strategy
  • Amhara
  • Ethiopia

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  • Funding Funding for this work was provided by The Carter Center Malaria and Trachoma Control Program. 1 Copenhill Avenue, Atlanta, Georgia, USA.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the Emory University Institutional Review Board (IRB no 079-2006) and the Amhara Regional Health Bureau.

  • Provenance and peer review Not commissioned; externally peer reviewed.