Population-based coverage survey results following the mass drug administration of azithromycin for the treatment of trachoma in Amhara, Ethiopia

Background: Trachoma is the leading infectious cause of blindness worldwide. In communities where the district level prevalence of trachomatous inflammation-follicular among children ages 1–9 years is ≥5%, WHO recommends annual mass drug administration (MDA) of antibiotics with the aim of at least 80% coverage. Population-based post-MDA coverage surveys are essential to understand the effectiveness of MDA programs, yet published reports from trachoma programs are rare. Methods: In the Amhara region of Ethiopia, a population-based MDA coverage survey was conducted 3 weeks following the 2016 MDA to estimate the zonal prevalence of self-reported drug coverage in all 10 administrative zones. Survey households were selected using a multi-stage cluster random sampling design and all individuals in selected households were presented with a drug sample and asked about taking the drug during the campaign. Zonal estimates were weighted and confidence intervals were calculated using survey procedures. Self-reported drug coverage was then compared with regional reported administrative coverage. Results: Region-wide, 24,248 individuals were enumerated, of which, 20,942 (86.4%) individuals were present. The regional self-reported antibiotic coverage was 76.8% (95%Confidence Interval (CI):69.3–82.9%) in the population overall and 77.4% (95%CI = 65.7–85.9%) among children ages 1–9 years old. Zonal coverage ranged from 67.8% to 90.2%. Five out of 10 zones achieved a coverage >80%. In all zones, the reported administrative coverage was greater than 90% and was considerably higher than self-reported MDA coverage. Main reasons reported for MDA campaign non-attendance included being physically unable to get to MDA site (22.5%), traveling (20.6%), and not knowing about the campaign (21.0%). MDA refusal was low (2.8%) in this population. Conclusions: Although self-reported MDA coverage in Amhara was greater than 80% in some zones, programmatic improvements are warranted throughout Amhara to achieve higher coverage. These results will be used to enhance community mobilization and improve training for MDA distributors and supervisors to improve coverage in future MDAs. Author summary: Mass drug administration (MDA) with antibiotics is a key component of the trachoma control strategy. The World Health Organization (WHO) recommends that at least 80% of the target population should be reached with MDA. Drug coverage estimates from population-based surveys may increase our understanding of factors affecting the effectiveness of MDA. We conducted a region-wide population-based survey to estimate the prevalence of self-reported drug coverage in all ten administrative zones of Amhara region, an area with a population of approximately 21 million people. The self-reported drug coverage was greater than 80% in five of the ten zones and was 76.8% region-wide. Zonal administrative coverage reports were greater than 90% and were considerably higher than self-reported coverage in all zones. The discrepancy between administrative and self-report coverages also suggest that efforts should be made to better understand the reasons for the disparity in the two measures. The main reasons reported for not attending the MDA included being physically unable to get to the distribution site, traveling during the campaign, and lack of knowledge about the campaign. These findings suggest that making the distribution site accessible to all individuals, informing constituents about timing of the campaign to allow for travel, and providing adequate information about the campaign would improve MDA participation.