title: Assessment of herd protection against trachoma due to repeated mass antibiotic distributions: a cluster-randomised trial.
abstract: BACKGROUND
  Trachoma-control programmes distribute oral azithromycin to treat the ocular strains of chlamydia that cause the disease and to control infection. Theoretically, elimination of infection is feasible if untreated individuals receive an indirect protective effect from living in repeatedly treated communities, which is similar to herd protection in vaccine programmes. We assessed indirect protection against trachoma with mass azithromycin distributions.
  
  
  METHODS
  In a cluster randomised trial, 24 subkebeles (government-defined units) in Amhara, Ethiopia, were randomised, with use of a simple random sample, to distribution four times per year of single-dose oral azithromycin to children aged 1-10 years (12 subkebeles, 4764 children), or to delayed treatment until after the study (control; 12 subkebeles, 6014 children). We compared the prevalence of ocular chlamydial infection in untreated individuals 11 years and older between baseline and 12 months in the treated subkebeles, and at 12 months between the treated and control subkebeles. Health-care and laboratory personnel were blinded to study group. Analysis was intention to treat. The study is registered with clinicaltrials.gov, number NCT00322972.
  
  
  RESULTS
  At 12 months, 637 children aged 1-10 years and 561 adults and children aged 11 years and older were analysed in the children-treated group, and 618 and 550, respectively, in the control group. The mean prevalence of infection in children decreased from 48.4% (95% CI 42.9-53.9) to 3.6% (0.8-6.4) after four mass treatments. At 12 months, the mean prevalence of infection in the untreated age group (>/=11 years) was 47% (95% CI 33-57) less than baseline (p=0.002), and 35% (95% CI 1-57) less than that in untreated communities (p=0.04).
  
  
  CONCLUSIONS
  Frequent treatment of children, who are a core group for transmission of trachoma, could eventually eliminate infection from the entire community. Herd protection is offered by repeated mass antibiotic treatments, providing a strategy for elimination of a bacterial disease when an effective vaccine is unavailable.
  
  
  BACKGROUND
  National Institutes of Health.
authors.affiliation: FI Proctor Foundation, University of California, San Francisco, USA.
authors.forename: Jenafir I
authors.initials: JI
authors.lastname: House
authors.forename: Berhan
authors.initials: B
authors.lastname: Ayele
authors.forename: Travis C
authors.initials: TC
authors.lastname: Porco
authors.forename: Zhaoxia
authors.initials: Z
authors.lastname: Zhou
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Hong
authors.forename: Teshome
authors.initials: T
authors.lastname: Gebre
authors.forename: Kathryn J
authors.initials: KJ
authors.lastname: Ray
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Keenan
authors.forename: Nicole E
authors.initials: NE
authors.lastname: Stoller
authors.forename: John P
authors.initials: JP
authors.lastname: Whitcher
authors.forename: Bruce D
authors.initials: BD
authors.lastname: Gaynor
authors.forename: Paul M
authors.initials: PM
authors.lastname: Emerson
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Lietman