Targeting antibiotics to households for trachoma control.
BACKGROUND
Mass drug administration (MDA) is part of the current trachoma control strategy, but it can be costly and results in many uninfected individuals receiving treatment. Here we explore whether alternative, targeted approaches are effective antibiotic-sparing strategies.


RESULTS
We analysed data on the prevalence of ocular infection with Chlamydia trachomatis and of active trachoma disease among 4,436 individuals from two communities in The Gambia (West Africa) and two communities in Tanzania (East Africa). An age- and household-structured mathematical model of transmission was fitted to these data using maximum likelihood. The presence of active inflammatory disease as a marker of infection in a household was, in general, significantly more sensitive (between 79% [95%CI: 60%-92%] and 86% [71%-95%] across the four communities) than as a marker of infection in an individual (24% [16%-33%]-66% [56%-76%]). Model simulations, under the best fit models for each community, showed that targeting treatment to households has the potential to be as effective as and significantly more cost-effective than mass treatment when antibiotics are not donated. The cost (2007US$) per incident infection averted ranged from 1.5 to 3.1 for MDA, from 1.0 to 1.7 for household-targeted treatment assuming equivalent coverage, and from 0.4 to 1.7 if household visits increased treatment coverage to 100% in selected households. Assuming antibiotics were donated, MDA was predicted to be more cost-effective unless opportunity costs incurred by individuals collecting antibiotics were included or household visits improved treatment uptake. Limiting MDA to children was not as effective in reducing infection as the other aforementioned distribution strategies.


CONCLUSIONS
Our model suggests that targeting antibiotics to households with active trachoma has the potential to be a cost-effective trachoma control measure, but further work is required to assess if costs can be reduced and to what extent the approach can increase the treatment coverage of infected individuals compared to MDA in different settings.
Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom. isobel.blake02@imperial.ac.uk
Isobel M
IM
Blake
Matthew J
MJ
Burton
Anthony W
AW
Solomon
Sheila K
SK
West
María-Gloria
MG
Basáñez
Manoj
M
Gambhir
Robin L
RL
Bailey
David C W
DC
Mabey
Nicholas C
NC
Grassly
D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017963:Azithromycin / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D002692:Chlamydia trachomatis / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification; D003140:Communicable Disease Control / Q000191:economics / Q000379:methods*; D019353:Endemic Diseases / Q000517:prevention & control; D005191:Family Characteristics; D005260:Female; D005714:Gambia / Q000453:epidemiology; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D013636:Tanzania / Q000453:epidemiology; D014141:Trachoma / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D055815:Young Adult
D000900:Anti-Bacterial Agents; D017963:Azithromycin