Latrine Promotion for Trachoma: Assessment of Mortality from a Cluster-Randomized Trial in Ethiopia

Teshome Gebre Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Berhan Ayele Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Mulat Zerihun Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Jenafir I. House Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Nicole E. Stoller Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Zhaoxia Zhou Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Kathryn J. Ray Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Bruce D. Gaynor Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Travis C. Porco Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Paul M. Emerson Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Thomas M. Lietman Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Jeremy D. Keenan Carter Center Ethiopia, Addis Ababa, Ethiopia; F.I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, California; Carter Center, Atlanta, Georgia

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Trachoma control strategies, including latrine construction and antibiotic distribution, are directed at reducing ocular chlamydia, but may have additional benefits. In a cluster-randomized clinical trial, 24 subkebeles (administrative geographic units) in Ethiopia were offered a single mass azithromycin treatment, and half were randomized to receive an intensive latrine promotion. At a follow-up census 26 months after the baseline treatment, 320 persons had died. The mortality rate of children 1–5 years of age was 3.87 (95% confidence interval [CI] = 2.19–6.82) per 1,000 person-years in the latrine promotion arm, and 2.72 (95% CI = 1.37–5.42) per 1,000 person-years in the control arm. In a multi-level mixed effects logistic regression model controlling for age, there was no difference in mortality in persons randomized into the latrine or control arms (odds ratio = 1.18, 95% CI = 0.89–1.58). Latrine promotion provided no additional effect on mortality in the context of an azithromycin distribution program (clinicaltrials.gov, #NCT00322972).

Author Notes

*Address correspondence to Jeremy D. Keenan, F. I. Proctor Foundation, University of California, San Francisco, 513 Parnassus Avenue, Room S309, San Francisco, CA 94143-0412. E-mail: jeremy.keenan@ucsf.edu

Financial support: The study was supported by the National Institutes of Health (NEI U10 EY016214, K23 EY019071, and NCRR/OD UCSF-CTSI KL2 RR024130), the Bernard Osher Foundation, That Man May See, the Bodri Foundation, the Harper Inglis Trust, the South Asia Research Fund, and Research to Prevent Blindness.

Disclosures: None of the authors has any conflicts of interest.

Authors' addresses: Teshome Gebre, Berhan Ayele, and Mulat Zerihun, The Carter Center-Ethiopia Bole K.K., Kebele 05, Addis Ababa, Ethiopia, E-mails: teshumanga2002@yahoo.com, berhanayele@yahoo.com, and mzerihun2003@yahoo.com. Jenafir I. House, Nicole E. Stoller, Zhaoxia Zhou, Kathryn J. Ray, F.I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, E-mails: jenafirh@yahoo.com, nicole.stoller@ucsf.edu, zhaoxia.zhou@ucsf.edu, and kathryn.ray@ucsf.edu. Paul M. Emerson, Carter Center, Atlanta, GA, E-mail: paul.emerson@emory.edu. Bruce D. Gaynor and Jeremy D. Keenan, F. I. Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, E-mails: bruce.gaynor@ucsf.edu and jeremy.keenan@ucsf.edu. Travis C. Porco, F. I. Proctor Foundation, Department of Ophthalmology, and Department of Epidemiology and Biostatistics, E-mail: travis.porco@ucsf.edu. Thomas M. Lietman, F. I. Proctor Foundation, Department of Ophthalmology, Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco, San Francisco, CA. E-mail: tom.lietman@ucsf.edu.

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