Sanitation, Water, and Instruction in Face-washing for Trachoma I/II

Trachoma Clinical Trial

— SWIFT I/II  

Official title:

Sanitation, Water, and Instruction in Face-washing for Trachoma I/II

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT02754583
• Other study ID #: 14-14004
• Secondary ID: U10EY023939
• Status: Recruiting
• Phase: Phase 3
• Start date: December 5, 2015
• Est. completion date: August 31, 2025

Study information

• Verified date: August 2023
• Source: University of California, San Francisco
• Contact: Dionna M Wittberg, MPH
• Email: dionna.wittberg[@]ucsf.edu
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

SWIFT I is a series of 3 cluster-randomized trials designed to assess several alternative strategies for trachoma control in communities that have been treated with many years of mass azithromycin distributions. The first trial (named WUHA) compares communities that receive a comprehensive Water, Sanitation, and Hygiene (WASH) package to those that receive no intervention. The second trial (named TAITU-A) compares communities randomized to targeted antibiotic treatment versus those randomized to mass antibiotics for trachoma, and the third trial (TAITU-B) compares communities randomized to targeted antibiotics versus those randomized to delayed antibiotics.

SWIFT II is a continuation of the first trial (WUHA I). WUHA I is an ongoing cluster-randomized trial in rural Ethiopia designed to determine the effectiveness of water, sanitation, and hygiene (WASH) for trachoma. 40 communities were randomized in a 1:1 ratio either to a comprehensive WASH package or to no intervention. The primary outcome is ocular chlamydia, monitored annually for 3 years.

In WUHA II we will treat all 40 WUHA communities with a single mass azithromycin distribution after the month 36 visit, and then continue the WASH intervention only in the 20 communities originally randomized to the WASH arm. We perform annual monitoring visits at months 48, 60, 72, and 84 for the primary outcome of ocular chlamydia among 0-5 year old children. A second aim of WUHA II is to perform a diagnostic test accuracy study of the tests already being conducted as well as several novel tests for trachoma surveillance. The novel tests include inexpensive, point-of-care nucleic acid amplification tests performed on conjunctival swabs, a lateral flow assay for chlamydia seropositivity tested on dried blood spots, and an automated algorithm to detect clinical signs of trachoma from conjunctival photographs. The primary objective of the second aim is to test the sensitivity and specificity of each of these trachoma surveillance tests.

By comparing the combined azithromycin-WASH communities to communities receiving mass azithromycin alone, we investigate the benefit of combining the "A", "F", and "E" components of the SAFE strategy as opposed to focusing on antibiotics alone. This is an important question given the expense of WASH interventions and the limited resources of trachoma programs.

Description:

Trachoma is a blinding disease caused by ocular strains of Chlamydia trachomatis. The Carter Center and Proctor Foundation have been jointly conducting trachoma research in the Amhara region of Ethiopia for the past 10 years, through a series of clinical trials. We have found that repeated mass administration of oral azithromycin can greatly reduce the prevalence of trachoma, but mass antibiotics have been unable thus far to eliminate infection.

The World Health Organization recommends not only antibiotics for control of trachoma, but an entire SAFE strategy (Surgery for in-turned eyelids, Antibiotics, Facial hygiene promotion, and Environmental improvements such as latrines and water points). The rationale for the SAFE strategy is based on many years of observational studies on trachoma. Cross-sectional studies have found that clinically active trachoma and ocular chlamydial infection are associated with several indicators of poor hygiene, including dirty faces, face-seeking flies, long distance to water supply, and lack of household latrine. There are few randomized trials testing the impact of WASH improvements on trachoma.

In the past, the WHO has recommended targeted antibiotic treatments to those individuals with active disease, so this could be an alternative treatment strategy that would limit antibiotic use in the community and perhaps be cost-saving. However, little research has assessed targeted treatments as a strategy for trachoma elimination following repeated mass azithromycin distributions.

Our long term goal is to eliminate trachoma even in the most hyperendemic communities. This cluster-randomized clinical trial will determine the role of a comprehensive package of sanitation measures for the elimination of trachoma. We will monitor clinical disease with photography, and monitor infection with a newer chlamydial polymerase chain reaction (PCR) test (Abbott m2000) that is more sensitive than earlier generation tests, and provides quantification. We will monitor other potential health benefits of a WASH intervention and test its overall cost effectiveness. We will also assess a competing strategy for minimizing antibiotic use: that of targeted azithromycin treatments to children testing positive for ocular chlamydia. We will model the long-term cost-effectiveness of these competing strategies for trachoma control after completion of several rounds of mass azithromycin distributions.

Our monitoring has revealed a high uptake of the SWIFT I/WUHA I intervention as well as evidence of subsequent hygiene behavior changes. However, communities started out with a high burden of ocular chlamydia and preliminary data suggests that elimination will be unlikely. We therefore were granted an continuation grant (SWIFT II) to determine the long-term benefit of WASH for trachoma when combined with antibiotics, and second, to explore possibilities for low-cost, highly accurate point-of-care test for chlamydia.

With SWIFT II, we are extending the WUHA I trial by performing a single mass azithromycin distribution in all 40 communities after the final study visit (i.e., month 36), and continuing the WASH intervention in the 20 communities originally randomized to WASH. We are monitoring for ocular chlamydia via PCR of conjunctival swabs. We ask whether antibiotic distributions combined with a comprehensive, well-functioning WASH package is more likely to eliminate trachoma than antibiotics alone. We will also collect extra swabs and dried blood spots during routine monitoring visits and compare several inexpensive, commercially available NAATs and serologic tests for chlamydia. The SWIFT II trial leverages our existing SWIFT I research infrastructure and takes advantage of the fact that the intervention has already been implemented, and will have been operating for more than six years by the end of the proposed study. WASH interventions are thought to take a long time to work given their reliance on changing behavior, and thus we will increase the chances of finding an effect if one truly exists. Moreover, we will advance knowledge regarding trachoma surveillance, which has become increasingly important as the world moves towards global elimination. The results of the SWIFT II study will be of interest to the trachoma community, and regardless of the outcome will directly help trachoma programs decide how to spend their limited resources.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 340000
• Est. completion date: August 31, 2025
• Est. primary completion date: January 31, 2024
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 1 Day to 120 Years

Eligibility

Community Level

• Inclusion Criteria

• Community in a school district that is within the study area of WagHimra

• Area within each school district with a site identified for water point construction

• At least 5 rounds of mass azithromycin distributions had been performed within community

• Exclusion Criteria:

• School districts that are too difficult to reach (more than a 1-day of travel to access)

• School districts in the 2 urban regions of the study area, since urban communities have better access to water and sanitation and have less trachoma

• Refusal of village chief

Individual Level

• Inclusion Criteria:

• All residents residing within a 1.5km radius from the most promising potential water point the water point sites within the school district that were identified for the study

• Exclusion criteria

• Refusal of participant [or parent/guardian]

Related Conditions & MeSH terms

• Trachoma

Intervention

Behavioral:
• Water, sanitation, and hygiene (WASH) intervention
WASH arm: Communities will receive the water, sanitation, and hygiene (WASH) intervention including water point construction and maintenance, hygiene and sanitation education and promotion, community-based hygiene promotion workers, household wash stations, household WASH education books, household soap distribution, and a hygiene curriculum for primary schools.
• Standard of care WASH intervention
Stand of care WASH arm

Drug:
• Azithromycin
20mg/kg
• Tetracycline
Tetracycline will be administered in lieu of azithromycin if individual is under 6 months, has a known azithromycin allergy, or is severely ill.

Other:
• Control
The control group will receive no intervention during the trial. They will be enrolled in mass antibiotic treatment at the conclusion of the trial.

Locations

Country	Name	City	State
Ethiopia	The Carter Center Ethiopia	Addis Ababa

Sponsors (5)

Lead Sponsor	Collaborator
University of California, San Francisco	Amhara Public Health Institute, Emory University, National Eye Institute (NEI), The Carter Center

Country where clinical trial is conducted

Ethiopia, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Village-specific ocular chlamydia among 0-5 children over time (first trial: WUHA)	Multiple time points will be used in a mixed effects regression model of the village-specific ocular chlamydia prevalences over time in 0-5 year olds as assessed by PCR.	12, 24, 36, 48, 60, 72, 84 months
Primary	Ocular chlamydia among 8-12 year olds (second trial: TAITU-A)	Cluster-specific prevalence of ocular chlamydia among individuals aged 8-12 years, compared between the targeted azithromycin arm and the mass azithromycin arm.	24 months
Primary	Incident ocular chlamydia in 0-5 year-olds (third trial: TAITU-B)	Incidence of new ocular chlamydia infection in 0-5 year-olds, compared between the targeted azithromycin arm and the delayed mass azithromycin arm.	24 months
Primary	Trial-based cost-effectiveness of intervention (intervention costs per percent of chlamydia reduction)	The short term analysis is designed to provide insight into whether each intervention (WASH or targeted antibiotics) is effective for our primary trial outcome of reducing ocular chlamydial infection in children. The time horizon of these analyses will be the duration of each trial.	24 months for TAITU, 36 months for WUHA
Secondary	Quantitative PCR chlamydia load	The analysis is proposed to be identical to that of the ocular chlamydia outcome, except that a village-specific index of chlamydia load at baseline and at follow-up times is used instead of prevalence. The analysis is two-sided at an alpha of 0.05.; This is a prespecified secondary analysis and will be reported as such.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Follicular trachoma scores; age-stratified (0-5, 6-9, 10 and up for WUHA; 0-5, 8-12 for TAITU)	Follicular trachoma scores (using the 5 level system) will be modeled longitudinally using linear mixed effects regression. Scores are indexed by participant, grader, visit, and village. Participant and village will be modeled as random effects; grader will be modeled as a fixed effect. We will use an AR(1) correlation structure.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Inflammatory trachoma scores; age-stratified (0-5, 6-9, 10 and up for WUHA; 0-5, 8-12 for TAITU)	Inflammatory trachoma grades will be modeled in the same way as Follicular Trachoma.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Clinical trachoma improvement as measured in photography	We anticipate having the following information available. For each child in the sampling frame, we will have a binary improvement score, based on baseline and follow-up photography. We propose to conduct clustered logistic regression (taking into account the clustered nature of the design) using village assignment as the predictor. We will estimate the log odds of the treatment effect. Significance testing will be conducted at 0.05 based on Monte Carlo permutation testing.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Chlamydial load, individual level analysis	Quantitative PCR results at the individual level will be modeled using standard procedures for semi-continuous variables.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Ocular chlamydia; age-stratified (6-9, 10 and up for WUHA; 8-12 for TAITU)	Longitudinal analysis of ocular chlamydia in the age 6-9 group will be modeled at the village level. A similar analysis will consider the 10 and over segment of the population.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Nasopharyngeal pneumococcal macrolide resistance	Using standard microbiological techniques, the lab will process the swabs using media selective for Streptococcus pneumoniae, and then test for antibiotic resistance. Nasopharyngeal macrolide resistance in age 0-5 will be modeled at the village level, using treatment arm as a covariate.	12, 24, 36, 84 months
Secondary	Proportion of the population with clean faces at the village level	The proportion of the population with clean faces will be compared (at the village level) between the two groups, using ANCOVA with baseline values and treatment arm as covariates.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Childhood growth (height)	Longitudinal analysis of anthropometric measurements between the two arms will be conducted using growth curve models.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Childhood growth (weight)	Longitudinal analysis of anthropometric measurements between the two arms will be conducted using growth curve models.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Soil-transmitted helminth prevalence	The prevalence of soil transmitted helminths will be compared between the WUHA treatment arms in a linear mixed effects regression as described above for ocular chlamydia.	12, 24, 36 months
Secondary	Soil-transmitted helminth density	Quantitative soil transmitted helminth results at the individual level will be modeled using standard procedures for semi-continuous variables.	12, 24, 36 months
Secondary	Prevalence of chlamydia and other antigen positivity from serological tests	The prevalence of chlamydia antigen positivity will be compared between the treatment arms in a linear mixed effects regression as described above for ocular chlamydia.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Prevalence of stool-based antigen (diarrheal pathogens, soil transmitted helminths) positivity from serological tests	The prevalence of soil transmitted helminths will be compared between the treatment arms in a linear mixed effects regression as described above for ocular chlamydia.	12, 24, 36, 48, 60, 72, 84 months
Secondary	Intestinal microbiome from rectal sample	Intestinal microbiome from rectal sample, using 16S rRNA deep sequencing and/or next generation sequencing	24 months
Secondary	Sensitivity and specificity of detecting STH using rectal swabs	Sensitivity and specificity of detecting STH using rectal swabs with logistic mixed-effects. Bulk stool samples will be used as the gold standard.	24 months