Sanitation, Water, and Instruction in Face-washing for Trachoma I/II
Phase: PHASE3
Conditions: Trachoma
Sponsor: University of California, San Francisco

Sanitation, Water, and Instruction in
Face-washing for Trachoma II
(SWIFT II)
MANUAL OF PROCEDURES
Francis I Proctor Foundation, University of California, San Francisco
The Carter Center
Amhara Public Health Institute
Emory University
Funder: NIH (UG1 EY023939)
clinicaltrials.gov (NCT02754583)
Version 1.1
March 4, 2022

Investigators:
Zerihun Tadesse2
Solomon Aragie2
Dionna M. Wittberg1
Jason Melo1
Scott Nash2
E. Kelly Callahan2
Paul M. Emerson3
Wondimu Gebeyehu4
Matthew C. Freeman5
Diana Martin6
Vicky Cevallos1
Catherine Oldenburg1
Thuy Doan1
Travis C. Porco1
Thomas M. Lietman1
Jeremy D. Keenan*1
*Principal Investigator
1Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
2The Carter Center, Atlanta, Georgia | Ethiopia
3International Trachoma Initiative, Decatur, Georgia
4Amhara Public Health Institute, Bahir Dar, Ethiopia
5Emory University, Atlanta, Georgia
6Centers for Disease Control and Prevention, Atlanta, Georgia
1

Table of Contents
1
Introduction
6
1.1
Speciﬁc Aims
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
1.2
Study Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
1.3
Research Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
2
Background and Rationale
10
3
Administrative Information
13
3.1
Trial Registry
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
3.2
Funding
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
3.3
Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
4
Research Design
27
4.1
Study Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
4.2
Eligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28
4.3
Randomization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29
5
Study Interventions
31
5.1
Mass azithromycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
5.2
WASH Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
2

6
Intervention Monitoring
36
6.1
Spot Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36
6.2
Household survey at annual census . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
6.3
Focus Group Discussions
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38
6.4
Structured observation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38
7
Census
40
7.1
Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
7.2
Mobile Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
7.3
Charging Devices
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
7.4
Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
7.5
Training and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
7.6
Census monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
8
Annual Monitoring Visits
43
8.1
Sampling Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43
8.2
Preparation
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44
8.3
Training
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
8.4
Exam Team
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
8.5
Registration Station . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
8.6
Swab Station . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
8.7
Anthropometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
53
8.8
Dried Blood Spots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
60
9
Data Collection, Management, and Quality Assurance
63
9.1
Data Collection Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
63
9.2
Data Consistency and Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65
3

9.3
Data Model
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65
9.4
Data Collection
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66
9.5
Costing data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
68
9.6
Data Security and Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
9.7
Sample Organization and Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
10 Outcome Assessment and Laboratory Procedures
70
10.1 Photograph Reading Center Overview
. . . . . . . . . . . . . . . . . . . . . . . . . . .
70
10.2 Chlamydia trachomatis sample processing
. . . . . . . . . . . . . . . . . . . . . . . . .
72
10.3 Macrolide resistance testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
75
10.4 Dried blood spot sample processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76
11 Treatment
77
11.1 Mass albendazole distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77
11.2 Mass azithromycin distribution (MDA) . . . . . . . . . . . . . . . . . . . . . . . . . . .
77
11.3 Adherence to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
78
11.4 Adverse Outcomes and Patient Death
. . . . . . . . . . . . . . . . . . . . . . . . . . .
78
11.5 Study Medication Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80
11.6 Dosage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80
11.7 Alternate Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
81
11.8 Treatment/Monitoring Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
81
11.9 Medication Procurement/Donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
81
11.10Study Medication Storage and Accountability
. . . . . . . . . . . . . . . . . . . . . . .
81
11.11Medication Quality Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82
11.12Checking Antibiotic Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82
12 Clinic-Based Case Finding
83
4

13 Costing
84
13.1 Assessment of costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84
13.2 Assessment of eﬀectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
85
13.3 Distribution of CEA analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
86
14 Protection of Human Subjects
87
14.1 Internal Review Board Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
87
14.2 Informed Consent
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
87
14.3 Adequacy of Protection Against Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . .
88
14.4 Inclusion of Pregnant Women and Children . . . . . . . . . . . . . . . . . . . . . . . . .
89
14.5 Compensation to Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
89
15 Data and Safety Monitoring
90
15.1 Primary Responsibilities of the DSMC
. . . . . . . . . . . . . . . . . . . . . . . . . . .
90
15.2 DSMC Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
91
15.3 Conﬂicts of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
91
15.4 Timing and Purpose of the DSMC Meetings . . . . . . . . . . . . . . . . . . . . . . . .
91
15.5 Procedures to Ensure Conﬁdentiality and Proper Communication . . . . . . . . . . . . .
92
15.6 Closed Sessions
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
92
15.7 Open Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
92
15.8 Progress Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
92
15.9 Minutes of the DSMC Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
93
15.10Recommendations to the Executive Committee (EC) . . . . . . . . . . . . . . . . . . . .
93
Appendix A Revision History
99
Appendix B WASH Book
100
5

Chapter 1
Introduction
Trachoma is among the most realistic candidate diseases for elimination. Trachoma has already been
eliminated in almost all industrialized countries, likely because of economic development with subsequent
improvements in hygiene and sanitation. Elimination is increasingly possible in less developed settings
as well, given the availability of donated azithromycin for mass distributions. Azithromycin is extremely
eﬀective at clearing the ocular strains of chlamydia that cause trachoma, and mass distributions greatly
reduce the community burden of infection.
Trachoma elimination may only be possible if antibiotics are combined with water, sanitation, and
hygiene (WASH) improvements. While mass azithromycin distributions are undoubtedly eﬀective, an-
tibiotics alone may be insuﬃcient for elimination. The WHO recommends 3-5 annual rounds of mass
azithromycin, but some hyperendemic settings have been receiving annual treatments for over a decade
and still have not eliminated trachoma. Re-infection commonly occurs after azithromycin treatments in
these settings, suggesting that transmission has not been interrupted. Transmission occurs from direct
contact of ocular secretions, classically through “ﬁngers, ﬂies, and fomites.” Eliminating these trans-
mission pathways is thought to require changes to hygiene behaviors as well as improvements to the
community’s water and sanitation infrastructure. Yet given the long duration of chlamydial infections,
it is unlikely that WASH interventions by themselves will lead to rapid elimination. The key may be
to combine antibiotic distributions with WASH improvements. This is the crux of the WHO’s SAFE
strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvements), but few interventional
studies have ever tested this hypothesis.
An ongoing randomized trial is currently testing the eﬃcacy of WASH for trachoma in the absence
of antibiotics. Aim I of the Sanitation, Water, and Instruction in Face-washing for Trachoma (SWIFT
I) (NCT02754583, Keenan PI) is a cluster-randomized trial being conducted in the Amhara region of
Ethiopia in which 20 clusters have been randomized to a WASH intervention and 20 clusters to no WASH
intervention. Aim I of SWIFT is commonly called WASH Upgrades for Health in Amhara I (WUHA I).
The intervention consists of a community water point and hygiene promotion workers, household wash
stations, soap distributions, and WASH manual, and a school WASH curriculum. Clusters had received
8 rounds of annual mass azithromycin distributions before the start of the study, but no antibiotics are
being distributed during the trial. Preliminary results suggest that elimination will not occur by the ﬁnal
6

time-point (January 2019).
Our long-term goal is to eliminate trachoma even in the most hyperendemic communities. Doing so
will require investigation of the best interventions for elimination as well as the optimal methods for
surveillance once elimination has been achieved. With SWIFT II, we test whether the combination of
antibiotics and WASH improvements will be more eﬀective than antibiotics alone, and also perform a
diagnostic accuracy study of several low-cost tests for ocular chlamydia. We propose to extend our ongo-
ing cluster-randomized trial by continuing our WASH intervention, performing annual mass azithromycin
distributions, and following communities for an additional three years. The primary outcome will be
chlamydial infection with a quantitative PCR test performed in a reference laboratory, but we will also
assess for trachoma with chlamydia serology from dried blood spots, low-cost conventional and quantita-
tive PCR and LAMP tests performed in the ﬁeld, and conjunctival photographs. Our central hypothesis
is that combining a comprehensive WASH package with antibiotic distributions will be more likely to lead
to elimination than antibiotics alone.
1.1
Speciﬁc Aims
Speciﬁc Aim 1: To determine the beneﬁt of WASH for trachoma control, when used in conjunction
with mass antibiotic distributions.
• Hypothesis: The prevalence of ocular chlamydia will be more likely in communities randomized
to WASH plus mass azithromycin compared to communities receiving antibiotics alone.
Speciﬁc Aim 2: To compare the diagnostic accuracy of inexpensive point-of-care trachoma tests.
• Hypothesis: A point-of-care PCR system will be more sensitive and speciﬁc than the current
standard of conjunctival grading for follicular trachoma.
This proposal presents an opportunity to leverage our existing WASH intervention and study infrastruc-
ture to assess what has long been dogma among trachoma experts: that elimination will occur only by
combining antibiotics, facial cleanliness, and environmental improvements. Furthermore, we take ad-
vantage of the monitoring in the trial to compare several novel tests that could be used by trachoma
programs to inexpensively yet accurately monitor the impact of their interventions. The knowledge gen-
erated should directly impact trachoma programs as they decide how to spend their limited resources to
eliminate blinding trachoma.
7

1.2
Study Outcomes
1.2.1
Primary Outcomes
Primary outcome: The primary outcome for SWIFT II is the same as SWIFT I: ocular chlamydia as
assessed by PCR, measured in a population-based sample of 0-5 year-old children at each study visit. In
this study, 0-5 year old children can be taken to mean 1 day-old children to 5 year-old children. We chose
the pre-school age group because previous studies have found the highest prevalence of both clinically
active trachoma and ocular chlamydia, and the highest chlamydial loads, in children 5 years and under.1–4
We use the exact same procedures that we have used in three previous clinical trials in Ethiopia; we are
experienced with these methods and also in training local staﬀto perform the methods. Note that we had
originally designated both ocular chlamydia and the clinical signs of trachoma as co-primary outcomes
of SWIFT I since they are both crucial when considering trachoma elimination. However, the trial’s
DSMC recommended selecting the infection outcome as a sole primary outcome since ocular chlamydia
is the underlying cause of trachoma, and the WASH interventions are intended speciﬁcally to interrupt
the transmission of chlamydial infection. We follow their recommendation for SWIFT II as well.
1.2.2
Secondary Outcomes
The secondary outcomes of most interest are the clinical signs of trachoma on photography and the in-
fectious load of chlamydia among those infected with ocular chlamydia. Clinical trachoma is an essential
outcome because conjunctival inﬂammation is the ultimate cause of scarring and blindness. Moreover,
clinical trachoma and ocular chlamydia infection complement each other in terms of their population
dynamics: clinical trachoma provides a relatively stable, slow-changing metric of trachoma, whereas
ocular chlamydia responds more quickly to interventions but is also more subject to random variation.
Chlamydial load is important because Individuals with higher loads are thought to be much more likely
to transmit infection.5 We will collect data on several other secondary outcomes in children aged 0-5
years, including nasopharyngeal pneumococcal macrolide resistance, anthropometry, and the presence
of a clean face on photography. We will perform similar assessments of ocular chlamydia and clinical
trachoma in a sample of children aged 6-9 years and a sample of individuals aged 10 years, and sim-
ilar assessments of facial cleanliness in the 6-9 year-old age group. We are monitoring for macrolide
resistance in nasopharyngeal pneumococcus because azithromycin treatments may select for antibiotic
resistance and because of the possibility that improved hygiene will have an added beneﬁt of reducing the
carriage of nasopharyngeal pneumococcus. We are monitoring anthropometry because of the possibility
that improved hygiene will result in accelerated growth in pre-school children. Our group has measured
both nasopharyngeal macrolide resistance and anthropometry in previous trials in Ethiopia.6–8 Another
important secondary outcome is improvement in conjunctival inﬂammation as assessed from serial con-
junctival photographs, measured in a longitudinal cohort of children aged 0-5 years at baseline.
8

1.3
Research Plan
We are extending our ongoing cluster-randomized trial (SWIFT I) by performing a mass azithromycin
distribution after the ﬁnal study visit and following communities for an additional four years. Forty com-
munities that had received 8 rounds of mass azithromycin distributions were randomized in a 1:1 ratio
to the WASH arm or a control arm in WUHA I (randomization performed January 2016). The WASH
package includes a community water point, community-based hygiene promotion workers, household
wash stations, household WASH education books, household soap distribution, and a hygiene curriculum
for primary schools. Annual monitoring visits are conducted in each community, with the ﬁnal WUHA I
3-year study visit taking place in February 2019. For WUHA II, the primary outcome is ocular chlamydia
infection among 0-5 year-old children at months 48, 60, 72, and 84. A secondary outcome is the load
of ocular chlamydia among infected children, assessed at the same time points. It is worth noting that
the WUHA II design is not dependent on the results of WUHA I. If the WASH intervention is found to
be eﬀective in WUHA I, then WUHA II will determine whether trachoma elimination is possible when
combining WASH with mass antibiotics. If we fail to ﬁnd a signiﬁcant beneﬁt of WASH in WUHA I,
then WUHA II will provide longer follow-up to allow the behavior changes in the WASH arm to take eﬀect.
We will continue the intervention in the 20 clusters of households that have already received the in-
tervention as part of SWIFT I. We will continue to monitor chlamydial infection among the 20 WASH
intervention and 20 delayed WASH intervention clusters from the SWIFT I trial. The primary outcome
will still be chlamydial infection with a quantitative PCR test performed in a laboratory, but we will also
assess for trachoma with chlamydia serology from dried blood spots, low-cost conventional and quantita-
tive PCR and LAMP tests performed in the ﬁeld, and conjunctival photographs. Our central hypothesis
is that combining a comprehensive WASH package with antibiotic distributions will be more likely to lead
to elimination than antibiotics alone. We also hypothesize that the diagnostic accuracy of inexpensive
point-of-care trachoma tests will be more sensitive and speciﬁc than the current standard of conjunctival
grading for follicular trachoma.
9

Chapter 2
Background and Rationale
Trachoma is an ancient disease that remains the most common infectious cause of blindness worldwide.9
Over 40 million people are currently aﬀected by active trachoma, with the highest burden in sub-Saharan
Africa.10 Trachoma is caused by ocular infection with Chlamydia trachomatis: conjunctival chlamydia
infection causes inﬂammation, with characteristic white follicles (germinal centers) on the upper tarsal
conjunctiva. Frequent bouts of infection and inﬂammation result in conjunctival scarring, entropion (in-
turning of the eyelids), and trichiasis (eyelashes touching the globe). Trichiasis is painful, and leads to
corneal abrasions, bacterial and fungal superinfections, corneal opacity, and blindness. The National Eye
Institute’s most recent 5-year plan encourages clinical trial interventions for blinding global eye diseases,
and speciﬁcally urges research in connection with trachoma control programs to cost-eﬀectively test op-
timal intervention strategies for global infectious causes of blindness.11
The World Health Organization (WHO) has called for elimination of trachoma as a public health problem
by the year 2020.12 Through its Global Elimination of Trachoma by 2020 (GET 2020) initiative, the
WHO has designated trachoma a priority eye disease, and has brought together academic institutions,
non-governmental organizations, and pharmaceutical companies to promote its elimination. Together,
this consortium supports the SAFE strategy: Surgical correction of trichiasis, Antibiotics to reduce the
community load of ocular chlamydia, and Facial cleanliness and Environmental improvements to reduce
the transmission of ocular chlamydia.13 Most trachoma experts are enthusiastic that trachoma can be
eliminated in the next two decades, and some even think that trachoma may be a candidate for global
eradication.14
Mass azithromycin distributions are clearly eﬀective in reducing the burden of ocular chlamydia, but have
not proven to be the magic bullet for elimination. Numerous community-randomized trials performed
in a variety of settings have found dramatic reductions in ocular chlamydia following mass treatments,
supporting the WHO’s recommendation of 3-5 annual rounds of treatment in areas with endemic tra-
choma.1,15–18 Mass azithromycin distributions may be capable of eliminating ocular chlamydia infections
in areas with hypo- or meso-endemic disease, but have not resulted in long-lasting elimination areas with
hyperendemic trachoma. Some areas of Ethiopia have been treated annually for over a decade and have
not experienced elimination. More frequent treatments should speed elimination according to mathemat-
ical models, but even 8 years of biannual treatments were not suﬃcient to eliminate chlamydial infection
10

in our previous study in Ethiopia. It is becoming clear that antibiotics alone will not eliminate trachoma
in the most severely aﬀected regions.
Few randomized trials have assessed the impact of WASH improvements on trachoma, and those that
have been performed have not been able to demonstrate a reduction in ocular chlamydia. Although this
may mean that water and sanitation interventions have no eﬀect on ocular chlamydia, it is also possible
that the limitations of these trials prevented a true eﬀect from being found. For example, the trials were
typically underpowered and had short follow-up. None provided all three WASH components (e.g., water,
sanitation, and hygiene) in concert.19,20 Most used clinically active trachoma as the outcome, based
on a ﬁeld grading scale that may not be a sensitive enough test.21,22 The state of evidence regarding
environmental modiﬁcations for trachoma control is perhaps best summarized by the 2012 Cochrane
Review article on this subject, which concluded: “Generally there is a dearth of data to determine the
eﬀectiveness of all aspects of environmental sanitation in the control of trachoma.” 23 Perhaps because of
this, many trachoma programs focus their activities around the “S” (surgery) and “A” components (an-
tibiotics), while neglecting the “F” (facial hygiene) and “E” (environmental improvements) components
of the SAFE strategy.24
Elimination of trachoma will require not only eﬀective interventions, but also accurate surveillance.
Trachoma programs currently rely on district surveys in which trained ﬁeld workers assess for follicular
trachoma (TF) in 1-9 year-old children. Decisions on initiating and discontinuing interventions are based
on the prevalence of TF during these surveys. However, the prevalence of TF in a community does
not correlate well with the prevalence of ocular chlamydia, and this correlation is even worse if mass
azithromycin treatments have recently been administered. The discrepancy is thought to result from dif-
ferential kinetics of infection vs. inﬂammation: infection clears quickly after antibiotics, but inﬂammation
takes much longer. Direct tests of ocular chlamydia may be preferable, since interventions are directed
toward reducing transmission of ocular chlamydia. Nucleic acid ampliﬁcation tests (NAATs) have gener-
ally been too expensive and complicated for ﬁeld use, but inexpensive and portable point-of-care NAATs
are increasingly becoming available, which could revolutionize diagnostics in resource-limited settings.
The SWIFT I trial, a three-year, NEI-funded, cluster-randomized trial aims to determine the impact of
WASH on ocular chlamydial infection. Our intervention consists of several community-level interventions,
including a community water point and a staﬀof hygiene promotion workers who travel door-to-door
to educate community members. Each household received a wash station (jerry can with faucet plus a
mirror) and a 66-page educational WASH book, and each household receives a monthly supply of soap.
We also implemented a hygiene curriculum for the primary schools in the study clusters, complete with
educational aids. We monitor the ﬁdelity of our intervention and ﬁne-tune its components through spot-
checks of households and schools, focus group discussions, structured observations of hygiene behaviors,
and an annual household survey. Our monitoring has revealed a high uptake of the intervention as well
as evidence of subsequent hygiene behavior changes. Given these initial successes, and given the paucity
of long-term randomized trials of WASH interventions for health outcomes, we propose a continuation of
the existing WUHA trial with annual monitoring for an additional three years in order to more accurately
gauge the true impact of WASH on trachoma.
The contributions of the trial are twofold: ﬁrst, 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-
11

of-care test for chlamydia. We are extending the WUHA trial by continuing the WASH intervention. We
are also performing annual mass azithromycin distributions in all study communities. We will continue
to monitor for ocular chlamydia via PCR of conjunctival swabs and serologic testing from dried blood
spots. 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 one additional
swab on each individual during routine monitoring visits and compare several inexpensive, commercially
available nucleic acid tests for chlamydia. The proposed trial leverages our existing research infrastructure
and takes advantage of the fact that the intervention has already been implemented, and will have been
operating for more than ﬁve 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 surveil-
lance, which has become increasingly important as the world moves towards global elimination. We think
the results of the proposed study will be of great interest to the trachoma community, and regardless of
the outcome will directly help trachoma programs decide how to spend their limited resources.
12

Chapter 3
Administrative Information
3.1
Trial Registry
The clinicaltrials.gov registry number is NCT02754583.
3.2
Funding
SWIFT I is funded by the National Eye Institute. (U10 EY023939). SWIFT II is also funded by the
National Eye Institute (UG1 EY023939).
3.3
Roles and Responsibilities
3.3.1
Protocol Contributors
• Zerihun Tadesse
The Carter Center, Ethiopia, Addis Ababa, Ethiopia
zerihtad@yahoo.co.uk
• Kelly Callahan
The Carter Center, Atlanta, Georgia
kelly.callahan@cartercenter.org
• Dionna M Wittberg
Francis I Proctor Foundation, University of California, San Francisco
dionna.wittberg@ucsf.edu
• Travis C Porco
Francis I Proctor Foundation, University of California, San Francisco
travis.porco@ucsf.edu
13

• Thuy Doan
Francis I Proctor Foundation, University of California, San Francisco
thuy.doan@ucsf.edu
• Thomas M Lietman Francis I Proctor Foundation, University of California, San Francisco
tom.lietman@ucsf.edu
• Jeremy D Keenan
Francis I Proctor Foundation, University of California, San Francisco
jeremy.keenan@ucsf.edu
3.3.2
Trial Sponsor
The NEI is sponsoring this trial. The NEI has no role in the collection, management, analysis, and
interpretation of data; writing of the report; or the decision to submit the report for publication, and
does not have ultimate authority on these activities. The sponsor has representation on the Data and
Safety Monitoring Board.
3.3.3
Study Partners
The Proctor Foundation and Carter Center are currently collaborating on the WUHA I trial, and have
worked together on 5 other large NEI- or Gates-funded cluster-randomized clinical trials since 2006 in
Ethiopia and Niger. The collaboration has been very productive, with numerous publications in high
impact journals. The research partners complement each other, with the Proctor Foundation providing
expertise in study design and analysis, and the Carter Center implementing the ﬁeld work in a thorough
yet eﬃcient manner.
Dr.
Matthew Freeman from Emory University is continuing to collaborate on
SWIFT II. Dr. Freeman is the WASH expert for WUHA I/II, and he has conducted cluster-randomized
trials of WASH interventions in Africa. He has been an invaluable member of the WUHA team. Diana
Martin from the CDC will continue to process the chlamydial serology samples. Dr. Martin helped
developed the technology and has collaborated with Proctor researchers in previous studies.
Francis I. Proctor Foundation
The Proctor Foundation is an organized research unit at the University of California, San Francisco. The
Foundation has a 73 year history of research in ocular infectious and inﬂammatory diseases and runs one
of the leading corneal fellowship training programs in the United States. Proctor Foundation faculty have
been involved in prevention of blindness research in developing countries since the foundation’s incep-
tion. The impetus for establishing the foundation in 1947 was to eradicate trachoma in the American
Southwest and in other parts of the world.
From this initial vision we have expanded our research eﬀorts to include the other major causes of
blindness worldwide, with a continuing emphasis on infectious and inﬂammatory eye diseases.
The
Proctor Foundation will be the main coordinating center for the study. Dr. Jeremy Keenan, Principal
Investigator of the study at Proctor Foundation, will be assisted by numerous co-investigators, a research
14

coordinator, a data management team, and a biostatistician.
Our experience working in Ethiopia has been very successful to date – with the TEF (Trachoma Elimi-
nation and Follow-up) study in the Gurage region, TANA (Trachoma Amelioration in Northern Amhara)
and the TIRET (Tripartite International Research for the Elimination of Trachoma) study in the Amhara
region.
We have partnered with ORBIS International and The Carter Center, respectively, to con-
duct/complete these large-scale projects.
The Carter Center – Ethiopia
The Carter Center is guided by a fundamental commitment to human rights and the alleviation of hu-
man suﬀering; it seeks to prevent and resolve conﬂicts, enhance freedom and democracy and improve
health. The trachoma control program does not just ﬁght disease, it ﬁghts the conditions that perpetu-
ate disease: poverty, poor sanitation, lack of knowledge, and hopelessness. Together, the Carter Center
and its program partners are working to build a brighter future for those at risk for this devastating disease.
The focus of the country program has been on trachoma control, and delivery of quality eye care and
blindness prevention programs to the majority of the population that live in rural areas (72%), largely
unserved by trained eye care professionals.
Partnering with the Carter Center has yielded very positive results.
The organization has an estab-
lished infrastructure for large scale health promotion and improvement programs, as well as a strong
working relationship with the Ethiopian Ministry of Health – both of which have contributed to the
success of our ﬁeld research.
Amhara Public Health Institute (formerly Bahir Dar Regional Health and Research Laboratory)–
Ethiopia
The Amhara Public Health Institute in Bahir Dar, Ethiopia was established to be a center of excellence
for the development of laboratory systems in the region. Construction of this CDC and USAID supported
laboratory was completed in 2011.
Conjunctival swabs will be processed with the Abbott RealTime
assay for Chlamydia trachomatis, using the automated Abbott m2000 System, which is already in use at
the laboratory. The Amhara Public Health Institute will also process the swabs using media selective for
Streptococcus pneumoniae, and then test for antibiotic resistance to erythromycin, penicillin, tetracycline,
and clindamycin using the Kirby Bauer disc diﬀusion assay.
Emory University
The Rollins School of Public Health comprises six academic departments: behavioral sciences and health
education, biostatistics, environmental and occupational health, epidemiology, health policy and manage-
ment, and global health. It also hosts over 20 interdisciplinary centers. Its location in Atlanta provides
ample interaction with other public health professionals interested in global health.
Speciﬁcally, the
15

school has close ties with the Carter Center and the Centers for Disease Control and Prevention, both of
which are in Atlanta and contribute faculty to the school. Dr. Matthew Freeman has a appointments in
the Department of Environmental Health, the Hubert Department of Global Health, and the Department
of Epidemiology.
Centers for Disease Control and Prevention
Dr. Diana Martin and her lab at the Centers for Disease Control and Prevention are developing new
serological tests to monitor trachoma elimination as well as other diseases of interest including helminths,
intestinal bacterial pathogens, and intestinal protozoal pathogens. Dr. Martin’s lab will complete serolog-
ical testing for trachoma and other diseases of interest using the dried blood spots collected throughout
the study.
3.3.4
Study Committees
Executive Committee
The Executive Committee will consist of Drs. Jeremy Keenan and Zerihun Tadesse. This committee will
act as the administrative and executive arm of the clinical trial and will meet twice per year to provide
overall oversight for the study and make decisions on day-to-day operation issues as described in the
following:
• Monitor study progress and data collection process
• Discuss any quality control issues that have arisen in the Trial Coordinating Center (TCC) and
Data Coordinating Center (DCC)
• Evaluate and adopt changes in study procedures as necessary
• Communicate with and implement recommendations from the Data and Safety Monitoring Com-
mittee (DSMC)
• Make executive decisions on the allocation of resources
• Establish policies on publications and authorship
• Approve and oversee ancillary studies
Trial Coordinating Center (TCC)
The TCC will be located at the Proctor Foundation. Dr. Jeremy Keenan will lead the center, which will
also include Dr. Thomas Lietman (co-investigator), Dr. Thuy Doan (co-investigator), Dr. Travis Porco
(biostatistician), Mr. Jason Melo (statistical analyst), and Mrs. Dionna Wittberg (Proctor research
coordinator). The role of the TCC will be to oversee and coordinate the overall implementation of the
trial. Speciﬁcally, this means:
16

Figure 1: SWIFT II organizational chart
• Maintaining an up-to-date manual of procedures
• Obtaining ethical approvals from all involved parties (UCSF, Emory, and Ethiopia)
• Conducting training and certiﬁcation of all study personnel
• Ensuring proper masking of outcome assessment
• Monitoring adherence and adoption of the study intervention
• Maintaining a list of study personnel for group authorship, as well as organize and store consents
to be included in the acknowledgement section for contributors not meeting criteria for group
authorship
The TCC will organize site visits at least once per year before each monitoring visit to conduct training
sessions with outcome assessors and monitor the quality of data collection. Either the principal inves-
tigator or research coordinator will be present at all site visits. The Proctor research coordinator, with
assistance from the local Carter Center study coordinator, will organize the training sessions and the
design and production of all educational messaging used in the hygiene promotion. This is a role she has
ﬁlled for other trials in Ethiopia for the past 5 years. The TCC will meet oﬃcially as a group at least 4
times per year. All members of the TCC are currently working on studies of trachoma in Ethiopia and
Niger. The group has close working relationships with the Carter Center staﬀin Ethiopia, and experience
with cluster-randomized trials in resource-poor settings.
Ethiopian Coordinating Center
The Ethiopian Coordinating Center will be located at the Carter Center Ethiopia headquarters in Addis
Ababa, Ethiopia. The center will be led by the study site principal investigator, Dr. Zerihun Tadesse,
17

and also include the Carter study coordinator, Dr. Solomon Aragie. Dr. Zerihun will oversee the study
activities that take place in Ethiopia, and will manage the day-to-day activities of the Carter Center study
coordinator. He will also assist with obtaining ethical approval from appropriate federal, regional, and
zonal agencies. He is supervised by Kelly Callahan from the Atlanta headquarters of the Carter Center.
The Carter Center study coordinator (Dr. Solomon Aragie) will work with the local health oﬃcials and
TCCE staﬀto implement all study activities, including but not limited to:
• Obtain ethical approval from appropriate federal, regional, and zonal agencies
• Facilitate customs clearance of drugs, equipment, and supplies used for the study
• Hire local personnel to serve as census workers, examiners, antibiotic distributors, hygiene cluster
coordinators, and health promotion workers (HPWs)
• Assist with the WASH intervention development including materials development, formative re-
search, and focus group discussions
• Ensure that the WASH intervention is implemented and progresses per protocol.
• Liaise with study partners including Catholic Relief Services
• Supervise all data collection activities of the census, exam, and treatment phases of the study
• Obtain Material Transfer Agreement (MTA) for relevant specimens, for shipment to San Francisco
• Arrange proper storage and transport of specimens
• Coordinate with the Amhara Public Health Institute to ensure the laboratory has adequate supplies
and processes the specimens in a timely fashion
• Coordinate data entry of paper forms
Data Coordinating Center (DCC)
The DCC will be located at the Proctor Foundation and led by Dr. Travis Porco. The Proctor Foundation
has served as a DCC for several other trials, including cluster-randomized trials of trachoma in Ethiopia
(TANA and TIRET continuation study, NEI U10 EY016214) and Niger (MORDOR; Gates OPP 1032340),
and individual cluster-randomized trials of corneal ulcers in India (SCUT, NEI U10 EY015114; MUTT,
NEI U10 EY018573). Dr. Porco, Dr. Keenan, Dionna Wittberg (research coordinator), and Jason Melo
(statistical analyst) will be responsible for data management, data quality control, event adjudication,
and training and certiﬁcation of data entry personnel. The DCC’s responsibilities include:
• Draft the trial’s statistical analysis plan
• Develop and maintain protocol for enrollment monitoring
18

• Monitor data collection and enrollment with the help of Salesforce.com reports and activity dash-
boards. An enrollment report will be generated prior to baseline, and the data analyst will monitor
this report on a monthly basis. Individual dashboards will be made to track the census, examina-
tions, treatment progress. These dashboards will be emailed to the PI, research coordinator, data
manager, data analyst, and Ethiopian study coordinator each morning during that study activity
period. Dashboards will be designed to depict the following quality control metrics:
– Census
∗Number of households stratiﬁed by date of census, census worker, randomization unit
∗Age and sex distribution stratiﬁed by census worker and randomization unit
∗Number of households with missing GPS coordinates stratiﬁed by census worker and
randomization unit
– Exams
∗Number of children examined, stratiﬁed by study population, type of swab/test, and
randomization unit
– Treatment
∗Treatment status of individuals stratiﬁed by date of treatment, treatment worker, ran-
domization unit
∗Cross-tabulation of treatment assigned vs. treatment received
• Coordinate the use of the electronic data capture system, including maintenance of the software
application and data backup
• Clean and manage the data
• Analyze data according to the Statistical Analysis Plan (SAP)
• Generate reports including enrollment, retention, and protocol violations once yearly and at the
request of the EC or other study team members. These reports will be generated prior to the UCSF
IRB Continuing Review application.
• Provide data requested for publications
• Coordinate and supervise the activities of the Data and Safety Monitoring Board
• Prepare interim and ﬁnal data reports
• Keep in close contact with the Ethiopian study coordinator to help address any data related issues
in Ethiopia.
Data and Safety Monitoring Committee (DSMC)
The DSMC has been formed according to NIH guidelines and is comprised of independent experts in
bioethics, biostatistics, epidemiology, ophthalmology, and international health. The DSMC will meet
at least once per year. Ad hoc meetings may be convened as needed. The DSMC approved the trial
protocol at the ﬁrst meeting (16 September 2014). At annual meetings, the DSMC will review data on
eﬀectiveness outcomes. A chief responsibility will be to decide whether ocular chlamydia infection levels
become high enough (around 20% in study clusters) to necessitate treatment with mass azithromycin.
They will also monitor for unanticipated events.
19

StaﬀResponsibilities
Principal Investigator (Dr. Jeremy Keenan, Proctor Foundation)
• Develop study design, speciﬁc aims and outcome measures, with help of biostatistician, research
coordinator, study coordinator, and partners
• Obtain grant funding and with help of partners, develop grant budget
• Ensure that staﬀfollow through on protocol and properly execute all areas of research
• Ensure that all ethical approval is maintained
• Oversee intervention implementation
• Write or add major contributions to all study-related publications
• Ensure proper masking procedure for staﬀinvolved in the study
• Supervise training certiﬁcation for all examiners
• Lead the Executive Committee and Trial Coordinating Center
• Participate as a member of the Data Coordinating Center
Research Coordinator (Dionna Wittberg, Proctor Foundation)
• Develop and maintain study protocol
• Ensure the execution of the study per protocol
• Maintain all clearances for the study, including IRB renewals (UCSF, Emory, APHI, NRERC, and
the Ethiopian FDA), the biological use authorization (BUA), Materials Transfer Agreement (MTA),
and DSMC-related approvals
• Coordinate the activities of the Data and Safety Monitoring Committee
• Manage budgetary items including the NIH award and subcontracts
• Participate as a member of the DCC
• Assist with data collection and management
• Maintain a list of all study personnel for inclusion in study manuscripts
• Coordinate with The Carter Center, Ethiopia (TCCE) and particularly with the TCCE study coor-
dinator, in execution of the study
• Manage correspondence between all collaborating organizations and parties
• Maintain communication and partnership with Principal Investigators regarding all study activities
and plans
• Direct development and implementation of WASH intervention
• In collaboration with Ethiopian study coordinator, prepare the census and examination application,
electronic tools, and paper forms necessary for ﬁeldwork (cluster registration lists, spot check
REDCap, costing forms, mini-spot check household lists, and etc.)
• Direct team, with help of TCCE study coordinator, while in Ethiopia
20

• With help of TCCE study coordinator, train census, exam and treatment workers on study activities
including the use of the electronic data capture system
• Train and certify hygiene cluster coordinators and health promotion workers (HPWs) with help of
TCCE study coordinator
• Arrange logistics and itineraries for traveling team members
• Purchase, maintain, organize, and transport of all necessary study supplies
Study Coordinator (The Carter Center, Ethiopia)
• Prior to the start of the study, secure necessary ethical and administrative approvals the Region
(APHI), NRERC (Ministry of Science and Technology), and the Ethiopian FDA
• At baseline and throughout the study, obtain and maintain permission from zonal health leaders
for the SWIFT study. Meet with and obtain permission/consent from all kebele and sub-kebele
leaders.
• Train and supervise census and household survey team as well as the treatment team, including
training in the electronic data capture system
• Supervise and train exam data collection teams (with emphasis on any new members) throughout
each collection, especially after departure of Proctor study team
• Manage the data collected during the census, exams, and treatment by ensuring that the app data
is uploaded to Salesforce.com and that the exam photographs are saved on external hard drives
• Arrange printing of study materials including educational materials for households, hygiene work-
shops, schools, and advertising
• Train, certify, and work closely with the hygiene cluster coordinators and the HPWs (with help of
Proctor research coordinator)
• Maintain all ﬁeldwork documents and records
• Complete all collection and intervention reports
• Work with Data Analyst to maintain census and exam database
• Help develop and implement WASH interventions
• Oversee transport of study samples to Amhara Public Health Institute
• Assist Proctor Coordinators in coordinating logistics in Ethiopia
• Train and supervise data entry staﬀat Carter Center Headquarters in Addis Ababa
• Analyze and provide data when requested by co-investigators or staﬀfrom Proctor Foundation
• Appropriately back-up all data
Co-Investigators (US and Ethiopia)
• Assume responsibility for the study in the absence of the Principal Investigator, if necessary
• Help supervise local workers, lab workers, nurses, and local health agents in the ﬁeld to ensure
conformity to study procedures
21

• Communicate with the research coordinator and principal investigator to ensure the execution of
the study as per the protocol
• Fulﬁll responsibilities of membership on Committees (EC, TCC, and DCC) and Centers as outlined
above
• Fulﬁll speciﬁc responsibilities as outlined in budget justiﬁcations
WASH Expert (Emory University)
• Serve as co-investigator and WASH technical advisor
• Provide technical assistance in fundamental behavioral interventions and qualitative methods
• Help design the formative research component of the study, including in-ﬁeld training and analysis
• Help design the structured observations methodology, including in-ﬁeld training and analysis
Biostatistician (Proctor Foundation)
• With the Principal Investigator, create the Statistical Analysis Plan (SAP)
• Receive all study data and review for quality control purposes
• Ensure appropriate masking
• Prepare data analysis plan for annual DSMC meetings. Help analyze and prepare all presented data
for DSMC meetings, DSMC reports, and all SWIFT study publications
Statistical Analyst (Proctor Foundation)
• Maintain database for all collection and results-related data for the study
• Monitor receipt of all census, treatment, and exam data after each collection activity
• Develop database for entry of costing data at the Carter Center, Addis Ababa
• Track and analyze process indicators including household WASH survey, spot check data, and
structured observations
• Develop consistency checks in the data management—verify any inconsistencies or questions re-
garding data through communication with Study Coordinator
• Analyze and provide data regarding collection and results for study staﬀwhen needed, such as for
publications or DSMC meetings
• Back-up all data appropriately
• Follow-up on any missing data or lab results
Microbiologist (UCSF)
• Train laboratory technicians, especially the microbiologists at the Amhara Public Health Institute,
for all lab procedures concerning the study: including Polymerase Chain Reaction (PCR) proce-
dures, macrolide resistance testing, standard laboratory procedures for all tests, record-keeping,
and quality control measures as per approved standards
22

• Verify equipment quality
Microbiologist/laboratory technician (Amhara Public Health Institute)
• Provide training review and supervise laboratory technicians for all lab procedures concerning the
study, including PCR procedures
• Perform all macrolide resistance testing
• Follow standard laboratory procedures for all tests
• Keep records of all tests performed
• Maintain quality control measures as per approved standards
• Make sure all equipment is calibrated and maintained
• Maintain stock of laboratory reagents and supplies
• Pool and prepare all PCR samples, and process using Abbott RealTime assay for Chlamydia tra-
chomatis, using the automated Abbott m2000 System
• Perform regular maintenance checks of the Abbott m2000 system, under direction of the UCSF
microbiologist
• Report PCR results to DCC
• Maintain cleanliness and maintenance of molecular biology laboratory and all equipment
Laboratory Assistants (Amhara Public Health Institute)
• Organize all study samples for PCR processing in at APHI
• Monitor correct receipt of study samples (using corresponding exam sheets) after each monitoring
visit
• Prepare samples for PCR processing
• Organize work ﬂow of PCR processing for laboratory technicians, in consultation with program
manager and principal investigator
• Maintain all samples in storage freezers; create and maintain clear map of study samples for each
freezer
• Process NP samples
Hygiene Cluster Coordinators (WagHimra, Amhara, Ethiopia)
• Complete intensive on-site training from the Proctor Foundation and Carter Center Ethiopia
• Work closely with the study coordinator (TCCE) to ensure proper implementation of WASH com-
ponents
• Responsible for overseeing 20 WASH clusters
• Responsible for overseeing 20 Hygiene Promotion Workers (HPWs)
23

• Conduct trainings for health extension workers, priests, and Health Development Army members
• Conduct monthly visits to all 20 WASH clusters
• Help with identiﬁcation of potential water point locations and management of the water point
construction (Water)
• Troubleshoot maintenance issues with Woreda Water Oﬃce or artisans (Water)
• Perform bi-monthly spot checks in 20 WASH clusters to check on water point functionality, school
curriculum implementation, and household WASH behaviors and infrastructure (visit 8 randomly
selected households with pre-school children during each visit)
• Encourage households to build a latrine and keep it in good working order (Sanitation)
• Lead latrine promotion campaigns (Sanitation)
• Training of Teachers: help conduct a training for teachers of primary schools in the study area;
“train-the-trainers” model where teachers then implement activities for students (Hygiene)
• Key messages: Help conduct focus groups in clusters to identify the educational messages that will
most motivate behavior change; work closely with study coordinator (TCCE) to help identify key
hygiene promotion messages in hygiene promotion activities and appropriate forums for education
(Hygiene)
• Monthly workshops: Supervise HPWs as they conduct monthly workshops in each cluster, with
educational messages in appropriate local venues (Hygiene)
Health Promotion Workers (WagHimra, Amhara, Ethiopia)
• Complete intensive on-site training workshop from the Proctor Foundation and Carter Center
Ethiopia
• Work closely with the hygiene cluster coordinator (TCCE) to ensure proper implementation of
WASH components
• Responsible for WASH education in 1 cluster
• Help troubleshoot maintenance issues (Water)
• Report issues with water points (Water)
• Liaise with Water Committee (Water)
• Encourage increased water use for hygiene activities and use of safe water sources (Water)
• Perform spot checks of latrine quality during household visits (Sanitation)
• Encourage and each households how to build a latrine and keep their latrine in good working order
(Sanitation)
• House to house visits: visits each household at least once per month to encourage positive WASH
behavior change and improvements to hygiene infrastructure at the household level (Hygiene)
• Monthly workshops: conduct educational hygiene focused workshops in each cluster (Hygiene)
• School curriculum: work with school principal and WASH club leader to promote WASH in the
schools and ensure that the schools are implementing the curriculum (Hygiene)
24

Health Development Army
• Local community members selected by woredas in Amhara, Ethiopia
• Assist with implementation of hygiene activities
• Participate in annual WASH promotion training given by hygiene cluster coordinators and/or HPWs
• Implement WASH promotion in 5 nearby households
Census Team
• The Carter Center will organize and train local workers to perform the census.
• During census phase, travel to enrolled clusters and obtain participant information. The census
will be performed with an electronic data capture system, with the following data inputs for each
household / household member:
– Name
– Gender
– Age
– School(s) any children attend
– Water point(s) household utilizes
– Presence and status of each household member
– Health provider(s) household utilizes
– GPS coordinates for each household
– GPS coordinates for each water source in the study area
– Presence or absence of usable household latrine and latrine-use
– Presence or absence of washing station and soap
– Information on hygiene behaviors (e.g., face-washing and latrine use)
Treatment Team
• Complete training by TCCE study coordinator and oﬃcials from Local Zonal Health Desk regarding
proper treatment protocols and procedures
• Travel to enrolled clusters and administer study medication to the study subject per protocol
– Directly observe consumption of azithromycin
– Record antibiotic coverage against the previous census
– Return to households until they have distributed antibiotics to at least 80% of selected indi-
viduals
• Inform patients of available health care facilities and procedures in local health centers and hospitals
• Collect information on the nature of any Adverse Events experienced by study subjects, and report
this back immediately to investigators
25

Examination Team: Local workers, nurses, and lab technicians
• At each collection phase, complete training and certiﬁcation in clinical examination, sample collec-
tion procedures, and data collection procedures
• Prepare all study-related materials before travel to study sites
• In each cluster, mobilize and identify all randomly selected participants
• Explain study purpose and procedure and obtain verbal consent for enrollment from each participant
or participant’s guardian
• Perform clinical exam for each patient and collect all participant study samples according to pro-
tocol.
• Store and record all samples correctly for transport, organization, and processing
• Counsel and motivate patients for follow-up monitoring visits
• Inform patients of available health care facilities and procedures in local health centers and hospitals
• Collect information on the nature of an Adverse Events experienced by study subjects, and imme-
diately report to investigators
3.3.5
Protocol Revisions
Any changes to the protocol made during the course of the study will be incorporated into this Manual
of Operations and Procedures (MOP), and recorded in a change log at the end of this document. Any
new forms will be incorporated in addendum. The protocol changes should be submitted and approved
by all relevant ethical review boards (UCSF, Emory, APHI, MoST, and E-FDA) and the DSMC.
3.3.6
Presentations and Publications
All presentations and publications should include acknowledgement of the funding sources and give
credit to the collaborating organizations and/or individuals involved.
Acknowledgements will include
grant source(s) and the DSMC members.
26

Chapter 4
Research Design
Most experts believe that WASH interventions require many years of sustained eﬀorts before having an
ultimate impact on health outcomes. Despite our intentions to roll out the intervention as quickly as
possible, setting up a WASH program takes time, and our intervention was not fully implemented until
month 12. This leaves two years of follow-up time in WUHA I, which may be insuﬃcient to see the full
impact of a WASH intervention. Moreover, despite 8 annual rounds of mass azithromycin, the prevalence
of ocular chlamydia started at a high level in WUHA I. WASH interventions may reduce transmission of
infection, but likely do not clear existing infections, and therefore it may be more diﬃcult to show an eﬀect
of WASH at a high prevalence of chlamydia. In WUHA II we will administer annual mass azithromycin
all 40 clusters, which should greatly reduce the prevalence of ocular chlamydia, and perhaps make it
easier to ﬁnd a diﬀerence between the 20 WASH + azithromycin clusters and 20 clusters that receive
antibiotics alone.
4.1
Study Area
SWIFT is being conducted in three woredas of the WagHemra zone of Amhara, Ethiopia: Gazgibella,
Sekota, and Sekota Town (Figure 2).
In Ethiopia, a woreda is a government-deﬁned administrative
subdivision that is in turn comprised of kebeles. WagHemra is arid and mountainous, and was chosen
Figure 2: SWIFT I/II study site
27

based on trachoma impact surveys performed by the Carter Center that determined the area had a high
prevalence of trachoma and a low prevalence of several WASH indicators.
4.2
Eligibility Requirements
Intervention Eligibility: School districts were eligible for inclusion in WUHA I if a site could be iden-
tiﬁed for water point construction and at least 5 rounds of mass azithromycin distributions had been
performed. School districts were excluded if they were in an urban area, since urban communities have
better access to water and sanitation and have less trachoma.25,26 School districts were also excluded
if they required more than 1 day of travel to access. Forty communities met the eligibility criteria and
were included. All 40 communities enrolled in WUHA I will also be enrolled in WUHA II.
4.2.1
Monitoring Eligibility:
Population-based sample:
For the population-based sample, we will monitor the following 3 groups: (1) a random sample of 30
children aged 0-5 years, (2) a random sample of 30 children aged 6-9 years, and (3) a random sample
of 30 individuals
10 years (Table 1). We will monitor the 0-5 and 6-9 year age groups annually and
the adult group at the start and end of the study period. Eligibility for each of these groups will be
based on the previous census; a new random sample will be selected each visit. All age strata will receive
conjunctival photography and swabbing, and children under 10 will have a face photograph taken and
a dried blood spot collected. In addition, a random sample of 15 children aged 0-5 years will undergo
nasopharyngeal swabbing to assess for macrolide resistance. We monitor all three age strata because
information on clinically active trachoma and chlamydial infection in the older age groups will be helpful
when comparing this study to previous studies and for future attempts to use the data in mathematical
models. In addition, the ability to report the prevalence of clinically active trachoma in 1-9 year-olds will
help put the results of the trial into context for trachoma programs, which base treatment decisions on
this metric.
28

Longitudinal cohort:
The longitudinal cohort will consist of the random sample of children aged 0-5 years at month 0, followed
annually until month 84. Children who are under 12 months and are selected for the random sample
will be added to this longitudinal population, to be followed until the conclusion of the trial. Note that
some of the children in the longitudinal cohort will also be selected as part of a population-based sample
and so may have additional tests performed. Children in the longitudinal sample will have conjunctival
swabs, conjunctival photographs, and dried blood spots performed at each annual study visit.
4.3
Randomization
Randomization unit
The randomization unit for this trial is the primary school district. We included 40 primary school districts
from the 3 woredas. We chose the school district for two reasons. First, school children in Ethiopia have
a considerable burden of trachoma, so units smaller than a school could be subject to contamination.
Second, we wished to incorporate school-based hygiene promotion in the intervention, which requires a
randomization unit of school district or larger. Within each school district, the best site for water point
development was identiﬁed via geohydrologic survey, and the cluster of households within 1.5km of this
potential water point was designated to receive the full package of WASH interventions as well as annual
monitoring visits for trachoma. We call these households a study cluster.
Selection of clusters
In the spring of 2015, collaborators from Catholic Relief Services in Ethiopia performed a geohydrologic
survey of the study area and identiﬁed sites that could potentially be developed as protected springs,
hand dug wells, or shallow boreholes. We chose the best site from each of 40 school districts for inclusion
in the trial, and censused all households within 1.5km of the potential water site.
Intervention randomization
We randomized communities to the WASH arm or delayed WASH arm after the baseline examinations in
order to limit the possibility of diﬀerential outcome assessment at the baseline visit. The randomization
sequence was generated by the trial biostatistician in San Francisco using a random number generator,
without stratiﬁcation or blocking.
29

4.3.1
Contamination
Cluster-randomized trials are subject to contamination between clusters, which could weaken the eﬀect
of the study intervention. We reduce the chances of contamination by studying only a single cluster of
households from a relatively large geographic area (i.e., school district), essentially creating a buﬀer zone
around each study cluster. The chances of contamination are further reduced for household-delivered
interventions since they are provided only to households enumerated during the census. We have made
no attempt to limit contamination from outside the study, which is theoretically possible since all 40 com-
munities have continued to receive the usual health promotion from the government. The government
program consists of two health extension workers per kebele who provide 16 diﬀerent services, among
them health education and promotion of hygiene and sanitation.
4.3.2
Masking
Because of the nature of the interventions, it is not feasible to mask the study participants to treatment
allocation. By not masking study participants, there is a chance that they will change their behaviors due
to knowledge of their allocated treatment group. In the case of this trial, however, the entire purpose
of the interventions is to change behaviors. Although there is a chance that individuals in the non-
intervention communities will also improve their hygiene due to knowledge of their allocated treatment
group, this is not likely—especially given the diﬃculty of causing behavior change even under optimal
programmatic conditions. Because all interventions occur at the community level, study participants are
surrounded by similarly treated individuals and therefore are not reminded of their treatment allocation
very often, if at all. Moreover, we monitor WASH outcomes in both the intervention and non-intervention
communities in order to assess the impact of the lack of masking on changes in hygiene behavior. We do
not inform census workers or outcome assessors of the treatment allocation, although we acknowledge
that this information would not be diﬃcult to obtain.
The emphasis of masking eﬀorts for the trial concerns the primary and secondary outcomes, which
can easily be masked. All laboratory staﬀare masked to treatment allocation, as are the conjunctival
photograph reviewers. All specimens collected in the ﬁeld are labeled with a 6-digit random identiﬁcation
number. Photographic graders and laboratory staﬀhave access only to this identiﬁcation number, and
not to any other identifying information for study participants.
We will also assess several key process indicators in a masked fashion from both intervention and control
clusters (e.g., annual household survey, structured observations), but others in an unmasked way only in
the intervention clusters (spot checks, focus groups).
30

Chapter 5
Study Interventions
5.1
Mass azithromycin
All individuals ages 6 months and older will be oﬀered a single directly observed dose of oral azithromycin
(1g for adults and 20mg/kg for children) annually. Children under 6 months, pregnant women, and those
with known macrolide allergies will be oﬀered two tubes of tetracycline ointment to be used twice daily
for 6 weeks. Antibiotic coverage will be assessed relative to the census population. Workers will return
to households until they distribute antibiotics to at least 80% of individuals. In previous studies, we have
routinely achieved >85% antibiotic coverage.27,28
5.2
WASH Interventions
A comprehensive WASH package was rolled out over the ﬁrst year of the study. The Carter Center
Ethiopia was the principal implementing partner. The interventions were informed by focus group discus-
sions held in the study area as well as nearby areas. Two study staﬀknown as hygiene cluster coordinators
are responsible for ensuring the ﬁdelity of the intervention. These individuals both had prior experience
implementing WASH interventions for local nongovernmental organizations, and have close ties to local
governmental health, water, and school oﬃcials. Each element of the package is described in more detail
below:
5.2.1
Water
• Community water point: We worked with Catholic Relief Services (CRS) to install water points.
CRS is a nongovernmental organization with extensive experience constructing water points in
Ethiopia. CRS performed a geohydrologic survey and coordinated water point construction in each
of the 20 WASH communities with the help of the local Ethiopian nongovernmental organization
Water Action. Of the 20 water points, 13 were spring developments, 4 were hand dug wells, and
31

Figure 3: Household Wash Station
3 were shallow boreholes.
• Water committee: Interactive community participation is important for the successful implemen-
tation of a water point.29 The Carter Center study coordinator and Catholic Relief Services worked
with kebele leaders to identify a 5-person water committee for each water point, with at least 2
female members. This committee developed a plan for maintenance of the water point, including
a payment system to subsidize repairs.
• Household wash station: During the initial focus group discussions conducted before the study,
community members pointed out that one barrier to good face hygiene was the lack of a dedicated
wash basin near the household. The ideal household wash station was identiﬁed as a jerry can with
a faucet, similar to the types of facilities they saw in bigger cities. Based on this information, we
provided all households in the intervention communities with such a jerry can (Figure 3), along
with a mirror. Households were responsible for building a base for the jerry can out of locally
available materials.
5.2.2
Sanitation
• Latrine promotion: Current government policies do not allow the provision of building materials
or direct assistance for building latrines, and so study activities were limited to latrine education
and promotion in WUHA I. Study staﬀknown as hygiene promoters (see below) are responsible for
promoting latrine construction and maintenance. Through door-to-door visits, hygiene promoters
observe for the presence and functionality of latrines, and provide education about the value of a
32

latrine as well as practical tips for construction. We continue to have discussions with local and
regional government oﬃcials, we are piloting cost-sharing of concrete latrine slabs for households
that are willing to pay for part of the slab purchase.
5.2.3
Hygiene
• Targeted behaviors: Hygiene education is most eﬀective when conﬁned to a few key messages,
repeated in many diﬀerent settings.30 Although the WASH package could have a positive impact on
many health outcomes (e.g., diarrhea, soil-transmitted helminths, respiratory infections), we focus
on two behaviors that are most biologically plausible to have the greatest impact on trachoma: (1)
using soap and water to wash a child’s face twice per day, and (2) consistently using latrines for
defecation. Our messaging (e.g., times of day to wash the face, inclusion of soap, promotion of
simple pit latrine, etc.) was based both on our initial focus group discussions and local government
policies.
• Community-based hygiene promotion:
– Household WASH book: During our initial focus group discussions in the study area, local
government health extension workers showed us educational pamphlets for family planning
that they found useful for education activities, and recommended that we create something
similar for WUHA. What resulted was a 65-page full-color book that provided a roadmap
for hygiene education for hygiene promotion workers and health development army members
(see Appendix in MOP). The content of the book was based on many focus groups held with
local educators, health oﬃcials, and water oﬃcials. Local artists provided the illustrations.
The book was translated into the two languages spoken in the study area. The pictures are
meant to be explanatory enough to be utilized independent of text for illiterate community
members. The professionally bound book was delivered to each household in the intervention
clusters, to be kept for the duration of the study.
– Soap distribution: The importance of soap was evident from the baseline focus group
discussions. An American soap manufacturer (SoapBox Soaps, Washington, DC) donated
funds to purchase 4 bars of locally produced bar soap to distribute to each household each
month. For WUHA II, we are increasing the soap provided to households with more than 4
members, since running out of soap in these larger households was a consistently reported
issue in WUHA I. Larger households will receive 1 bar per person per month; households
with 4 or fewer members will continue to receive 4 bars per month. The soap is purchased
in Addis Ababa and transported by truck to the study site, where it is stored in one of two
custom-built storage sheds in the study area.
– Hygiene promotion workers (HPWs): Twelve people were initially hired as HPWs to live
in the study communities and perform door-to-door education activities. The HPWs use the
WUHA household WASH book as a basis for interactive teaching, with the goal of covering
all topics of the book with each household over the study period. The HPWs also use a
standardized form to make hygiene observations at each household (e.g., the presence and
use of latrines and wash stations), and use the results to focus their activities. HPWs report
to the study hygiene cluster coordinators. As part of SWIFT II, we increased the number of
33

Figure 4: Household Wash Book
HPWs to 20, so that one HPW is assigned to each cluster, since this aspect of the intervention
has proved to be quite popular among participants.
– Non-study personnel:
∗Health Development Army (HDA): This is a government-run program in which commu-
nities are divided into one-to-ﬁve networks, with one HDA household in charge of health
education for ﬁve other households. HDA members receive government training in var-
ious health topics, including hygiene. For WUHA, we perform annual supplementary
training sessions on hygiene and encourage the HDA members to promote hygiene and
sanitation messages to the 5 other households in their network at least monthly using the
WUHA household WASH book. HPWs check-in with the local HDA members regularly.
∗Priests: People in this part of Ethiopia are overwhelmingly Christian and devout. We
perform an annual training session for all priests in the intervention communities and ask
them to promote improved hygiene practices once per month at Sunday services. The
HPWs work with the priests to present during these educational sessions.
• School-based hygiene promotion
– Schools provide a convenient site for hygiene promotion and dissemination for several reasons.
First, ocular chlamydia is primarily transmitted by children. Second, hygiene behaviors and
habits are established in childhood. Third, parents identiﬁed school-children as a potential
vehicle for hygiene education during focus group discussions.
– Curriculum: We developed a primary school hygiene curriculum in collaboration with The
Carter Center and Ethiopian Department of Education that was based oﬀa series of key
informant interviews with teachers, principals, and health oﬃcials. The curriculum consists of
5 to 6 age-appropriate lesson plans per year for grades 1 through 4. Curriculum development
was highly iterative, with many rounds of feedback from all stakeholders as well as thorough
pilot-testing in our study area. The curriculum was designed to be interactive and student-
centered, and to integrate well with the existing government curriculum.
– Teacher training: a 3-day training was held before the school year in the fall of 2016 and
2017. Refresher trainings are held annually for all new teachers, all 20 principals, and the
20 WASH club leaders. Germ theory and the general principles hygiene are discussed, as are
each of the lesson plans.
34

– WASH clubs: In this part of Ethiopia, children are required to participate in at least one ex-
tracurricular activity, and many schools have health or hygiene clubs. For WUHA, we provided
training materials for WASH activities (songs, dances, dramas, community engagement ac-
tivities) to existing WASH club leaders, and worked with principals of all intervention schools
to ensure that WASH clubs were formed if they did not exist. All 20 intervention schools
have active WASH clubs.
• Hygiene cluster coordinator and hygiene promotion worker trainings After their selection,
the hygiene cluster coordinators and hygiene promotion workers (HPWs) are trained at an inten-
sive workshop led by the Proctor Foundation and Carter Center. We review basic information
about trachoma and its transmission, as well as the beneﬁts of the WASH strategy for preventing
transmission of trachoma. Although not the target of the current intervention, we also include
information about diarrhea prevention. We make training as participatory as possible using various
methodologies, including lectures, case studies, role play, and games. We train the hygiene cluster
coordinators and HPWs using a “train the trainer” paradigm, since they are in turn be responsible
for leading workshops in the study communities. We use a “teach-back” model, where the hy-
giene cluster coordinator/HPW is asked to convey health promotion information back to the study
coordinators, and the study coordinators provide feedback.47 Before being certiﬁed, the hygiene
cluster coordinators and HPWs have to pass a written and oral examination in the local language,
conducted by the Carter study coordinator.
35

Chapter 6
Intervention Monitoring
Figure 5:
Spot check example.
March
2017 spot check of 20 WASH communi-
ties, visualized as a heat map (blue=100%
of households; red=0%).
We designed several ways to monitor the ﬁdelity of the in-
tervention.
6.1
Spot Checks
The study hygiene cluster coordinators conduct several an-
nual rounds of spot checks in intervention clusters. At each
spot check, the hygiene cluster coordinator assesses the us-
ability of the well and checks in with the school teachers in
the cluster to review their implementation of the hygiene cur-
riculum. The hygiene cluster coordinator also visits a random
sample of 8 households with pre-school children and docu-
ments the presence of a wash station and its functionality
(e.g., presence of water in the container and soap), the pres-
ence of a latrine and its functionality (e.g., whether walls
and a roof are present), and evidence for latrine use (e.g.,
trodden latrine path, fresh feces in the pit). The content of
these structured spot checks is based on our experience in
Ethiopia and the experience of others who have conducted
similar surveys.31,32 The hygiene cluster coordinator enters
all data into a smartphone using an oﬄine REDCap mobile
application, and then syncs the data later that evening. Elec-
tronic data capture is important, since it allows us to analyze
and share the data more rapidly. As shown in Figure 5, the
spot check data are visualized as a heat map in order to easily
identify the hygiene gaps in each community. The hygiene
cluster coordinators then convey this information to the hy-
giene promotion workers during their monthly phone call and
36

they brainstorm ways to improve the deﬁciencies.
6.2
Household survey at annual census
We perform an annual household survey in a random sample of 33% of households during the census.
Census workers are not informed of the study purpose or the randomization allocation.
The survey
questions capture both self-reported hygiene behaviors as well as objective observations and has been
crucial for understanding the uptake of the intervention and for guiding remediation eﬀorts. Figure 6
shows the results from key survey items from the ﬁrst three censuses (December 2015, 2016, and 2017).
The month 24 results show that communities randomized to the WASH intervention are more likely
to have a household WASH station and latrine, and household members from WASH communities are
more likely to report having washed their face and used the latrine in the past day. Behavior changes in
the WASH arm were most evident between the month 12 and 24 visits, which is likely due to two main
reasons. First, hygiene behaviors are notoriously diﬃcult to change, and hygiene interventions are thought
to require long periods of time before they can inﬂuence behavior. Second, our WASH intervention has
many components, and was not fully implemented until the month 12 visit, meaning that the period of
time between month 12 and 24 is likely a more accurate reﬂection of its impact. Given how diﬃcult it is
to change hygiene behaviors, these results suggest a real and marked diﬀerence between the two arms,
and provide strong evidence that our intervention is being implemented as intended.
Figure 6: Household survey at month 0, 12, and 24. The survey was performed on a random 33% of
households from 20 WASH clusters and 20 control clusters during the annual census.
37

6.3
Focus Group Discussions
Hygiene promotion must take the local context into account. Barriers to changing hygiene practices
and factors that motivate changing behavior are site-speciﬁc. We build oﬀprevious successful hygiene
promotion eﬀorts that have relied on formative research and community participation to guide health
messaging priorities.33–35
The study team will hold focus groups periodically throughout the trial. The team will choose a rep-
resentative sample of communities and they will use a discussion guide to lead the focus groups in a
discussion about barriers and motivations for hygiene practices, especially as they relate to face washing
and latrine use. Sessions will last no more than 2 hours. We will target all appropriate stakeholders.
These will include at least the following groups:
• (1) Health Development Army
• (2) Community Leaders
• (3) Strong WASH performers
• (4) Poor WASH performers: Poor WASH performers are a group of people that will be identiﬁed
by HPWs as those individuals who have poor hygiene behaviors. This may mean that they do not
own or use a latrine, that they do not have a wash station at the household, that their compound
is not kept clean, etc.
The focus groups are analyzed during the study visit during which they are conducted in order to inform
the WASH intervention in a timely manner.
For example, we performed a round of focus group discussions in 5 intervention communities in June
2017 to assess the impact of the intervention and also to help guide our intervention moving forward.
We learned that community members highly valued the hygiene promotion workers and soap distribution.
We probed for reasons that latrine construction was low; participants reported that besides people’s
habits being diﬃcult to change, the costs of latrine construction were a major barrier. We also learned
that households appreciated the WASH book, that it was regularly used during home visits, and that the
illustrations were easily understandable.
6.4
Structured observation
Although we will capture the presence of hardware (e.g., improved water points, latrines, washing sta-
tions) during the annual census, this trial also requires detailed assessment of hygiene behaviors (e.g.,
face-washing and latrine use). Moreover, these assessments must occur in both treatment groups in
order to fully assess the impact of the WASH package. Various methodologies exist to measure hygiene
behaviors, including qualitative techniques, surveys, and structured observation.33,36,37 Each has limi-
tations. For example, structured observations are vulnerable to reactivity, wherein those being observed
38

change their behaviors simply from the process of being observed.38 Although it cannot completely be
eliminated, we tried to limit reactivity by ﬁrst performing a nutrition survey in 20 households per com-
munity, and telling observed households that we were observing their nutrition as opposed to their hygiene.
Structured observation has been used routinely and is well accepted by the WASH sector. We hired
and trained a team of local individuals to perform 22 hour structured observations of face-washing and
latrine behaviors in both the WASH and control communities during SWIFT I, and we aim to do the same
during SWIFT II. By performing the observations in both intervention and control communities, we will
be able to better determine whether hygiene behaviors are signiﬁcantly diﬀerent in the WASH clusters.
We will also use this information to improve the intervention. We performed the SWIFT I structured
observations in September 2017. They were conducted in 5 randomly selected households from each of
the 20 intervention and 20 control communities. Workers slept overnight at the observed household so
that they could observe face-washing and latrine behaviors when they are most likely to occur: in the
evening and early morning. The data was double data-entered in Ethiopia.
39

Chapter 7
Census
We will perform a house-to-house census of the study area in November-December of each year, ap-
proximately one month before the exams. The ﬁrst census took place in November 2015 (Table 2). We
hire local workers to perform the census and performed all data collection using a custom-built mobile
application. Census workers record the name, sex, and age of each household member, the primary
school(s) that any children attend, and the GPS coordinates of the house. In a random one-third of
households, we perform a household survey to gauge self-reported socioeconomic status, access to water,
and hygiene behaviors, and also perform observations of household latrines and wash stations.
7.1
Equipment
Each census worker is given the following equipment:
• Tablet computer: Huawei Ascend mate 2 or Mi A2 (one)
• Battery Pack: Anker dual port charger (one)
40

• Charging cord (from charger to electrical socket); (one)
• Connecting cord (from computer to charger); (one)
• Protective case (one)
• Sealable canvas bag to hold all equipment (one)
7.2
Mobile Application
A custom-made software application, which runs on the Android platform, will be used for data collection
in the study. Census workers will enter all data directly into the application. The application is capable
of using Amharic letters, so census workers will type the names of all study participants in Amharic.
Census workers will be trained how to upload and download data.
At the initial census, there was
no pre-existing data so downloading is unnecessary, but census workers should upload each night when
they return from the ﬁeld. At a follow-up census, the pre-existing data from the most recent census will
be downloaded in the morning before going to the ﬁeld. The data will be updated in the ﬁeld, and then
uploaded when the teams return back to town at night.
The data will be uploaded to a secure online server on a daily basis so that the study team can monitor
census progress in real time.
7.3
Charging Devices
During training, the Carter Center study coordinator will be responsible for charging all devices each
night. This will be done at the coordinator’s hotel. The study coordinator will be charging 20 devices
and 20 chargers per night, so will need to bring suﬃcient power strips for this task. During the census,
the census workers will be responsible for charging their census phones and external batteries at home
each night.
7.4
Personnel
The Carter Center will advertise for and hire local census workers. Prospective candidates should be
familiar with technology, and quick to learn new tasks. Candidates should also be able to walk long
distances.
41

7.5
Training and Monitoring
The study coordinators from the Proctor Foundation and TCCE will run a 3-day training workshop at
the woreda center for all census workers to train them in the following topics:
• General use of the tablet computers
• Entering data into the mobile application
• Acquiring GPS coordinates with the device
• How to ask the census and household survey questions correctly
• Re-charging the device
After the in-class training, census workers are accompanied in the ﬁeld for training in a practice village
and for the ﬁrst few days of actual data collection to ensure that quality data is consistently collected.
A team leader is selected from each 3-person census team, and that person is responsible for team
supervision, ensuring good coverage of the cluster, uploading, and daily charging.
7.6
Census monitoring
The research coordinator will be responsible for monitoring enrollment and loss to follow-up during the
census. Salesforce.com will automatically generate a daily enrollment report, which will be emailed to
the principal investigator, Ethiopian study coordinator, and hygiene cluster coordinators on a daily basis
during active census periods.
42

Chapter 8
Annual Monitoring Visits
We will perform annual monitoring visits in all study clusters. At each visit, we will collect samples on a
subset of the population in the study cluster, as described below.
Note: we will only include the results of an annual monitoring visit in the ﬁnal analysis if they occur
three months or more after a round of mass drug administration. Mass drug administration would be
expected to greatly reduce infection in both treatment arms, which could potentially mask the eﬀect of
the hygiene intervention.
8.1
Sampling Strategies
8.1.1
Population-Based Sample
The population-based sample will consist of an age-stratiﬁed cross-sectional sample at each monitoring
visit (Table 3). Eligibility will be based on the most recent census (which will be completed annually
several weeks before monitoring visits). We will sample a separate cross-section of individuals at each
monitoring visit, so individuals may or may not be sampled at successive visits . We employ this strategy
in order to be able to obtain an unbiased population-based estimate of infection and other outcomes at
each visit of the trial.
8.1.2
Longitudinal Sample
For outcomes such as anthropometry, clinically active trachoma, and facial cleanliness, we are interested
in assessing changes within an individual. Therefore, we will also employ a longitudinal sampling strategy
for these outcomes. Speciﬁcally, we will assess longitudinally the entire cohort of children that is aged
0-5-years at baseline. As children are born, we want to capture them in this longitudinal sample as well.
To operationalize this, 0-12 month old children who are included in the population-based sample each
year are added into this longitudinal sample in the following year and going forward. For the outcomes of
43

face photographs, conjunctival photographs, dried blood spots, we will monitor the 0-5-year-old cohort
from baseline over the course of the study visits in both SWIFT I and II. We will monitor anthropometry
in the longitudinal sample during SWIFT I.
8.2
Preparation
8.2.1
Registration Lists
Registration lists must be made prior to going to the ﬁeld. This is done in Salesforce.com, keeping the
following points in mind:
• Make sure the census is complete.
Check in the app to make sure all households have been
completed.
• Make sure the sub-phase is set to Examination on the Geographic Work Unit object.
• Make sure you are logged in with an account that is set to the Ethiopian timezone.
• Navigate to the Geographic Work Unit and click on Create Morbidity Study.
• Generate a PDF to give to the mobilizer(s) for participant recruitment.
• Before going to the ﬁeld, download the registration lists on each tablet/smartphone. This requires
internet connectivity.
Supplemental Children: If the desired 80% coverage is not reached after 2 visits to a cluster, the
research coordinator or the study coordinator will add supplemental children. This is done in the Morbidity
Exam Phase tab on SFDC.
44

8.3
Training
8.3.1
Pre-Monitoring Visit Training
All new members of the San Francisco-based team will complete a training at the Proctor Foundation
before departing for Ethiopia. The training will focus on 1) travel to Ethiopia, 2) study background
and rationale, 3) how to perform the clinical exam and 4) how to perform all collection procedures and
protocols in order to standardize procedures among graders and tubers. The training will be led by the
Proctor research coordinator, with input from the laboratory technician on proper collection and data
recording techniques if necessary. The principal investigator or co-investigator will oﬀer in-depth training
on performing the clinical exam while in Ethiopia.
8.3.2
In-Country Training
Before the start of the study, local health workers will be selected to complete study ﬁeldwork and will
undergo a series of rigorous trainings and certiﬁcation in clinical grading and swab collection.
At the start of each successive collection phase, examination team members (nurses, lab workers and
other health workers from the Ministry of Health as well as general workers from WagHimra) will partic-
ipate in four-day training in WagHimra. Each team (registration, anthropometry, swabbing, and blood
collection) will participate in a role speciﬁc trainings and practice during these classroom days. The ﬁrst
1-2 days of ﬁeldwork are practice training days for all specimen collectors and graders on the data collec-
tion teams. The principal investigator and study coordinators will oﬀer on-going training and supervision
to all specimen collectors and graders in the ﬁeld throughout the SWIFT study monitoring visits.
8.4
Exam Team
8.4.1
Mobilizers
The Carter Center study coordinator will hire a community member from each monitored community to
mobilize the selected children and ensure a high turnout for the monitoring visit. This person will also
select the location for the monitoring visit set-up within the community and remove any study speciﬁc
hygiene materials that could unmask the outcome assessment.
8.4.2
Outcome Assessors
In collaboration with woreda health oﬃcials, the Carter Center study coordinator will hire lab workers,
nurses, and general workers from WagHimra to perform all outcome assessments. These workers will
receive a 4-day training session at the beginning of the monitoring visit to review all study procedures.
45

They will be masked to treatment allocation.
8.5
Registration Station
8.5.1
Personnel
One registration worker is needed per exam team. This person must be familiar with the mobile data
collection application, comfortable using a tablet/smartphone, and speak the local language. The regis-
tration person will be recruited from the general worker population in WagHimra.
8.5.2
Procedures
The Registration Station is always the ﬁrst station that study participants should visit. It should be
placed in a visible area. The registration worker performs the following:
• Download the registration list in the mobile application; normally this will be done before the team
arrives in the ﬁeld, in a location with good internet connectivity.
• Identify the participant on the list of potential participants from the mobile application, and click
the name to enter the participant’s registration page.
• Verify demographic information (name, age, sex, mother, father).
• Note the background color of the participant’s name in the mobile application. This color corre-
sponds to the exam station that they must visit.
• Place the next available sticker from the roll of random number stickers onto a bracelet with
the color the matches the participant’s background color in the application. This number is the
participant’s registration number.
• Write the participant’s full name onto the bracelet.
• Have the participant hold the bracelet below their chin, and press the photo button on the partic-
ipant’s registration data page such that a photograph is taken of the face that also includes the
person’s name and registration number.
• Fasten the bracelet around the participant’s wrist. This should be done fairly tightly, so that the
bracelet cannot be easily removed.
• Direct the participant to the next station.
46

8.6
Swab Station
8.6.1
Personnel
In collaboration with district health oﬃcials, the local study coordinator will hire staﬀfrom a neighboring
district to perform all swabs. The swabbers and tubers will be nurses or health staﬀ. Swabbing staﬀwill
receive a 4-day training session at the beginning of the monitoring visit to review all study procedures,
and will be masked to treatment allocation. Each swab team will be comprised of 3 people:
• Tuber: must be meticulous and detail-oriented
• Swabber/Grader: must have good clinical skills
• Photographer: must be familiar with the mobile data collection application and be a fast learner
8.6.2
Procedures
Scanning registration code
The photographer will use the bar code scanner function on the mobile application to scan the registration
code on the participant’s bracelet.
Clinical Photography
Four speciﬁc team members will be designated as photographer in order to ensure high quality pho-
tographs by an experienced photographer. The photographer will take photographs of the conjunctiva
with a handheld Samsung NX digital SLR camera with a macro lens (1:1). Conjunctival photography
causes no damage to the eye, is well tolerated by children, and is a standard clinical procedure at UCSF.
Clinical photography will be performed before conjunctival swabbing. Photography is incorporated in the
mobile application; photographs will be taken under a speciﬁc child’s record and therefore automatically
associated with the child’s unique identiﬁer. Photographs are stored on the memory card in the camera.
A compressed version of the photograph is synchronized to the study database along with the other data.
The full-size version of the photograph will be transferred to an external hard drive each week. Batteries
are charged each night; each camera bag has at least 1 spare external charger.
Photography Protocol
Equipment needed
• Camera: Samsung NX, which has the advantage of running on Android, and therefore has seamless
integration with the mobile application
47

• Miscellaneous equipment: Extra battery, media card reader, lens ﬁlter, extra media card
Camera Setup
• Lens: Samsung 60mm ƒ/2.8 macro lens
• Settings: The photographer does not need to adjust the camera settings because the settings are
automatically set by the mobile application according to the following parameters:
– White balance- automatic
– Aperture Priority
– F-stop: ƒ/32
– ISO 400
– Manual focus
– Flash: on (ﬁll-in)
– EV (brightness): 0
Conjunctiva Photograph Procedure
• Place participant into position that will allow maximum stability; standing, sitting or “head-clamp”
position. Employing a village volunteer to help is very useful.
• Extend lens fully, to the 1:1 position
• Image is brought into focus by changing the working distance, not by turning the lens. This is
because the lens is ﬁxed in its manual setting. The working distance is approximately 20 cm from
the eye with our current settings
• Take minimum of 2 photos. If there is any doubt of the quality of the photo while the patient is in
position it is better to continue to take more photographs before the patient is allowed to leave.
• Check photos before allowing child to leave. If they are not acceptable, repeat procedure. Only
stop if the patient or guardian requests that we stop, or if is deemed impossible, even with further
attempts.
• If the child cannot be photographed for some reason, it does not aﬀect the eligibility of the child. A
notation is made on the child’s record of why the photograph cannot be taken, but no replacement
is sought. This is expected to be a rare event.
Face Photograph Procedure
Face photographs are taken with the same camera and lens, using settings deﬁned by the mobile appli-
cation (same as above, except an F-stop of ƒ/11). The photographer stands approximately 1-2 meters
from the participant and moves the lens until the face ﬁlls the frame of the photograph, with only a
48

small amount of space between the chin/ears/cranium and the edge of the photograph.
Photo Troubleshooting Guide
Note all camera settings are permanently embedded in every photo that is taken and can be viewed
with the camera or with any standard commercial photo-viewing software (e.g., Adobe Photoshop; Pho-
tomechanic, Nikon View, Canon, etc.)
• Photos too dark: Make sure ﬂash is functioning.
If ﬁrst photos in series are acceptable and
then they gradually become less exposed (darker) it might be because the battery is gradually
losing power during the session. Note that the ﬂash reaction time increases as the battery power
decreases.
• Image not centered: Movement of child or camera (hold child’s head between knees of “helper”;
stabilize camera with second hand)
• Reﬂection artifact: Move camera slightly between ﬁrst and second photos to achieve diﬀerent angle;
gently dab conjunctiva with swab- must be done at periphery to avoid creating inﬂammation
Conjunctival exam/swab
Gloving
Any hand that will touch a participant’s skin must be gloved for the examination. The examiner will put
latex gloves on both of their hands prior to touching a participant’s skin, and a new pair of gloves will
be used for each participant. Instant Hand Sanitizer will be available for hand sanitization.
Equipment
• Swabbing/tubing: tubes, swabs, labels, tube box, cooler, cold packs, metal container for swabs,
aprons, garbage bags, absorbent blue pads/chucks, hand sanitizer
• Grading: 2.5X loupes, penlight
• Photography: camera, external battery and cord, lens wipes
Examination Position
• Young children: The examining position to be used in the ﬁeld for young children will be the classic
pediatric ophthalmic examination technique. With the aid of a helper seated directly opposite to
the examiner, the child will be positioned with his/her head between the examiner’s knees, with the
child’s face looking upwards toward the examiner. The legs of the child will be straddled across the
helper and the arms held gently across the child’s chest. Care should be taken to keep the child’s
eyes above the level of the examiner’s knees, in order to properly take the conjunctival swab.
49

• Older children/adults: For examining adults and older children, the participant should stand or sit
facing the seated examiner, such that the participant’s eyes are at the examiner’s eye-level.
Everting the Upper Eyelid
For all participants, only the right upper eyelid will be examined; the only exception to this is if the
right eye is diﬃcult to examine due to eye disease or injury, in which case the left eye will be examined.
In order to avoid passing contamination from the child into the eye, once the examiner dons a new pair of
gloves, their gloved hands should not be used to position the child. The examiner uses their ﬁngertips to
grasp the central portion of the participant’s upper lid eyelashes. The upper lid is then everted, using a
ﬁnger of the examiner’s other hand (or the end of a sterile swab) as a fulcrum, positioned superior to the
tarsal plate. The everted lid is held in place by the examiner’s non-dominant hand holding the eyelashes
against the orbital rim, thus keeping the examiner’s dominant hand free for swabbing the participant’s
tarsal conjunctiva later.
Trachoma Grading
The examiner uses the 2.5X magnifying ocular loupes to assess the tarsal conjunctiva of the everted
upper right eyelid. The examiner will grade the conjunctiva according to the World Health Organization
Simpliﬁed Trachoma Grading Scale, as shown in Table 4. A hand-held penlight will be used by the
examiner for illumination of the conjunctiva at all times; the only substitute for this is direct sunlight.
The examiner tells the trachoma grade to the photographer, who records the grade into the mobile appli-
cation on the Samsung camera. Before being allowed to grade in the ﬁeld, each grader must complete a
training workshop and pass a photographic test with a kappa of 0.6 or greater relative to a gold standard
grade, where the gold standard is the consensus grade from a panel of 3 expert graders,
50

Procedures
In this trial, we will collect 2 swabs. The examiner uses a separate pair of gloves for each study participant.
We will store the swabs in microcentrifuge tubes without transport media.
• The tuber opens a Dacron swab in a sterile manner, revealing only the tip of the swab shaft, with
the swab head itself remaining sterile deep within the sachet, and makes it available to the swabber
to take.
• The swabber passes the Dacron swab ﬁrmly over the right everted upper tarsal conjunctiva three
times, rotating 120ºC between each pass.
• The tuber holds a tube with the cap open
• The swabber deposits the swab in the tube, and snaps oﬀthe shaft of the swab. This should not
require counterpressure with the tube cap.
• The tuber ﬁrmly screws closed the cap. The tuber checks to make sure that the swab is at the
bottom of the tube and taps the tube until the swab falls.
• The tuber places the tube in the tube box within the cooler. Tubes are put in chronological order
of swabbing, ﬁlling a horizontal row, starting with the top left-hand corner of the box.
• The tuber closes the cooler in between swabs.
Control swabs Two sets of control swabs will be taken in the course of examinations:
• Negative "air" swabs: a swab will be waved in the air, taking care not to contaminate the swab.
This will be done near the beginning and end of the work day. The tuber and swabber should
collect these swabs when they are still in position with all of their equipment (cooler, tube box,
loupes, etc. and personal protective equipment (apron, chuck, gloves) in place. The tube codes
are scanned into the mobile application in the designated ﬁeld.
• Duplicate swabs: The mobile application will randomly select 2 participants per community for a
duplicate swab. The swabber will collect duplicate swabs from these participants.
Transportation and Storage of Conjuntival Samples In accordance with the Abbott RealTime protocol,
swab samples taken in the ﬁeld will be transported on ice in a closed, insulated container, and then
transfered within 8 hours to a -20°C freezer at a local health center. Swabs will be shipped within 4
weeks to the APHI, where they will be stored at -20°C before being processed.
Nasopharyngeal Specimen Collection
At baseline (month 0, the study’s midpoint (month 36), the ﬁnal study visit (month 84), we will collect
nasopharyngeal swabs from 15 randomly selected children aged 0-5 years per community. We selected
this age group because pre-school children in sub-Saharan Africa have been shown to have high rates of
pneumococcal carriage.39
51

• Immediately after completion of the conjunctival eye swab collection (and if necessary, control
swab collection), the tuber will select an NP swab and open the swab sachet in a sterile manner
(revealing only the tip of the swab shaft, with the swab head itself remaining sterile deep within
the sachet).
• The examiner will remove the NP swab from the sachet and place the tip into the participant’s
nasopharynx.
• The examiner will quickly rotate the swab 120° three times back and forth, and then remove the
swab from the nose.
• The examiner will place the swab in a tube containing 1.0 mL of STGG (skim milk, tryptone,
glucose, and glycerin) media. The tuber will cut the handle oﬀusing sterile scissors (cleaned with
alcohol pads between participants). The tuber will close the cap of the STGG tube with the swab
immersed.
• We will keep the swabs on ice in the ﬁeld and then in a -20°C freezer as described above for
the conjunctival swabs. The Amhara Public Health Institute will process the swabs using media
selective for Streptococcus pneumoniae, and then test for antibiotic resistance to erythromycin,
penicillin, tetracycline, and clindamycin using the Kirby Bauer disc diﬀusion assay.
Materials for NP Collection
• Nasopharyngeal Swabs: Specimens will be collected using sterile, individually-wrapped pediatric
calcium alginate swabs with a malleable plastic swab shaft for patient comfort and safety
• Nasopharyngeal Sample Tubes: All ﬁeld samples for DNA testing will be collected into sterile 2.0ml
microcentrifuge tubes, manufactured by RPI®.
• Cooler Bags with Frozen Ice Packs: Insulated cooler bags will be used to carry samples to and
from the ﬁeld. In addition, frozen gel ice packs designed to thaw slowly will be used to maintain
the temperature in the cooler bags during transport.
• -20°C Freezer: A standard -20°C freezer will be used strictly for the storage and freezing of ice
packs and samples. This freezer is kept in a locked room on the grounds of the Health Center,
which is under 24-hour security guard supervision.
• Latex Gloves: latex examination gloves will be used to perform nasopharyngeal examinations. Each
glove will be used once and never shared between participants. Used gloves will be collected in a
trash bag and incinerated at the local Health Center incineration facility.
Transportation and Storage of Nasopharyngeal Samples The nasopharyngeal swab samples in skim milk-
tryptone-glucose-glycerin (STGG) will be initially stored in the ﬁeld using Yeti cooler bag ﬁlled with
Fisher brand ice gel packs and then transferred along with the conjunctival swabs ﬁrst to a -20 freezer
in WagHimra and then to Bahir Dar.
52

8.7
Anthropometry
Using methods we have already used in several studies in Ethiopia and Niger, we will measure the
height, weight, and middle upper arm circumference (MUAC) of the longitudinal cohort of 0-5 year-old
children.8,40 Each index will be measured in triplicate and the median measurement used for analysis. We
will use a Shorr Board to measure height, Seca 874 ﬂoor scale to measure weight, and standard Ministry
of Health distributed MUAC tapes to measure MUAC. Anthropometric measurements in previous studies
have had excellent repeatability, and we have found such assessments to be feasible and inexpensive. We
will urgently refer any children with severe acute malnutrition, deﬁned as MUAC <12.5cm, to a local
health clinic for treatment. The guideline for referral was recently changed from 11cm to 12.5cm by a
new government guideline.
8.7.1
Observe Signs of Malnourishment
When the participant presents for examination, ﬁrst examine him/her for signs of malnourishment:
• Kwashiorkor: look for edema or swelling; thin, sparse, or discolored hair; and skin with discolored
patches that may crack and peel.
• Marasmus: look for severe wasting; the appearance of ‘skin and bones;’ and a face that looks like
an old man’s.
• Pedal edema: look for swelling due to excess ﬂuid in the foot. Press the child’s foot with your
thumb. If the foot is swollen and the indentation remains after you press it, the child has edema.
8.7.2
Measuring and Recording Guidelines
Measurements are taken to the nearest 0.1 cm (1.0 mm) for height/length and MUAC, and 0.01 kg for
weight.
8.7.3
Measuring Length and Height
A lightweight measuring board will be used to measure the participant’s height to the nearest 0.1 cm.
Height/length will be assessed with a ShorrBoard (ShorrBoard®, Shorr Productions, LLC, Olney, MD,
USA).
Length: If a child is less than 2 years old, measure recumbent length. In the app, select L to indi-
cate that length was measured. A child’s length is measured lying down (recumbent).
Height: If a child is aged 2 years or older and able to stand, measure standing height. In the app,
select H to indicate that height was measured. Height is measured standing upright.
53

If the child has braids or hair ornaments that will interfere with length/height measurements, remove
them if possible. Check that any shoes or socks have also been removed.
Whether measuring length or height, the mother or guardian is needed to help with measurements
and to soothe and comfort the child. Explain to the mother the reasons for the measurements, and the
steps in the procedure. Answer any questions she might have. Show her and tell her how she can help
you. Explain that it is important to keep the child still and calm to obtain the best measurement.
Procedures for Length Measurement
• Cover the length board with a chuck (or another absorbent, disposable material) for hygiene and
for the baby’s comfort.
• Explain to the mother that she will need to place the baby on the length board and then help to
hold the baby’s head in place while the measurement is taken. Show her where to stand when
placing the baby down (i.e. opposite you, on the side of the length board away from the tape).
Also show her where to place the baby’s head (against the ﬁxed headboard) so that she can move
quickly and surely without distressing the baby.
• When the mother understands your instructions and is ready to assist: Ask her to lay the child on
his back with his head against the ﬁxed headboard, compressing the hair.
• Quickly position the head so that an imaginary vertical line from the ear canal to the lower border
of the eye socket is perpendicular to the board. (The child’s eyes should be looking straight up.)
Ask the mother to move behind the headboard and hold the head in this position.
• Speed is important. Standing on the side of the length board where you can see the measuring
tape and move the footboard:
– Check that the child lies straight along the board and does not change position.
– Shoulders should touch the board, and the spine should not be arched. Ask the mother to
inform you if the child arches the back or moves out of position.
– Hold down the child’s legs with the one hand and move the footboard with the other. Apply
gentle pressure to the knees to straighten the legs as far as they can go without causing injury
or distress. Note: it is not possible to straighten the knees of newborns to the same degree
as older children. Their knees are fragile and could be easily injured, so apply only minimum
pressure.
– If a child is extremely agitated and both legs cannot be held in position, measure with one
leg in position.
– While holding the knees, pull the footboard against the child’s feet.
• Upon reading the measurement, the examiner will clearly call out the number to the recorder.
Record the child’s length in centimeters to the last completed 0.1 cm. (1.0 mm).
• Keeping the child in place, release the sliding footboard, and prepare to repeat the measurement.
Re-position the child for a second and third measurement.
54

Figure 7: Measuring Length
Procedures for Standing Height Measurement
• Ensure that the height board is on level ground with a wall or tree behind it to support the
backboard.
• Working with the mother or another helper, and kneeling/bending in order to be at the level of
the child:
– Help the child stand on the baseboard with the weight of the child evenly distributed on both
feet.
– The heels of the feet are placed together with both heels touching the base of the vertical
board.
– Place the feet pointed slightly outward at a 60-degree angle.
– The back of the head, shoulder blades, buttocks, calves, and heels should all touch the vertical
board. Arms should hang freely by the sides of the body with the palms facing the thighs.
Note: Standing with all body parts touching the board may be diﬃcult for some children, in
which case, help the child to stand on the board with one or more contact points touching
the board.
– Ask the helper to hold the child’s knees and ankles to help keep the legs straight and feet
ﬂat, with heels and calves touching the vertical board. Ask her to focus the child’s attention,
soothe the child as needed, and inform you if the child moves out of position.
– Position the child’s head so that a horizontal line from the ear canal to the lower border of
the eye socket runs parallel to the baseboard.
– Ask the child to inhale deeply and to stand fully erect without altering the position of the
heels. If necessary, push gently on the belly to help the child stand to full height.
55

Figure 8: Measuring standing height
– Still keeping the head in position, use your other hand to pull down the headboard to rest
ﬁrmly on top of the head and compress the hair.
• Upon reading the measurement, the examiner will clearly call out the number to the recorder.
Record the child’s height in centimeters to the last completed 0.1 cm (1.0 mm).
• Keeping the child in place, release the sliding headboard, and prepare to repeat the measurement.
Re-position the child for a second and third measurement.
Dismantling the Shorr Board
• Stand the board upright: face the board and step on the base with one foot to keep it stable.
• Slide the head/foot piece into the base of the main board.
• Release the clasp on the back of the extension piece and remove it. Push the clasp FLAT against
the extension piece.
• To attach the extension piece to the main board, turn the front of the extension piece inward and
place it against the front of the main board. Make sure that all sides of the extension piece are
straight and in line with the main board.
• Push on the bolt that is on the back of the extension piece and screw it into the main board.
• Put the board back inside of the carrying case for storage until your next use.
56

Figure 9: Points of contact
8.7.4
Measuring Weight
The SECA 874 scale or suitable alternative will be used to weigh infants and children to the nearest 0.01
kg (Seca 874 ﬂat ﬂoor scale, seca GMBH Co. Kg, Hamburg, Germany). Infants and young children
can also be weighed simultaneously with their parent or guardian by the unique “mother-baby” function
(parent or guardian is weighed and then the infant or child is weighed while held by the parent).
Explain to the parent that we want to weigh their child to see how he or she is growing. If she has
a baby or a child who is unable to stand, s/he will hold the child on the scale. If the child is 2 years or
older, the child will be weighed alone. Children should be wearing only light clothing, no shoes, no hair
ornaments, and no jewelry. Explain that the child needs to remove outer clothing and shoes in order to
obtain an accurate weight. If the baby is wearing a diaper, the diaper should be removed. If any heavy
clothes remain on the child, make a note in the notes section of the app.
Procedures
• Remove scale from bag.
• Be sure that the scale is placed on a ﬂat, hard, even surface. All 4 legs of the scale should make
contact with the ground surface without wobbling.
• Turn the power on the scale when you are ready to begin weighing the child.
– Note: When batt appears in the display, you should change the batteries. Remove the old
batteries and insert 6 new batteries.
• Press the start key with no load on the scale. The scale is ready for use when it sets to 0.00.
57

– Note: if necessary, switch the weight display to KG: hold down the 2 in 1 key for about 3
seconds.
• Weighing the child alone
– Ask the child to stand in the middle of the scale. Once on the scale, the child must stand
still. The HOLD function is automatically activated for weights over 1.5 kg/3.3 lbs. The
display ﬂashes until a stable weight has been measured. The display is then frozen until the
next weighing operation.
– Note: If the child jumps on the scale or won’t stand still, you will need to use the 2-1 tared
weighing procedure instead.
– The positioner will clearly call out the child’s weight to the recorder. Record the child’s weight
to the nearest 0.01 kg.
– Have the child step oﬀand back onto the scale
– The positioner will clearly call out the child’s weight to the recorder.
– Record the child’s weight to the nearest 0.01 kg.
– Repeat one more time
• 2-1 feature: If the child is unable to stand on the scale, you will use the 2 in 1 weighing function
(called tared weighing). The 2 in 1 function enables the weight of babies and small children to be
determined while an adult holds them.
– Ask the adult to stand in the middle of the scale without the child. She should remove any
long garments, as these can cover the display and also lead to variable measurements.
– After the mother’s weight appears on the display, tell her to remain standing on the scale.
Press the 2 in 1 key to activate the function.
– The scale stores the weight of the adult and the display returns to zero. When 0.00 appears
on the display, hand the child to the adult. The scale will determine the weight of the child.
Once the value is stable for about 3 seconds, the weight is measured.
– Note: If a mother is very heavy (e.g. more than 100 kg) and the baby’s weight is relatively
low (e.g. less than 2.5 kg), the baby’s weight may not register on the scale. In such cases,
have a lighter person hold the baby on the scale.
– Repeat the measurement 2 more times. Note that only the baby needs to be removed from
the scale; the mother may remain on the scale the entire time.
– To turn oﬀthe 2 in 1 function, press the 2 in 1 key. The 2 in 1 function remains on until you
press the 2 in 1 key again, or until the scale switches oﬀautomatically.
– If several children are to be weighed consecutively with the same adult holding the babies,
it is important that this person’s weight does not change due to a piece of clothing being
removed/added.
• The scale automatically turns oﬀafter 2-3 minutes
58

Figure 10: Measuring MUAC
Scale Calibration
We have shown that the weight measurements captured from the Seca 874 do not change over time,
even in ﬁeld conditions.8 In order to monitor the calibration of the scales over time, each team will weigh
a 5 kg test weight at the beginning and end of the day. This measurement will take place at the site of
the scale storage so that the weights do not need to be carried to the ﬁeld.
8.7.5
Measuring MUAC
The child’s MUAC will be measured at the midpoint of the right arm between the tip of the shoulder
and the tip of the elbow, to the nearest millimeter using non-stretch MUAC tapes used by the Ethiopian
Ministry of Health and interpreted according to WHO guidelines41 .
Procedures for Measuring MUAC
• Have the child stand up straight with the arms relaxed at the sides. The examiner will stand facing
the child’s right side.
• The measuring tape is placed around the upper arm at the arm’s mid-point.
• Wrap the tape around the arm, pulling it to lie ﬂat against the surface of the skin. Be careful not
to pull the tape too tightly (to compress the skin).
• Read the number that lies between the two arrows on the window on the MUAC tape. Make sure
that the lines inside and outside the window are completely aligned (that the line inside the window
is not tilted). Upon measuring, the examiner will clearly call out the number to the recorder. Record
to the nearest 0.1 cm (0.1 cm = 1 mm).
59

8.7.6
Materials for Anthropometry
• ShorrBoard
• Seca scale
• MUAC strips (2)
• Chucks
• Marker
• Trash bags
• Extra set of AA batteries (6)
8.8
Dried Blood Spots
The gold standard microbiological test for detecting ocular chlamydia infection is a nucleic acid ampliﬁ-
cation test of a conjunctival swab. However, new serological tests being developed by the United States
Centers for Disease Control and Prevention (CDC) are promising diagnostic modalities for monitoring of
trachoma elimination. A positive test indicates a previous exposure to chlamydia as opposed to current
infection; antibodies remain detectable even after a mass azithromycin treatment.42 Preliminary testing
in a hypoendemic setting in Tanzania has shown that serologic results in 1-3 year-old children is correlated
with the prevalence of ocular chlamydia infection in a community, suggesting that the serology results
in young children may provide information about the level of transmission.43 Current serologic methods
are expensive, but the CDC is currently developing a much simpler and less expensive lateral ﬂow assay
(LFA) for use with eluted dried blood spots.44
In a setting where ocular chlamydia transmission has been eliminated, the youngest children will not
be exposed to chlamydia and therefore should not have a positive serological test. The serological test
in young children may therefore be a sensitive measure of chlamydial transmission within a community.
Furthermore, we will use the blood spots to test antibody responses to other diseases of interest including
helminths, intestinal bacterial pathogens, and intestinal protozoal pathogens. These tests are still being
developed, but we anticipate that they will have been optimized by the time of the conclusion of this trial.
Therefore, we will also collect dried blood spots from all children aged 0-9 years in the population-based
sample each year. We will lance the index ﬁnger of each child and express 4-5 dried blood spots onto a
TropBio ﬁlter paper. Filter papers will be labeled with a random number identiﬁcation sticker and stored
in the -20 freezer for later processing in Atlanta.
8.8.1
Steps for Blood Spot Collection
• Inform the mother that her child’s ﬁnger will be pricked to obtain blood to test for trachoma and
other diseases. Describe the ﬁnger prick procedure, reassure her, and answer all questions. The
60

blood specimen should be collected as described below to minimize the discomfort of the child and
to ensure suﬃcient blood volume collection.
• Label the ﬁlter paper with the corresponding random number sticker.
• Enter the child’s information from their bracelet and scan the ﬁlter paper’s code.
• Put on gloves
• Prepare the disposable lancet. Make sure to use a new disposable lancet for each child. Do not
re-use lancets.
• Position the child for the ﬁnger stick. Make sure that the child’s hand is warm and relaxed. It
should be below their heart.
• Hold the child’s thumb, middle, or ring ﬁnger between your left thumb and ﬁnger
• Gently stimulate blood ﬂow towards the puncture site by lightly squeezing the child’s thumb or
ﬁnger from the top of the knuckle towards the ﬁngertip
• Disinfect the ﬁnger with alcohol wipe.
• Prick the side of the thumb/ﬁngertip
• For the best blood ﬂow and least pain, prick the side of the thumb/ﬁngertip, not the center.
• Wipe away the ﬁrst 2 drops of blood with a new sterile cotton ball
• Grip the ﬁlter paper on the side without small circles.
• Place a droplet of blood from the ﬁnger onto ﬁve of the six circles. To ﬁll the cirle, touch the side
of the circle. Fill the side whole cirle before moving on to the next cirle. It is more important to
completely ﬁll the cirles than to put blood on all 5 cirlces.
• Leave the last circle blank.
• Note: Allow blood to ooze out on its own. Do not squeeze forcefully avoid “milking” as it may
dilute the blood with tissue plasma.
• Carefully slide the ﬁlter paper onto a pencil to air dry for at least an hour. There should be about
1 cm in between each sample. Secure the pencil into a Styrofoam surface in a cardboard box.
• When dry, place each blood spot paper into an individual small plastic bag while wearing gloves
• Combine all bagged samples in a larger community bag. Add desiccant packets
• Label large bags with:
– SWIFT “visit number”
– Cluster name
– Number of samples collected
– When were samples collected: (e.g. 19JAN2019)
61

Risk minimization
It is important to handle all specimens with care to minimize risk of infection.
• Wear gloves: New gloves must be worn for each child.
• Have the child hold the cotton ball. Do not place on table because it can contaminate the table.
• Clean spills: In the event of a blood spill or splash, clean immediately with disinfectant and wipe
with absorbent material.
• Disposal of sharps: All lancets must be disposed of properly in sharps containers.
Materials for Blood Collection
• Gloves
• Disposable lancets
• Alcohol wipes
• Cotton balls
• 10% household bleach to clean spills
• Absorbent material for spills (cotton)
• Sharps container
• TropBio circular cards
• Small zip plastic bags
• Desiccant packs
• Large Ziploc bags (handful)
• Materials for drying apparatus: 12 sharpened pencils, Styrofoam, cardboard box
62

Chapter 9
Data Collection, Management, and
Quality Assurance
Similar to our previous studies, all study personnel who assess outcomes will attend an intensive, 2-
day training session prior to the annual census, monitoring, and treatment visits. Study personnel will
collect all data from the census, monitoring, and treatment visits on tablet computers using a mature
custom-built mobile application. Data will be uploaded to a secure Salesforce.com server.
9.1
Data Collection Tools
9.1.1
Tablet Computers
The Proctor Foundation will provide training on operating tablet computers to all data collectors. In our
experience, a tablet computer typically retains its charge for a full day’s activities, though each team will
also have a backup battery pack. Tablets and batteries will be charged overnight in safe, secure houses
or a hotel.
9.1.2
Mobile Application
A custom mobile application will be used for all census, monitoring, and treatment visits. For monitoring,
this software assigns a unique identiﬁcation number to each study participant enumerated during the
census. The software integrates the monitoring visits with the census information by linking to this
unique identiﬁer. We will provide training to use this mobile application for all study activities.
63

9.1.3
Data Uploading
Data should be uploaded every day that data is collected. Data is uploaded from the devices after logging
in online, and navigating to the Upload Status page. Before logging in, the user can choose whether to
upload photos or not, by selecting the appropriate box in the Settings page.
Non-photo data:
We will routinely upload data from the tablet computers to Salesforce.com servers using local mobile
connection. Non-photo data normally uploads within a few minutes.
Photo data:
Photograph ﬁles are larger and can take a longer time to upload. If good mobile connection or wiﬁis
available, photographs can be uploaded in the ﬁeld. If a good mobile connection or wiﬁis not available
at the ﬁeld site, then photos can be uploaded from the tablets once the study coordinator returns to the
Carter Center Ethiopia headquarters.
9.1.4
Data Downloading
Data should be downloaded whenever the mobile application needs to be populated with pre-existing
data. Data is downloaded by logging in online and navigating to the Upload Status page. Key times
when data should be downloaded include:
Census:
Before going to the ﬁeld for a follow-up census, data from the previous census phase should be downloaded
for the study cluster being visited that day.
By doing this, all previously entered information about
individuals and households will appear in the application, and the worker must only update the status
ﬁelds, but not re-enter names/ages, etc.
Examination:
Before going to the ﬁeld for any examination, the registration list data must be downloaded on all tablets.
This is absolutely crucial for the registration tablet, but also important for the swabbing stations, since the
counts of participants from the registration list is used in the algorithm of choosing random participants
for duplicate samples.
64

Treatment:
Before going to the ﬁeld for any treatment phase, data should be downloaded to the tablet. Only by
doing this will the worker know who needs to be treated.
9.2
Data Consistency and Validity
Through range checks, the software ensures to a large extent that there are no inconsistencies or invalid
data.
The software will create an error ﬁle with relevant data such as the form identiﬁcation, ﬁeld
names and data. Data consistency and errors will also be monitored from Dashboards that are created
in Salesforce.com. A Dashboard is a real-time tabulation of data from the trial, and can be used to
monitor: enrollment, completion of the phase, number of doses of medication used, number of swabs
collected, missing data from the examination phase, and other pertinent information.
9.3
Data Model
The data is organized as a relational database with several objects:
• Geographic Work Unit (GWU; normally the randomization unit)
• Household (HH)
• Person
• Treatment
• Morbidity Exam Phase
• Morbidity Child Details
• Exam Station
• Test Samples
• Conjunctiva
9.3.1
Census
The census data entry uses the GWU, HH, and Person objects. When a new individual or household is
entered, this creates a master record that can be changed at any point in the study. At each census visit,
at the end of the data collection, the worker must press Census Complete. Pressing this button creates
a Snapshot record that records the data as of the time the census is completed.
65

9.3.2
Exam
After the census for the entire study cluster is performed, a registration list is made by logging into Sales-
force and navigating to the GWU object for the study cluster of interest. After setting the sub-phase to
Exam, the New Morbidity Study button is clicked. Doing so will create a list of Morbidity Child Details
records, and it is these records that are downloaded to the tablet to populate the registration list during
the examinations.
During the exam visit, the participant checks into the Registration Station and has a registration code
associated with the Morbidity Child Details record. This registration code is then scanned into the tablets
of all subsequent stations. The registration code is the way to link each of the measuring stations (e.g.,
each of the conj. swabs) to the Morbidity Child Details object, and hence, to the Person and Household
pages from the census.
9.3.3
Treatment
Before going to the ﬁeld, the GWU subphase must be changed to treatment. Doing so will cause the
treatment assignment and medication icons to appear in the application. The view for the worker is
the same as for the census, except icons indicate who needs to be treated and who has been treated.
A treatment record is created when the treatment icon is pressed, and the relevant dosing information
entered. Note that treatment records belong to a particular Snapshot and are never treated as a Master
record.
9.4
Data Collection
The data collection application is available in Amharic and English. Data is collected in Amharic.
9.4.1
Census
The following data is directly input into the mobile application during the census visit:
• Village name, schools/clinics/water sources used by village
• Household identiﬁers (address, phone, GPS coordinates)
• Consent
• Name, age, and sex of household members
• Location and status of household members
• A hygiene survey is collected during the census for 33% of households
66

Household numbers and individual numbers for further identiﬁcation of individuals within each household
will be automatically assigned by the application and Salesforce.com. After the household information
is entered, the Census Complete button is pressed. Pressing this button creates a snapshot of the data,
and is used for registration lists. Data can be updated after pressing Census Complete, but these updates
will be applied only the the Master Record, and not to the Snapshot.
9.4.2
Examinations
The following data is directly input into the mobile application during the examination visit:
Registration tablet:
Name, age, sex are pre-populated when the registration list is downloaded; these are conﬁrmed. A regis-
tration code is taken from a roll of unique random number stickers and placed on a participant bracelet.
The bracelet color chosen for a participant to wear should correspond to the color on the participant’s
registration page; this color indicates which stations the participant must visit. The registration code
is scanned into the participant’s page with a bar code scanner. The worker takes a face photo of the
individual to help track them to resolve data discrepancies at a later time; this photo should also include
the registration code and the name of the participant.
Swab tablet/camera
The photographer is responsible for all data entry at the Swab Station. The main menu for the swab
station on the mobile application has various colors that correspond to the colors of bracelets being
used for the study. It is important to select the correct tab based on the participant being examined
(e.g., the color tab that matches the color bracelet). The diﬀerent colored tabs correspond to diﬀerent
complements of tests, so if the incorrect color is pressed, then that participant will not have the correct
tests performed.
After pressing the color tab, the participant’s bracelet is scanned with a bar code
scanner. A list of buttons with the required tests appears; the swab sites on the list should be performed
in order, from top to bottom. In each subsequent button, it is possible to enter age and sex information;
this should be done only once.
• Conjunctiva: The default eye being examined is the right eye, but this can be changed by pressing
the Left tab. Photographs are taken. The trachoma grade reported by the Swabber is entered; this
is a multi-select ﬁeld (TF, TI, TT, TS, CO). After the conjunctiva and nasopharyngeal swab(s)
are taken, the appropriate tube’s random number sticker is scanned with the bar code scanner.
• Negative controls: In order to assess the possibility of ﬁeld contamination of swabs, a negative
control swab is performed at the beginning and end of the day and entered into the appropriate
ﬁeld in the application.
67

• Positive controls: For all swabs, a random 5% of participants will be selected by the application
to have a duplicate swab. This is evident because a second button appears next to the required
duplicate swab after scanning the participant’s bar code.
Anthropometry tablet
The anthropometry section functions like the swab station screen, with colors for diﬀerent groups. The
anthropometry data collector will select the correct tab based on the participant being examined (e.g.,
the color tab that matches the color bracelet). After pressing the color tab, the participant’s bracelet is
scanned with a bar code scanner. The data collector enters the participant’s age and sex information.
Height and weight will be entered in triplicate for each anthropometry study participant. MUAC will be
entered once for each study participant The presence or absence of kwashiorkor, marasmus, and pedal
edema will be noted for each participant. This data will be entered into the app, which employs data
validation.
Blood tablet
The blood section functions like the swab station screen, with colors for diﬀerent groups. The blood
data collector will select the correct tab based on the participant being examined (e.g., the color tab that
matches the color bracelet). After pressing the color tab, the participant’s bracelet is scanned with a bar
code scanner. The data collector enters the participant’s age and sex information.
Before the blood spots are taken, the blood spot’s random number sticker is scanned with the bar
code scanner.
9.4.3
Treatment
During the treatment visit, any data from the census can be updated. following data is directly input
into the mobile application during the examination visit:
• Treatment consent
• Medication distributed
• Medication dose
9.5
Costing data
Cost related data will be collected on standardized paper forms. The Proctor Foundation research coordi-
nator and Carter Center study coordinator will be responsible for training the driver/logistics coordinator
68

and the hygiene cluster coordinators in ﬁlling out the costing forms. We will use paper cost forms, with
data double-entered into a database by Carter Center personnel in Addis Ababa. During data entry,
computers will be automatically backed up once daily.
9.6
Data Security and Storage
Databases at the central site will be stored on an encrypted server in a temperature-controlled locked
room at the Proctor site, and oﬀ-site backups will be maintained.
Backup encryption keys will be
maintained oﬀ-site in a secure vault. Database procedures will include full transaction logs. The DSMC
can make requests to have access to the data at any point during the course of the study.
9.7
Sample Organization and Storage
9.7.1
Sample Organization
The samples are automatically linked to the person-data via the Salesforce.com database and the appli-
cation that was built for this study. Once samples and sample organization data from Salesforce.com are
received by the Amhara Public Health Institute, a staﬀmember uses an electronic data capture system
(Brady Code Reader 3.0) to scan the random number stickers on the sample tubes. These are exported
as an Excel ﬁles and sent to San Francisco for the pooling algorithm.
Samples are organized according to collection time point and study cluster. A detailed sample stor-
age chart is created by the lab staﬀfor each visit and all samples are linked with the study database.
9.7.2
PCR Pooling
Computerized randomization is utilized to prepare samples for pooling.
9.7.3
Sample Storage
Samples will be stored at the Amhara Public Health Institute in -20° freezers. APHI has a protocol to
monitor the temperature of the freezers and switch to generator power when needed.The PCR samples
are stable if stored at -20°.
After the analyses are completed, all positive samples and a random 10% of negative samples will
be banked for future analyses. While samples will be processed in a timely manner, the researchers will
not have to contend with sample degradation concerns in relation to time elapsed between data collec-
tion and processing. This allows the researchers to continue to utilize the samples for additional future
analyses.
69

Chapter 10
Outcome Assessment and Laboratory
Procedures
10.1
Photograph Reading Center Overview
The Reading Center for grading of conjunctival and face photographs will be based at Gondar University.
Three graders will independently grade each photograph, masked to treatment allocation. We will choose
the consensus or median grade for all outcomes. We will assess inter- and intra-observer agreement with
kappa statistics.
10.1.1
Facility/Equipment
A dedicated room with a two computer monitors will be used to grade photographs. Full-screen pho-
tographs will be read at 26 inches with the shades drawn and lights oﬀ.
10.1.2
Naming Conventions
The Proctor data analyst and program manager will be responsible for organizing the photographs taken
during the study. The photos are stored on Salesforce, and they are labeled with an “attachementID”
code. The program manager will download the photos and their metadata including the photo code, the
phase they were taken during, and the participant’s master record that they belong to. The photos will
be uploaded to the oﬄine program and linked to their metadata for grading.
10.1.3
Storage
Photographs are stored on the Salesforce.com server and on two separate external hard drives.
70

Figure 11: Questions for conjunctiva grading
71

10.1.4
Grading Clinical Conjunctival Photographs
Six ophthalmology residents will grade the photographs at the conclusion of SWIFT I and the conclusion
of SWIFT II. They are masked to treatment allocation. We will present graders all photographs taken from
a phase for one individual. Graders will grade the set of photographs together for photo quality, follicles,
inﬂammation, scarring according to the grading scale described in ﬁgure 11. We chose this grading
system because it provides enhanced granularity of grades compared to other grading scales, allowing for
detection of more subtle diﬀerences in clinical trachoma. Graders will also compare the initial and ﬁnal
photographs of the set and document whether the ﬁnal photograph has less, more, or equivalent follicles
and inﬂammation compared with the initial photograph. Note that each set of photographs will have
between 1 and 4 photographs, depending on how many photographs the photographer took during the
monitoring visit. We use photographic grades as the co-primary outcome of the trial since high quality
photographs have good agreement with in-ﬁeld grades, and oﬀer the beneﬁt of a masked outcome.45,46
10.1.5
Assessment of Facial Cleanliness
The ophthalmology residents will grade the face photographs for each child. The photos will be organized
and uploaded in the same way as the conjunctiva photos. The photo set (1 child’s face photos at 1
phase) will be graded on photo quality and the presence or absence of the following items: dust or
dirt on the face, food on the face, dry secretions around the eyes, wet secretions around the eyes, dry
secretions around the nose, and wet secretions around the nose. The number of ﬂies on the face will
also be counted. The grader will be masked to treatment allocation. Note that this is a novel way to
determine facial cleanliness, and should result in complete masking of observers.
10.2
Chlamydia trachomatis sample processing
10.2.1
Specimen Collection for Microbiological Tests
Samples will be collected with reference to age, gender, household, and study cluster, but participant
names will not be included in laboratory records. Samples will thus not be associated with the individual’s
name, but with a 5-digit random identiﬁcation number, masking laboratory personnel and preventing
identiﬁcation of the individuals infected.
Lab results will not be available for weeks if not months,
typically after the average duration of an ocular chlamydial infection.
10.2.2
APHI Lab: Abbott RealTime Assay
Laboratory testing is the current standard of care for the identiﬁcation of C.trachomatis infections in the
U.S. After collection, all samples will be processed the APHI and will be ﬁlled with 1 ml of M4RT media,
and tested for C. trachomatis.
72

Swabs will be processed with the Abbott RealTime assay for Chlamydia trachomatis, using the au-
tomated Abbott m2000 System, which is already in use at APHI. The RealTime assay targets the cryptic
plasmid of C. trachomatis. The assay has been shown to be highly sensitive and speciﬁc for the diagnosis
of sexually transmitted C. trachomatis, with sensitivities exceeding that of the nucleic acid ampliﬁcation
test used in most recent trachoma studies (Roche AMPLICOR).47,48
10.2.3
Processing of Samples for PCR
Samples are handled as per Abbott RealTime sample processing protocol, a highly sensitive assay that
targets the cryptic plasmid of C. trachomatis.48,49 We will perform the following modiﬁcations:
1. Samples are boiled for 10 minutes at 100ºC. Boiling of samples is an accepted treatment method
to remove substances that may be inhibitory to the PCR ampliﬁcation process.
2. Samples are pooled.
10.2.4
Procedure for Masking Samples
The PCR results will be recorded according to the random number assigned to the sample, thus masking
the lab since the lab workers do not have access to Salesforce in order to link this number with the child
who provided the sample. Once the sample is processed, the analyst will then link the sample random
number to the child’s record on Salesforce to reveal the test results by cluster.
10.2.5
Procedure for Pooling Samples
We will increase the eﬃciency of chlamydial testing by combining swabs from the same age stratum
and same community into pools of 5 random swabs for processing. An internal control will be run with
each pool to rule out the possibility of PCR inhibitors. Any inhibitory pools will be re-tested, and if still
inhibitory, the swabs will be individually re-tested. If PCR from any pool is equivocal, then all swabs
from the pool will be tested individually. While samples will necessarily be diluted in this process, this
is not thought to aﬀect the sensitivity of the test.50 We will test individually all swabs from positive
pools in the 0-5 year age stratum and estimate the community prevalence of chlamydial infection as the
proportion of positive swabs. We will estimate the community prevalence of infection in the 6-9 and 10
(WUHA) year age strata using maximum likelihood estimation, similar to our previous trials: the number
of individual swabs with the maximum likelihood of having resulted in the observed pooled results will
be chosen as the estimate for that village.27,51
In order to pool the conjunctival samples in the lab, the microbiology lab staﬀat APHI will assign
a new pool ID number for every sample, and samples will be stored at -20°C freezer until PCR testing
(if not processed that day).
73

10.2.6
Quality Control
• A C. trachomatis(+) control and a C. trachomatis(-) control (targeting 136 base pairs of a pumpkin
gene) is included in each test run of the Abbott RealTime assay.
• To test the eﬀect of sample processing, a known positive sample is processed and tested in each
test run. (This control is helpful when testing large numbers of negative samples.)
• An internal control intended to identify specimens that contain polymerase inhibitor is run routinely
on each sample. The internal control helps identify false negative results.
10.2.7
Calibration
Two levels of calibration must be performed every 6 months:
1. Optical calibration: The machine must have optical calibration performed by the manufacturer.
2. Load calibration: After the optical calibration has been performed, the PCR technician must
perform a standard curve using twofold dilutions of a standard concentration of C. trachomatis.
This load calibration is valid for 6 months or until the next optical calibration.
10.2.8
Quantiﬁcation
For every 0-5-year-old who tests positive for chlamydia, we will also run PCR for the beta actin gene on
the same sample, in order to normalize the quantity of chlamydial DNA to the amount of the specimen.
Quantitative results from the Abbott system are given in terms of a decision cycle (DC) number. We
will generate a ratio of the DC number of the chlamydial DNA to the DC number of the beta actin gene
and use the resulting ratio as the chlamydial load.
10.2.9
Laboratory Results Reporting
All lab results will be kept in computer ﬁles as well as uploaded to Salesforce by the analyst. The principal
investigator and the DSMC will be updated regularly on the progress of the lab work throughout the
course of the study.
10.2.10
Assessment of ocular chlamydia
Qualitative PCR for chlamydial DNA
Swabs will be processed with the Abbott RealTime assay for Chlamydia trachomatis, using the automated
Abbott m2000 System, which is already in use at the APHI. The RealTime assay targets the cryptic
74

plasmid of C. trachomatis. The assay has been shown to be highly sensitive and speciﬁc for the diagnosis
of sexually transmitted C. trachomatis, with sensitivities exceeding that of the nucleic acid ampliﬁcation
test used in most recent trachoma studies (Roche AMPLICOR).48,49 We will increase the eﬃciency of
chlamydial testing by combining swabs from the same age stratum and same community into pools of 5
random swabs for processing. An internal control will be run with each pool to rule out the possibility of
PCR inhibitors. Any inhibitory pools will be re-tested, and if still inhibitory, the swabs will be individually
re-tested. If PCR from any pool is equivocal, then all swabs from the pool will be tested individually.
While samples will necessarily be diluted in this process, 5-pooling has been shown to not signiﬁcantly
aﬀect the sensitivity of the test.50 We will unpool all positive pools in the 0-5 year age stratum and
estimate the community prevalence of chlamydial infection as the proportion of positive swabs. We will
estimate the community prevalence of infection in the 6-9 and ≥10 strata directly from the pooled swabs
using maximum likelihood estimation, similar to our previous trials: the number of individual swabs with
the maximum likelihood of having resulted in the observed pooled results will be chosen as the estimate
for that village.27,51 Note that we are currently working with APHI to perform chlamydial testing, so
the swab storage, transport, and processing protocols are already in place.
Quantitation of chlamydial load
We will assess the infectious load for all individual specimens from 0-5-year-old children who test positive
for chlamydia. Load will be determined relative to a reference housekeeping gene (beta actin) using the
Abbott RealTime assay, and expressed as the ratio of chlamydia to this housekeeping gene. We chose
beta actin because this is a cytoskeletal structural protein that is ubiquitous and not thought to vary its
expression.52
10.3
Macrolide resistance testing
10.3.1
Specimen Collection for Macrolide Resistance Testing
Nasopharyngeal samples will be collected with reference to age, gender, household, and cluster, but
participant names will not be included in laboratory records. Samples will thus not be associated with
the individual’s name, but with a 5-digit random identiﬁcation number, masking laboratory personnel
and preventing identiﬁcation of individuals.
10.3.2
Methods
The nasopharyngeal swab for pneumococcal resistance testing will be transported and processed using
standard microbiological techniques at APHI. We will store swabs in STGG medium, keeping swabs on ice
in the ﬁeld and then in the -20°C freezer as described above for the conjunctival swabs. APHI will process
the swabs using media selective for Streptococcus pneumoniae, and then test for antibiotic resistance to
erythromycin, penicillin, tetracycline, and clindamycin using the Kirby Bauer disc diﬀusion assay.
75

10.3.3
Procedure for Masking Samples
The microbiologist and all lab staﬀwill be masked to the cluster and randomization group assignment.
10.3.4
Quality Control
We will follow the standard quality control methods already in place at the laboratory. For example, lab
staﬀwill perform positive and negative growth controls for all media, and positive controls for all stains
at a pre-determined schedule.
10.3.5
Laboratory Results Reporting
All lab results will be kept in computer ﬁles as well as in hard-copy form by the microbiologist.
10.4
Dried blood spot sample processing
We use Trop-Bio ﬁlter paper for dried blood spots in SWIFT I/II. Each paper has 6 ears, and we ﬁll 5
ears with a drop of blood.
We ship the dried blood spots to Dr. Diana Martin at the CDC, who processes them for pgp3 and
CT694 using the Luminex platform. The Luminex assay results are reported as a quantitative value
(median ﬂuorescence intensity minus background; MFI-BG); these results can be dichotomized based on
the results of a receiver operating characteristic (ROC) curve from a set of known positives and negatives
run on the same bead coupling. Serologic results provide evidence for exposure to chlamydial infection,
and thus may be an especially sensitive metric of transmission.
76

Chapter 11
Treatment
11.1
Mass albendazole distribution
The clusters were initially dewormed with a single mass albendazole distribution to all pre-school aged
individuals who are 1 year or older (200mg for children aged 12-23 months and 400mg for individuals
24 months and older). Another albendazole treatment is not scheduled, but school age children receive
deworming on a routine basis at the health post.
11.2
Mass azithromycin distribution (MDA)
11.2.1
MDA prior to SWIFT I
The WagHemra zone received 8+ annual rounds of mass azithromycin before the start of the trial, with
the most recent treatment occuring 6 months before the baseline visit.
11.2.2
MDA during SWIFT I
No mass azithromycin distributions are planned during SWIFT I.
If the average prevalence of ocular chlamydia in 0-5-year-old children is too high, we will conduct a
mass azithromycin treatment immediately after the next scheduled annual monitoring visit. No threshold
is set, but consideration will be given to prevalence above 20%.
77

11.2.3
MDA during SWIFT II
One annual round of antibiotics will be oﬀered as single directly observed dose of oral azithromycin (1g for
adults and 20mg/kg for children).53 Antibiotic coverage will be assessed relative to the census population.
Workers will return to households until they distribute antibiotics to at least 80% of individuals. In
previous studies, we have routinely achieved >85% antibiotic coverage.27,28 If MDA takes place within
the 3 months prior to examinations, the examination results will not be included in the ﬁnal analysis.
11.2.4
Mass azithromycin eligibility
During the annual mass treatment, all individuals will be oﬀered a single dose of oral azithromycin,
20mg/kg for children using height-based dosing and 1g for adults or topical tetracycline.53
All age groups and sexes are eligible to receive azithromycin, except those contraindicated by Federal
Ministry of Health, which currently are:
• Those self-reported as pregnant
• Children under six months old
• Those known to be allergic to azithromycin or macrolides such as erythromycin
These three exceptions will be treated with 2 tubes of topical tetracycline ointment, to be used twice
daily for two weeks.
Of note, if the average prevalence of ocular chlamydia in 0-5 year old children is too high, we will consider
conducting a second annual mass azithromycin treatment. No threshold is set, but consideration will be
given to prevalence above 20%.
11.3
Adherence to Treatment
Adherence to azithromycin treatment will be essentially 100% of those treated since administration of the
single dose of antibiotic is directly observed by the distribution team. Adherence to topical tetracycline
treatment is less well known.
11.4
Adverse Outcomes and Patient Death
More than 450 million doses of oral azithromycin have now been distributed for trachoma, and reports
of serious side eﬀects are essentially non-existent. This may be due in part to minimal surveillance. It
also may be due to the fact these are extremely rare with a single dose of azithromycin. In fact, where
78

carefully monitored, there were actually fewer GI side eﬀects after taking azithromycin. We will create a
network to identify any possible post-treatment serious adverse eﬀects.
Azithromycin is generally well-tolerated. The most common side eﬀects of azithromycin and erythromycin
are diarrhea or loose stools, nausea, abdominal pain, and vomiting, each of which may occur in fewer
than one in twenty persons who receive azithromycin. Rarer side eﬀects include abnormal liver function
tests, allergic reactions, and nervousness. Diarrhea due to Clostridium diﬃcile has been rarely reported.
11.4.1
Adverse Outcomes
Non-serious side eﬀects are not uncommon, and serious side eﬀects are possible. The inability of even
frequent mass azithromycin distributions to bring about elimination in areas with highly prevalent tra-
choma suggests that other, non-antibiotic measures may be needed.
The adverse reactions that may occur after taking azithromycin will be explained to individuals prior
to enrollment in this study. In the event of an adverse outcome, an alternative treatment for trachoma
(e.g. tetracycline ointment) will be administered if the patient needs to continue treatment or for next
annual round of MDA. If a patient experiences a serious adverse outcome, they will be advised to alert
the health promotion worker or health extension worker, who will help them seek care. This person will
in turn inform The Carter Center study coordinator, who will contact the co-investigator at Proctor or at
the Carter Center. If, for any reason, they will need further eye care, they will be referred to the nearest
health center for examination and treatment, and the most appropriate action will be taken to provide
immediate care.
The study team will ensure that appropriate medical care is provided, and that the frequency and severity
of adverse events can be assessed. In addition, all adverse events will be recorded and monitored for each
individual and reports on adverse events will be made to the DSMC.
11.4.2
Patient Death
The infant mortality rate is quite high in this area of Ethiopia. All deaths since the ﬁrst census will be
carefully recorded during the study. Since the major causes of infant mortality in the area are diarrhea,
respiratory infections, and malaria, it is possible that receiving Azithromycin treatment may actually have
a positive eﬀect.
In addition, a recent study showing an association between azithromycin and sudden death in adult
hospitalized patients.
All death records (if available) will be gathered via the annual census.
The incidence of mortality
for each study arm will be made available to the DSMC by the statistical analyst.
79

11.5
Study Medication Description
11.5.1
Zithromax®
Zithromax® is supplied for oral administration as ﬁlm-coated, modiﬁed capsular shaped tablets contain-
ing azithromycin dehydrate equivalent to either 250mg or 500mg azithromycin and the following inactive
ingredients: dibasic calcium phosphate anhydrous, pregelatinized starch, sodium croscarmellose, magne-
sium stearate, sodium lauryl sulfate, hydroxypropyl methylcellulose, lactose, titanium dioxide, triacetin
and DC red 30 aluminum lake.
Zithromax® for oral suspension is supplied in bottles containing azithromycin dehydrate powder equiva-
lent to 300mg, 600mg, 900mg, or 1200mg azithromycin per bottle and the following inactive ingredients:
sucrose; sodium phosphate, tribasic, anhydrous; hydroxypropyl cellulose; xanthan gum; FDC Red 40;
and spray dried artiﬁcial cherry, crème de vanilla and banana ﬂavors. After constitution, each 5mL of
suspension contains 100mg or 200mg of azithromycin.
11.5.2
Albendazole
Albendazole is available in generic form in Ethiopia as a chewable fruit-ﬂavored 400mg tablet.
11.6
Dosage Information
11.6.1
Azithromycin
Azithromycin will be administered as a single dose, in tablet form for adults and in oral suspension form
for children. Dosing will be as per the WHO recommendations for treatment of active trachoma:
• 1) Single dose of one gram of azithromycin for adults
• 2) Height-based dosing of children will be acceptable, as per The Carter Center’s program—note
that this is supported by the WHO PBD group.
Individuals who are either under the age of 6 months, pregnant, or allergic to macrolides/azalides will be
treated with 1% tetracycline eye ointment to be applied twice daily to both eyes for a 6 week period. If
the appropriate ethical committee in Ethiopia suggests pregnancy tests for self-reported pregnant women,
or if the women are unsure of their pregnancy status, then they may be oﬀered an on-site pregnancy test.
80

11.6.2
Albendazole
Albendazole will be administered to all individuals aged 1 year and up. Children aged 12-23 months will
receive half a 400mg tablet (i.e., 200mg) and all other individuals will receive a single 400mg tablet, as
per WHO recommendations. Individuals with a known allergy will not receive deworming treatment.
11.7
Alternate Therapies
11.7.1
Alternates to Zithromax®: Tetracycline Ophthalmic Ointment
Tetracycline ophthalmic ointment (1%) is the current standard treatment in Ethiopia for ocular trachoma,
and will be distributed to study patients who are not eligible to receive azithromycin.
11.8
Treatment/Monitoring Schedule
As discussed, if the average prevalence of ocular chlamydia in 0-5 year old children is greater than 15% in
the treatment arm, we will conduct a mass azithromycin treatment immediately after the next scheduled
annual monitoring visit.
11.9
Medication Procurement/Donation
Pﬁzer, Inc. will provide the donation of Zithromax® (azithromycin), which will be shipped directly to
Ethiopia and received by a representative of the Ethiopian Ministry of Health, who will manage the
customs process and transport the medication from the port to a storage site. The exemption of duties
and taxes will be settled by the Ethiopian Customs Authorities and the Ethiopian Ministry of Health.
11.10
Study Medication Storage and Accountability
11.10.1
Azithromycin
Zithromax® tablets will be stored between 15° to 30°C (59° to 86°F), as recommended by Pﬁzer. A
record of the exact number of tablets distributed and quantity of oral suspension dispensed will be kept
by The Carter Center treatment distribution team.
81

11.10.2
Albendazole
Albendazole tablets will be stored between 20°-25°C, as recommended by the manufacturer.
11.11
Medication Quality Control
Study medication will be stored in The Carter Center project oﬃce prior to use. The hygiene cluster
coordinators and the study coordinator will regularly check and record the study medication expiry dates.
The expiration dates on the medication containers will be strictly monitored and all expired study medicine
will be discarded appropriately.
11.12
Checking Antibiotic Coverage
The application allows the users to monitor antibiotic treatment coverage, since treatment is recorded
in the application. The application supplies all individuals needing treatment in the app, and treatment
is then entered into this page. Treatment coverage can be viewed on Salesforce.com in real time.
The study coordinator will also monitor treatment coverage by visiting the clusters after treatment
has occurred and arbitrarily choosing individuals in the cluster to see if they were treated as marked.
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Chapter 12
Clinic-Based Case Finding
We will perform clinic-based case ﬁnding at all health posts serving the study clusters. Eligible health
posts will be identiﬁed by interviewing local community leaders during the census and woreda health
oﬃcials. The cluster coordinators will take photographs of the health post log books. A data entry
worker will use the photographs to enter the data into a REDCap form. Data will include age, gender,
community, diagnosis, and treatment. Diagnosis of infection or treatment with an antimicrobial will be
considered an infectious disease. We will collect data on all individuals who live in a study cluster. We
will retrospectively collect data for a full calendar year before the start of the study in order to provide
baseline values.
83

Chapter 13
Costing
We will perform both a short-term and long-term cost eﬀectiveness analysis (CEA) from the societal
perspective. For the short-term analysis, we will perform a trial-based cost eﬀectiveness analysis using
community-level data from the clinical trial. For the long-term analysis, we will create a decision model to
estimate the costs and eﬀectiveness after the conclusion of the study, and determine the cost eﬀectiveness
at varying time horizons. For each analysis, we will report the incremental cost eﬀectiveness at a given
time point, with a range of uncertainty. The research plan adheres to guidelines for the design and
analysis of trial-based and decision analytic cost-eﬀectiveness analyses.54,55
13.1
Assessment of costs
13.1.1
Trial-based CEA
We will prospectively collect cost data for all interventions in the WASH clusters during the study period,
using the WASHCost costing framework as a guide. WASHCost is a well-accepted methodology in the
WASH sector that provides a complete accounting not only of the upfront capital expenses, but also
expenditures on capital, maintenance and local support (e.g., community water committees and local
governments).
• MDA: The cost of the MDA will be included in the CEA.
• Water points, wash stations, and soap: the study coordinator will record the costs of labor, super-
vision, materials and supplies, and transport of materials to the community.
• Hygiene promotion: we will record the costs of printed educational materials and supplies for
schools, printed materials for workshops and transportation for promotion of WASH intervention
• Salaries and Per Diems: We will include the salaries of the 2 hygiene cluster coordinators and 20
health promotion workers and the per diems given to teachers, kebele leaders, HDAs, and priests
during their respective workshops, and also transportation costs for these individuals.
84

• All Interventions: We will also include as costs the time of community members who volunteer time
for one of the interventions (e.g., helping with water point-building or latrine-building, attending
workshops or trainings).
• Maintenance: We will make special eﬀorts to enumerate the maintenance costs of the intervention
during the second and third year of the trial. Maintenance costs will include the personnel costs of
the education and sanitation oﬃcer and health promoters, any supplies and equipment needed for
maintenance of the water points or latrines, and the time of community members spent at hygiene
workshops and repairing latrines or wells.
• Fixed Costs: Finally, we will include a portion of the ﬁxed costs of maintaining the Sekota and
headquarters Carter Center oﬃces.
• We will report costs separately for each intervention, as costs per community.
As in previous studies, costing data will be collected at the time the costs are incurred, using standardized
forms. We will not include certain protocol-induced costs in the intervention costs. For example, we will
not include the costs of the study coordinator, census, or monitoring visits, which are costs imposed by
the trial protocol, and would not exist outside the trial. We will, however, keep track of these costs,
since they may be useful for secondary analyses.
13.1.2
Decision Model-based CEA
We will use WASHCost’s life-cycle costing approach to model the long-term costs of the WASH interven-
tion. We will estimate future costs based on maintenance costs recorded from the second and third year
of the trial and using assumptions about the lifetime of the hardware (water points, wash stations, and
soap) based on interviews with local service providers. Future costs will be discounted to adjust them to
their present value. In modeling long-term costs, we will assume that maintenance-MDA is done at an
appropriate interval.
13.2
Assessment of eﬀectiveness
Eﬀectiveness outcomes are discussed elsewhere in this Manual of Procedures, but include:
• Ocular chlamydia (from monitoring visits)
• Mortality (from census)
• Stunting (from anthropometric monitoring)
• All-cause and cause-speciﬁc health clinic visits (from clinic-based case ﬁnding)
85

13.3
Distribution of CEA analysis
The CEA analysis will be published in order for it to be useful to governments and other program
implementers. If interested parties would like more information about the CEA analysis and data, they
will be welcomed to reach out to the Proctor team to further discuss this aspect of the trial.
86

Chapter 14
Protection of Human Subjects
14.1
Internal Review Board Approval
14.1.1
UCSF Committee on Human Research
The University of California, San Francisco, Committee on Human Research will annually review study
protocol for ethical approval.
All changes to the protocol will be submitted and approved prior to
implementation.
14.1.2
Ethiopian IRB
The study protocol is reviewed annually for ethical approval by the Amhara Region, the Ethiopian National
Research Ethics Review Committee (NRERC/MoST), and the Ethiopian FDA (formerly FMHACA). All
changes to the protocol will be submitted and approved prior to implementation.
14.1.3
Emory University Institutional Review Board
The Emory University Institutional Review Board will annually review study protocol for ethical approval.
All changes to the protocol will be submitted and approved prior to implementation.
14.2
Informed Consent
The head of each kebele will be asked for permission to include the cluster in the study. Additionally, the
study will be discussed with all adult family members in the cluster by the participating Carter Center
staﬀmembers who speak Amharic or the other local language.
87

At each collection visit, parents/guardians of study participants who are 0-6 years of age will be in-
formed about the possible risks and beneﬁts examination, swabbing, photography, and treatment (if
applicable), and asked to give a verbal consent. Young adults and children below 18 years of age, who
cannot give consent by law, will be included in the study only following the receipt of verbal informed
consent from a parent or guardian. Verbal assent will be obtained by any child over the age of 7. If, at
any time, a parent or guardian elects to withdraw themselves or a family member from the study, it will
be made clear that they will be oﬀered the same medical treatment outside the study.
14.3
Adequacy of Protection Against Risk
There are several layers of procedures to help minimize study-associated risk to participants.
14.3.1
Conjunctival swabbing
There are minimal risks to the subject who receives conjunctival swabbing for chlamydia. We are aware
of no reported complications from this procedure, although a small amount of conjunctival bleeding can
occur and a corneal abrasion is possible. Any adverse eﬀects will be treated by the examiners. Ocular
examinations will be oﬀered to everyone, even if they choose not to participate in the study. Appropri-
ate ophthalmic care or referral will be provided for any conditions detected during these examinations,
regardless of participation in the study.
14.3.2
Nasopharyngeal swabbing
Nasopharyngeal swabbing causes some temporary discomfort but it involves minimal risks without further
complications. Any adverse eﬀects, such as nose-bleeds, will be treated immediately by the examiners.
Other health care will be provided at no cost to the study participant if necessary, to address a study-
related adverse health event.
14.3.3
Clinical photography
Clinical photography of the conjunctiva causes no damage to the eye, is well tolerated by children, and
is a standard clinical procedure at UCSF.
14.3.4
Treatment
If treatment is necessary, the risk of antibiotic treatment will be minimized by treating only those who ﬁt
in the approved age and inclusion category, as well as by regularly scheduled follow-up examinations by a
trained trachoma grader. Should the antibiotic be ineﬀective to an individual, the study medication will
88

be discontinued for them. In the event of any adverse eﬀects, appropriate medical care will be provided
by the local health center.
14.4
Inclusion of Pregnant Women and Children
All participants, regardless of gender, will be accepted. We will obtain informed consent from all study par-
ticipants prior to entering the study. Pregnant women will be excluded from receiving oral azithromycin,
and will be oﬀered topical tetracycline eye ointment in its place.
14.5
Compensation to Participants
There is no cost to the participant and there is no reimbursement for overall participation in this study.
Each participant will receive free ophthalmic examinations during the course of the study.
89

Chapter 15
Data and Safety Monitoring
This chapter will deﬁne the primary responsibilities of the DSMC, its relationship with other trial com-
ponents, its membership, and the purpose and timing of its meetings. This chapter will also provide
the procedures for ensuring conﬁdentiality and communication, statistical monitoring guidelines to be
implemented by the DSMC, and an outline of the content of the reports that will be provided to the
DSMC.
15.1
Primary Responsibilities of the DSMC
The DSMC will be responsible for safeguarding the interests of trial participants, assessing the safety and
eﬃcacy of the interventions during the trial, and monitoring the overall conduct of the trial. The DSMC
will provide recommendations about stopping or continuing the trial. To contribute to the integrity of the
trial, the DSMC may also formulate recommendations relating to the selection, recruitment, retention of
participants, to protocol-speciﬁed regimens, and the procedures for data management and quality control.
A chief responsibility of the DSMC will be to review data on ocular chlamydia prevalence and make
recommendations regarding the need for mass azithromycin treatments. The DSMC will make a decision
about thresholds for initiating treatment at each meeting. For WUHA I, the DSMC purposefully did
not set a threshold to trigger re-treatment, but rather a threshold triggering a discussion about whether
antibiotic treatment was needed. This threshold was 20% prevalence of ocular chlamydia among the 0-5
year-old age group. It is anticipated that a similar threshold will be used for WUHA II, although the
DSMC will discuss this issue at each in-person or telephone meeting.
The DSMC will be advisory to the trial leadership group, hereafter referred to as the Executive Committee
(EC). The EC will be responsible for promptly reviewing the DSMC recommendations and determining,
whether to continue or terminate the trial, and to determine whether amendments to the protocol are
required. If needed, the DSMC may seek the advice of a content expert outside of the committee.
90

15.2
DSMC Membership
The DSMC is an independent multidisciplinary group consisting of epidemiologists, biostatisticians,
bioethicists, and clinicians that collectively has experience in the management of infectious diseases
and in the conduct and monitoring of randomized clinical trials including sub-Saharan Africa.
15.3
Conﬂicts of Interest
The DSMC membership has been restricted to individuals free of apparent conﬂicts of interest. The
source of these conﬂicts may be ﬁnancial, scientiﬁc, or regulatory. Thus, neither study investigators nor
individuals employed by the sponsor, nor individuals who might have regulatory responsibilities for the
trial products, are members of the DSMC.
The DSMC members will disclose to fellow members any consulting agreements or ﬁnancial interests
they have with the sponsor of the trial, with the contract research organizations (CRO) , or with other
sponsors having products that are being evaluated or that are competitive with those in the trial. The
DSMC will be responsible for deciding whether these consulting agreements or ﬁnancial interests mate-
rially impact their objectivity.
The DSMC members will be responsible for advising fellow members of any changes in any of the
membership requirements that occur during the course of the trial. It may be appropriate for DSMC
members who develop signiﬁcant conﬂicts of interest resign from the DSMC.
DSMC membership is to be for the full duration of the trial. If any members leave the DSMC, the
EC, in consultation with the DSMC, will promptly appoint a replacement.
15.4
Timing and Purpose of the DSMC Meetings
15.4.1
Organizational Meeting
The initial meeting of the DSMC was held 16 September 2014. The committee provided an advisory
review of scientiﬁc and ethical issues relating to study design and discussed the standard operating pro-
cedures, as well as the format and content of the reports that will be used to present trial results.
The Organizational Meeting was attended by all DSMC members, lead trial investigators, and the trial
biostatistician. The DSMC reviewed drafts of the trial protocol, the Statistical Analysis Plan, and this
DSMC chapter. At subsequent meetings, committee members will receive data reports and an updated
MOP and SAP.
91

15.4.2
Future meetings
Future DSMC meetings will be held on a yearly basis, with an option for more frequent phone meetings
or email updates at the discretion of the DSMC and/or principal investigator.
15.5
Procedures to Ensure Conﬁdentiality and Proper Communica-
tion
To enhance the integrity and credibility of the trial, procedures will be implemented to ensure the DSMC
has access to all emerging information from the trial regarding comparative results of eﬃcacy and safety,
aggregated by treatment arm.
15.6
Closed Sessions
Sessions involving only DSMC members and, where appropriate, those unmasked trial investigators (on
the Data Coordinating Committee) who generate the Closed Reports (called Closed Sessions) will be held
to allow discussion of conﬁdential data from the trial, including information about the relative eﬃcacy
and safety of interventions.
At a ﬁnal Closed Session, the DSMC will develop a consensus on its list of recommendations, including
that relating to whether the trial should continue.
15.7
Open Sessions
In order for the DSMC to have access to information provided, by study investigators, or members of
regulatory authorities, a joint session between these individuals and DSMC members will be held between
the Closed Sessions.
15.8
Progress Reports
For each DSMC meeting, a report will be provided. The report will include data on recruitment and
baseline characteristics, exam coverage, exam results, pooled data on eligibility violations, adverse events,
and completeness of follow-up and compliance. The data analyst will prepare this report.
The report should provide information that is accurate, with follow-up that is complete to within 1-
2 months of the date of the DSMC meeting.
The Reports should be provided to DSMC members
approximately three days prior to the date of the meeting.
92

15.9
Minutes of the DSMC Meeting
The research team will prepare minutes for the open portion of the meeting, including the DSMC’s
recommendations.
15.10
Recommendations to the Executive Committee (EC)
At each meeting of the DSMC during the trial, the committee will make a recommendation to the Ex-
ecutive Committee to continue or terminate the trial. This recommendation will be based primarily on
safety and eﬃcacy considerations and will be guided by statistical monitoring guidelines deﬁned in this
chapter.
Recommendations to amend the protocol or conduct of the study made by the DSMC will be con-
sidered and accepted or rejected by the EC. The EC will be responsible for deciding whether to continue
or to stop the trial based on the DSMC recommendations.
The DSMC will be notiﬁed of all changes to the protocol or to study conduct. The DSMC concur-
rence will be sought on all substantive recommendations or changes to the protocol or study conduct
prior to implementation.
The EC may communicate information in the Open Report to the sponsor and may inform them of
the DSMC recommended alterations to study conduct or early trial termination in instances in which the
EC has reached a ﬁnal decision agreeing with the recommendation. The EC will maintain conﬁdential-
ity of all information it receives other than that contained in the Open Reports until after the trial is
completed or until a decision for early termination has been made.
93

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37 Stephen P Luby, Mubina Agboatwalla, John Painter, Arshad Altaf, Ward L Billhimer, and Robert M
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38 Pavani K Ram, Amal K Halder, Stewart P Granger, Therese Jones, Peter Hall, David Hitchcock,
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41 Alain B Labrique, Parul Christian, Rolf D W Klemm, Mahbubur Rashid, Abu Ahmed Shamim, Al-
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42 Erica Brook Goodhew, Sheri Maria G Morgan, Andrew J Switzer, Beatriz Munoz, Laura Dize, Char-
lotte Gaydos, Harran Mkocha, Sheila K West, Ryan E Wiegand, Patrick J Lammie, and Diana L
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43 Diana L Martin, Ryan Wiegand, Brook Goodhew, Patrick Lammie, Carolyn M Black, Sheila West,
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Achham District, Nepal: A Cross-Sectional Study from the Nepal National Trachoma Program. PLoS
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45 S K West and H R Taylor. Reliability of photographs for grading trachoma in ﬁeld studies. The Br.
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46 Anthony W Solomon, Richard J C Bowman, David Yorston, Patrick A Massae, Salesia Safari, Brian
Savage, Neal D E Alexander, Allen Foster, and David C W Mabey. Operational evaluation of the use of
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3 2006.
47 Jens Kjølseth Møller, Lisbeth Nørum Pedersen, and Kenneth Persson.
Comparison of the Abbott
RealTi&lt;em&gt;m&lt;/em&gt;e CT New Formulation Assay with Two Other Commercial Assays for
Detection of Wild-Type and New Variant Strains of &lt;em&gt;Chlamydia trachomatis&lt;/em&gt;.
J. Clin. Microbiol., 48(2):440 LP – 443, 2 2010.
48 Annie Cheng, Qinfang Qian, and James E Kirby. Evaluation of the Abbott RealTime CT/NG assay in
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2011.
49 Jens Kjølseth Møller, Lisbeth Nørum Pedersen, and Kenneth Persson.
Comparison of the Abbott
RealTime CT new formulation assay with two other commercial assays for detection of wild-type and
new variant strains of Chlamydia trachomatis. J. clinical microbiology, 48(2):440–443, 3 2010.
50 S A Morré, R van Dijk, C J Meijer, A J van den Brule, S K Kjaer, and C Munk. Pooling cervical
swabs for detection of Chlamydia trachomatis by PCR: sensitivity, dilution, inhibition, and cost-saving
aspects. J. clinical microbiology, 39(6):2375–2376, 3 2001.
51 Jonathan Diamant, Roger Benis, Julius Schachter, Jeanne Moncada, Frankye Pang, Hem C Jha,
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tests to determine the prevalence of ocular Chlamydia trachomatis infection. Ophthalmic Epidemiol.,
8(2-3):109–117, 1 2001.
52 Hendrik J M de Jonge, Rudolf S N Fehrmann, Eveline S J M de Bont, Robert M W Hofstra, Frans
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Arja ter Elst. Evidence based selection of housekeeping genes. PloS one, 2(9):e898, 9 2007.
53 Eva V Basilion, Peter M Kilima, and Jeﬀrey W Mecaskey. Simpliﬁcation and improvement of height-
based azithromycin treatment for paediatric trachoma. Transactions Royal Soc. Trop. Medicine Hyg.,
99(1):6–12, 3 2005.
54 Milton C Weinstein, Bernie O’Brien, John Hornberger, Joseph Jackson, Magnus Johannesson, Chris
McCabe, and Bryan R Luce. Principles of good practice for decision analytic modeling in health-care
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Soc. for Pharmacoeconomics Outcomes Res., 8(5):521–533, 2005.
98

Appendix A
Revision History
11 March 2020
• Converted MOP from word doc to Overleaf doc
• Re-organized sectioning of MOP chapters
• Added more speciﬁc information on data collection and management plan
4 March 2022
• Speciﬁed if a round of MDA takes place within the 3 months prior to a round of examinations,
the results from that examination will not be included in the ﬁnal analysis, since the mass drug
administration would be expected to greatly reduce infection in both treatment arms, potentially
masking the eﬀect of the hygiene intervention.
99

Sanitation, Water, and Instruction in 
Face-washing for Trachoma I 
Francis. I. Proctor Foundation, 
The Carter Center, 
Amhara Public Health Institute, 
Emory University 
Investigators: 
Zerihun Tadesse2 
Kelly Callahan2 
Paul M. Emerson3 
Solomon Aragie2 
Wondimu Gebeyehu4 
Matthew C. Freeman5 
Vicky Cevallos1
Jason Melo1
Dionna M. Wittberg1 
Travis C. Porco1 
Thomas M. Lietman1 
Jeremy D. Keenan*1
NCT02754583   
May 13, 2020
*Principal Investigator
1Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California, USA;
2The Carter Center, Atlanta, Georgia, USA & Ethiopia, 3International Trachoma Initiative,
4Amhara Public Health Institute , Bahir Dar, Ethiopia, 5Emory University, Atlanta, Georgia

 
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CONTENTS 
1. 
INTRODUCTION ............................................................................................................................................. 5 
1.1 
SPECIFIC AIMS OF THE STUDY .............................................................................................................................. 6 
1.2 
STUDY OUTCOMES ............................................................................................................................................ 7 
2. 
BACKGROUND AND RATIONALE .................................................................................................................... 9 
3. 
ORGANIZATION AND POLICIES .................................................................................................................... 12 
3.1 
STUDY ORGANIZATION ..................................................................................................................................... 12 
3.2 
COLLABORATING INSTITUTIONS .......................................................................................................................... 16 
3.3 
DUTIES & RESPONSIBILITIES OF STAFF ................................................................................................................. 17 
3.4 
POLICY MATTERS ............................................................................................................................................ 23 
3.5 
PRESENTATIONS AND PUBLICATIONS ................................................................................................................... 23 
4. 
RESEARCH DESIGN ....................................................................................................................................... 24 
4.1 
STUDY AREA ................................................................................................................................................... 24 
4.2 
RANDOMIZATION ............................................................................................................................................ 24 
4.3 
ELIGIBILITY REQUIREMENTS ............................................................................................................................... 25 
4.4 
MASKING ...................................................................................................................................................... 26 
5. 
STUDY INTERVENTIONS ............................................................................................................................... 27 
5.1 
WUHA TRIAL: WASH UPTAKE FOR HEALTH IN AMHARA (SPECIFIC AIM 1) ............................................................... 27 
5.2 
TAITU: TARGETED ANTIBIOTIC INTERVENTION FOR TRACHOMA IN UNDER-5S (SPECIFIC AIM 2) .................................... 30 
6. 
INTERVENTION MONITORING AND EVALUATION ........................................................................................ 32 
6.1 
SPOT CHECKS .................................................................................................................................................. 32 
6.2 
HOUSEHOLD SURVEY AT ANNUAL CENSUS ............................................................................................................. 32 
6.3 
FOCUS GROUP DISCUSSIONS ............................................................................................................................. 33 
6.4 
STRUCTURED OBSERVATION .............................................................................................................................. 34 
7. 
CENSUS........................................................................................................................................................ 35 
7.1 
EQUIPMENT ................................................................................................................................................... 35 
7.2 
MOBILE APPLICATION ...................................................................................................................................... 35 
7.3 
TRAINING AND SUPERVISION ............................................................................................................................. 35 
7.4 
CHARGING DEVICES ......................................................................................................................................... 36 
8. 
ANNUAL MONITORING (EXAMINATION) PROCEDURES ............................................................................... 37 
8.1 
SAMPLING STRATEGIES ..................................................................................................................................... 37 
8.2 
PREPARATION ................................................................................................................................................. 38 
8.3 
TRAINING ...................................................................................................................................................... 38 
8.4 
EXAM TEAM ................................................................................................................................................... 38 
8.5 
REGISTRATION STATION ................................................................................................................................... 39 
8.6 
SWAB STATION ............................................................................................................................................... 39 
8.7 
CLINICAL PHOTOGRAPHY .................................................................................................................................. 40 
8.8 
ANTHROPOMETRY ........................................................................................................................................... 45 
9. 
OUTCOME ASSESSMENT AND LABORATORY PROCEDURES ......................................................................... 57 
9.2 
SPECIMEN COLLECTION FOR MICROBIOLOGICAL TESTS ........................................................................................... 59 
9.3 
MACROLIDE RESISTANCE TESTING ....................................................................................................................... 61 
9.4 
DRIED BLOOD SPOTS ........................................................................................................................................ 62 

 
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10. CLINIC-BASED CASE FINDING ....................................................................................................................... 63 
11. COSTING ...................................................................................................................................................... 64 
11.1 
ASSESSMENT OF COSTS ..................................................................................................................................... 64 
11.2 
ASSESSMENT OF EFFECTIVENESS ......................................................................................................................... 65 
12. TREATMENT ................................................................................................................................................ 66 
12.1 
MASS ALBENDAZOLE DISTRIBUTION ..................................................................................................................... 66 
12.2 
MASS AZITHROMYCIN DISTRIBUTION ................................................................................................................... 66 
12.3 
ADHERENCE TO TREATMENT .............................................................................................................................. 66 
12.4 
ADVERSE OUTCOMES AND PATIENT DEATH .......................................................................................................... 66 
12.5 
STUDY MEDICATION DESCRIPTION ...................................................................................................................... 67 
12.6 
DOSAGE INFORMATION .................................................................................................................................... 68 
12.7 
ALTERNATE THERAPIES ..................................................................................................................................... 68 
12.8 
TREATMENT/MONITORING SCHEDULE ................................................................................................................ 68 
12.9 
MEDICATION PROCUREMENT/DONATION ............................................................................................................ 68 
12.10 
STUDY MEDICATION STORAGE AND ACCOUNTABILITY ........................................................................................ 69 
12.11 
MEDICATION QUALITY CONTROL ................................................................................................................... 69 
12.12 
CHECKING ANTIBIOTIC COVERAGE .................................................................................................................. 69 
13. PROTECTION OF HUMAN SUBJECTS............................................................................................................. 70 
13.1 
INTERNAL REVIEW BOARD APPROVAL ................................................................................................................. 70 
13.2 
INFORMED CONSENT ....................................................................................................................................... 70 
13.3 
ADEQUACY OF PROTECTION AGAINST RISK ........................................................................................................... 70 
13.4 
INCLUSION OF PREGNANT WOMEN AND CHILDREN ................................................................................................ 71 
13.5 
COMPENSATION TO PARTICIPANTS ..................................................................................................................... 71 
14. DATA AND SAFETY MONITORING COMMITTEE CHARTER ............................................................................ 72 
14.1 
PRIMARY RESPONSIBILITIES OF THE DSMC ........................................................................................................... 72 
14.2 
DSMC MEMBERSHIP ...................................................................................................................................... 72 
14.3 
CONFLICTS OF INTEREST ................................................................................................................................... 72 
14.4 
TIMING AND PURPOSE OF THE DSMC MEETINGS .................................................................................................. 73 
14.5 
PROCEDURES TO ENSURE CONFIDENTIALITY AND PROPER COMMUNICATION .............................................................. 73 
14.6 
MINUTES OF THE DSMC MEETING .................................................................................................................... 74 
14.7 
RECOMMENDATIONS TO THE EXECUTIVE COMMITTEE (EC) ..................................................................................... 74 
14.8 
DSMC CONTACT INFORMATION ........................................................................................................................ 74 
15. DATA COLLECTION, MANAGEMENT, AND QUALITY ASSURANCE ................................................................. 76 
15.1 
DATA COLLECTION TOOLS ................................................................................................................................. 76 
15.2 
MOBILE APPLICATION ...................................................................................................................................... 76 
15.3 
DATA TRANSFER ............................................................................................................................................. 76 
15.4 
DATA QUALITY ............................................................................................................................................... 76 
15.5 
DATA CONSISTENCY AND VALIDITY ..................................................................................................................... 76 
15.6 
DATA COLLECTION .......................................................................................................................................... 76 
15.7 
EXAMINATION, SWABBING, AND ANTHROPOMETRY ............................................................................................... 77 
15.8 
COSTING ....................................................................................................................................................... 77 
15.9 
DATA SECURITY AND STORAGE........................................................................................................................... 77 
15.10 
DATA ANALYSIS ESTIMATION OF DISEASE PREVALENCE....................................................................................... 77 
15.11 
SAMPLE ORGANIZATION AND STORAGE ........................................................................................................... 78 
16. STATISTICAL ANALYSES ................................................................................................................................ 79 

 
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17. APPENDICES ................................................................................................................................................ 80 
17.1 
SWIFT-STH SUPPLEMENT ................................................................................................................................. 80 
17.2 
RECTAL SWABS PROTOCOL ................................................................................................................................ 83 
18. REFERENCES ................................................................................................................................................ 86 
19. SWIFT REVISIONS HISTORY .......................................................................................................................... 90 
 

 
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1. INTRODUCTION 
 
Trachoma is one of the few realistic candidate diseases that could be eradicated in the next 
two decades. The chances of eradication stem partly from the use of mass azithromycin 
distributions, which have had enormous success in reducing the prevalence of the ocular strains 
of chlamydia that cause the disease. However, recent evidence suggests that antibiotics alone 
may be insufficient for eradication. There are at least 3 limitations of mass antibiotic distributions 
for trachoma. First, the efficacy of azithromycin in clearing infection may not be as high as 
previously thought. In severely affected areas such as Ethiopia, even 7 mass antibiotic 
distributions fail to predictably eliminate chlamydia—and infection rapidly returns after 
treatments are discontinued. Second, mass antibiotic distributions select for resistance. While no 
resistance has yet been observed in chlamydia, mass azithromycin clearly selects for resistance 
in nasopharyngeal pneumococcus. And third, adverse events are possible. Non-serious side 
effects are not uncommon, and serious side effects are possible, with a recent study showing an 
association between azithromycin and sudden death in hospitalized patients. The inability of 
even frequent mass azithromycin distributions to bring about elimination in areas with highly 
prevalent trachoma suggests that other, non-antibiotic measures may be needed. 
 
Improvements in water and sanitation are thought to change the transmission dynamics of 
ocular chlamydia, and may be necessary to eliminate trachoma in the most hyperendemic 
locations. Historically, trachoma disappeared in many areas before widespread use of antibiotics, 
often concomitant with improvements in environmental public health measures. Lack of water 
and sanitation, along with poor facial hygiene, have long been known to be associated with 
trachoma, and the World Health Organization (WHO) recommends facial hygiene and 
environmental improvements as important components of their SAFE strategy for trachoma 
(Surgery, Antibiotics, Facial hygiene, and Environmental improvements).  
 
Water and sanitation interventions have yet to be proven effective for reducing ocular 
chlamydia. The randomized clinical trials of water, sanitation, and hygiene (WASH) interventions 
that have been conducted for trachoma have typically been underpowered. Those that 
monitored clinical disease did so with a grading scale that may not be sensitive enough for 
research purposes. The few studies that monitored ocular chlamydial infection did so with an 
earlier generation, less sensitive PCR test (Roche Amplicor) that may have misclassified some 
infections. None of the prior trials monitored infectious load of chlamydia, which is thought to 
be important for transmission. Furthermore, few of the trials have implemented multiple hygiene 
interventions together. It is possible that the effectiveness of each of the WASH components 
depends on the others. Finally, there is general consensus that non-antibiotic measures may take 
longer to work than the 1-2-year duration of most previous trials. We believe that the lack of 
evidence does not indicate that these measures are ineffective—simply that they have not been 
adequately assessed. 
 

 
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Our long-term goal is to eliminate trachoma even in the most hyperendemic communities. In 
order to advance this goal, we will conduct a cluster-randomized clinical trial to 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 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. 
Our central hypothesis is that instituting an integrated WASH package including water points, 
latrines, and facial hygiene promotion will reduce both the prevalence and the severity of both 
clinical disease and infection. If these measures prove effective and analyses demonstrate a 
favorable cost-effectiveness profile, the implementation of these interventions would increase 
dramatically.  
 
1.1 Specific Aims of the Study 
Specific Aim 1: To determine the efficacy of non-antibiotic measures for trachoma control.  
 Hypothesis 1: The prevalence of ocular chlamydia will be lower in clusters randomized to a 
WASH package compared to clusters not receiving this intervention.  
 
Specific Aim 2: To determine the efficacy of targeting antibiotics to infected children for 
trachoma control. 
 Hypothesis 2A: The incidence of ocular chlamydia in uninfected pre-school children will be 
lower in clusters where infected pre-school children are periodically treated with 
azithromycin than in clusters not treated with azithromycin.  
 Hypothesis 2B: The prevalence of ocular chlamydia in clusters randomized to periodic 
targeted azithromycin treatments will be non-inferior to those treated with a single mass 
azithromycin treatment. 
 
Specific Aim 3: To model the long-term cost-effectiveness of competing strategies for trachoma 
control after completion of several rounds of mass azithromycin distributions. 
 Hypothesis 3: We will assess the incremental cost effectiveness of an integrated WASH 
package versus a targeted antibiotic strategy versus no specific intervention over a 10-year 
time horizon, and anticipate that the incremental cost effectiveness will favor the WASH 
package over the long-term. 
 
This research will provide the strongest type of evidence—that from a randomized clinical trial—
to guide treatment decisions for trachoma programs. With less than 10 years until the WHO’s 
2020 target date for trachoma programs, this research will provide an assessment of the current 
SAFE strategy and equip trachoma programs to spend their limited resources on interventions 
most likely to result in elimination. The research will have applicability even if trachoma 
elimination is achieved by 2020, since it will determine whether WASH interventions are able to 
maintain trachoma elimination once mass antibiotics have stopped 

 
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1.2 Study Outcomes 
1.2.1 
Primary Outcomes:  
The primary outcome is ocular chlamydia as assessed by PCR, measured in a population-based 
age-stratified sample of the entire community. We age-stratify since the risk of ocular chlamydial 
infection is strongly associated with age (i.e., infection much more common in younger children), 
but trachoma elimination will require elimination of infection from the entire community, so 
infection data in older age groups is of interest.1-4  
 
1.2.2 
Secondary Outcomes:  
The secondary outcome of most interest is the infectious load of chlamydia among 0-5-year-old 
children infected with ocular chlamydia. Individuals with high chlamydial loads are thought to be 
much more likely to transmit infection.5 Therefore, it is conceivable that reduction of chlamydial 
load is more important in the short term than reducing the prevalence of chlamydia, since 
individuals with low loads will be less likely to propagate the infection. However, because this 
outcome has never been assessed as part of a randomized clinical trial, we have designated it as 
a secondary outcome. Our other secondary outcome of highest interest is improvement in 
conjunctival inflammation as assessed from serial conjunctival photographs, measured in a 
longitudinal cohort of children aged 0-5 years at baseline. We will collect data on several other 
secondary outcomes in children aged 0-5 years, including dried blood spots for serological 
assessment of ocular chlamydia and other diseases of interest, nasopharyngeal pneumococcal 
macrolide resistance, anthropometry (height and weight), the presence of a clean face on 
photography, stool samples for the presence of Necator americanus, Ancylostoma duodenale, 
Trichuris trichiura, Ascaris lumbricoides, and Strongyloides stercoralis, for the presence and 
density of soil-transmitted helminths. For WUHA, we will perform similar assessments of ocular 
chlamydia and clinical trachoma in a sample of children aged 6-9 years and a sample of individuals 
aged ≥ 10 years, and similar assessments of facial cleanliness in the 6-9-year-old age group. For 
TAITU, we will perform similar assessments of ocular chlamydia and clinical trachoma in a sample 
of children aged 8-12 years. We are monitoring for macrolide resistance in nasopharyngeal 
pneumococcus because azithromycin treatments may select for antibiotic resistance and 
because of the possibility that improved hygiene will have an added benefit of reducing the 
carriage of nasopharyngeal pneumococcus. We are monitoring anthropometry because of the 
possibility that improved hygiene will result in accelerated growth in pre-school children. Our 
group has measured both nasopharyngeal macrolide resistance and anthropometry in previous 
trials in Ethiopia.6-8 
 
1.2.3 
Research Design 
We will conduct a series of cluster-randomized clinical trials with long-term follow-up to 
determine whether adding an integrated WASH package to mass azithromycin treatment will be 

 
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effective for trachoma. We will conduct two complementary trials to take place in 80 clusters of 
households that have already received five or more rounds of mass azithromycin treatments. 
Specific Aim 1 describes the first trial, in which 40 clusters will be randomized either to an 
integrated WASH package (water points, latrine promotion, and hygiene promotion) or to no 
intervention until the conclusion of the study. The second trial, described in Specific Aim 2, 
studies a competing antibiotic minimization strategy in which 36 clusters will be randomized 
either to targeted azithromycin treatments of children infected with ocular chlamydia or to a 
single mass azithromycin distribution. The primary outcome for both trials will be ocular 
chlamydia infection, assessed in 0-5 year-old children at months 12, 24, and 36 for the first trial 
and assessed in both 0-5- and 8-12-year-old children at month 12 and 24 for the second trial. 
Important secondary outcomes will include the load of ocular chlamydia among infected children 
and the prevalence of clinically active trachoma, assessed at the same time points. 

 
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2. BACKGROUND AND RATIONALE  
 
Trachoma is the most common infectious cause of blindness worldwide.9 Caused by ocular 
strains of chlamydia, over 40 million people are currently affected with active trachoma—mostly 
in sub-Saharan Africa.10 Ocular chlamydia infection causes conjunctival inflammation, with 
characteristic white follicles (germinal centers) present on the upper tarsal conjunctiva. Frequent 
bouts of infection and inflammation result in cicatricial changes to the conjunctiva, with 
subsequent inturning of the eyelids (entropion). With this this inturned eyelid position, eyelashes 
touch the globe (trichiasis), causing pain and creating the conditions for corneal abrasions, 
bacterial and fungal superinfections, corneal opacity, and blindness. The National Eye Institute’s 
most recent 5-year plan encourages clinical trial interventions for blinding global eye diseases, 
and specifically urges research in connection with trachoma control programs to cost-effectively 
test optimal intervention strategies for global infectious causes of blindness.11 
 
The World Health Organization has called for elimination of trachoma as a public health 
problem by the year 2020.12 Through its Global Elimination of Trachoma by 2020 (GET 2020) 
initiative, the WHO has designated trachoma a priority eye disease, and has brought together 
academic institutions, nongovernmental organizations, and pharmaceutical companies to 
promote elimination of this blinding condition. Trachoma may even be a candidate for 
eradication. Many countries in Asia and the Middle East have had great success in reducing the 
prevalence of trachoma, and no longer require active trachoma control efforts.13 If these 
experiences can be replicated in the heaviest affected areas of Africa, trachoma may be the first 
bacterial disease ever to be eradicated from the planet. 
 
Although antibiotics have proven highly effective in reducing ocular chlamydia, many believe 
that trachoma elimination will require non-antibiotic measures. There are several reasons why 
antibiotics may not be the sole pathway to eliminate trachoma. First, they may not be effective 
enough: multiple rounds of antibiotic distributions have not been shown to eliminate ocular 
chlamydia in areas with moderate to high amounts of trachoma—even when treatments are 
given as frequently as every 3-6 months.14-17 Second, they may cause adverse events. While mass 
antibiotic distributions have not been shown to induce chlamydial resistance, they do select for 
resistant strains of commensal bacteria such as nasopharyngeal Streptococcus pneumoniae.6,18 
Resistant strains have so far remained susceptible to penicillin, but clonal spread of commensal 
bacteria resistant to both macrolides and penicillins could limit the role of mass azithromycin 
distributions in the future. Although azithromycin generally has a favorable side effect profile, 
some believe that azithromycin may cause sudden death in rare instances.19 Finally, they may 
not be necessary: trachoma was eliminated in the United States long before organized mass 
antibiotic efforts, and has even been dramatically reduced in some African countries—likely as a 
result of improvements in public health and sanitation.20-22  
 
The World Health Organization recommends several non-antibiotic measures in its “SAFE” 
strategy for trachoma control. The components of the SAFE strategy include Surgical correction 

 
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of trichiasis, Antibiotics to reduce the community load of ocular chlamydia, and Facial hygiene 
and Environmental improvements to reduce the transmission of ocular chlamydia. 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 only a handful of randomized trials testing a water, sanitation, or hygiene 
intervention for trachoma. Most of these trials have been unable to detect any effect of the 
tested intervention, though there is some evidence supporting hygiene education.23,24 None of 
the trials has been able to detect a difference in ocular chlamydia due to the intervention. 
Although this may mean that water and sanitation interventions have no effect on ocular 
chlamydia, it is also possible that the limitations of these trials prevented a true effect from being 
found. For example, the trials were typically underpowered and had short follow-up. Most trials 
monitored only for clinically active trachoma, which is an unreliable indicator of ocular chlamydial 
infection.25 Those trials that have monitored for ocular chlamydia have generally been 
underpowered.26,27 None provided all 3 components (e.g., water, sanitation, and hygiene) 
simultaneously. The state of evidence regarding environmental modifications for trachoma 
control is perhaps best summarized by the 2012 Cochrane Review article on this subject, which 
concluded: “Generally there is a dearth of data to determine the effectiveness of all aspects of 
environmental sanitation in the control of trachoma.”28 Perhaps because of this lack of evidence, 
many trachoma programs focus their activities around the “S” (surgery) and “A” components 
(antibiotics), while neglecting the “F” (facial hygiene) and “E” (environmental improvements) 
components of the SAFE strategy.29 
 
We expect to determine whether an integrated approach to improve access to water, 
sanitation and hygiene (WASH) technologies and related behaviors (i.e., the “F” and “E” 
components of SAFE) is effective in reducing the prevalence of ocular chlamydia. Although no 
single water, sanitation, or facial hygiene intervention has been shown to be effective for 
trachoma, it is possible that roll-out of the entire package of interventions will be effective—as 
has been voiced by several trachoma experts and endorsed by the WHO.30,31 This trial will provide 
the first attempt to test this hypothesis, while also determining whether any benefits of the 
interventions are also cost-effective. If we find a reduction in ocular chlamydia with all 
interventions together, this would provide motivation to trachoma programs to include these 
non-antibiotic measures in their program activities. Further studies could be done to determine 
which of the “F” and “E” components are most important. If we fail to find a reduction in ocular 
chlamydia, this would trigger re-assessment of the ability of programs to alter transmission of 
ocular chlamydia through non-antibiotic measures, and would argue for new ways of 
implementing face hygiene promotion and environmental improvements. The results of this 
study could be used immediately by trachoma programs when planning program activities, and 
therefore promise to have a major impact on the effort to eliminate blinding trachoma. 
 

 
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Figure 1: Putative causal framework depicting relationships between hygiene factors and ocular chlamydia 
infection. In the diagram, the blue figure represents the infected individual, who can transmit ocular chlamydia through 
fingers, flies, and fomites. The brown figure represents the uninfected, susceptible individual. The susceptible 
individual’s household risk factors are on the right, and the community risk factors are listed on the left. Lack of 
latrines promotes fly populations, which can transmit ocular chlamydia. Lack of water and hygiene awareness 
promotes dirty faces, which can be a reservoir for chlamydia and attract flies. Note that while household sanitation 
and hygiene play a role in the transmission of ocular chlamydia for household members, the community’s participation 
in sanitation and hygiene is also important.  
 
 
Dirty face 
Dirty face 
Infected eye 
SUSCEPTIBLE 
EYE 
Lack of 
community 
latrine use 
Lack of 
community 
water use 
Infected 
finger/fomite 
Infected 
finger/fomite 
Infected face/flies 
Lack of  
HH water use 
Lack of HH 
hygiene 
education 
Lack of 
community 
hygiene 
education 
Lack of HH 
latrine use 
HOUSEHOLD 
RISK FACTORS 
COMMUNITY RISK FACTORS 

 
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3. ORGANIZATION AND POLICIES 
3.1 Study Organization 
3.1.1 
Study Partners 
The Proctor Foundation and Carter Center are the ideal partners to conduct the proposed 
research. They have worked together on 2 large NEI-funded cluster-randomized clinical trials in 
Ethiopia starting in 2006, and are currently collaborating on a Gates Foundation-funded trial of 
mass azithromycin in Niger. The research partners complement each other, with the Proctor 
Foundation providing expertise in study design and analysis, and the Carter Center implementing 
the field work in a thorough yet efficient manner. Matthew Freeman from Emory University will 
also be a crucial member of the research collaboration; Dr. Freeman is a WASH expert who has 
conducted cluster-randomized trials of WASH interventions in Africa and has experience with 
qualitative methods. 
3.1.2 
Executive Committee 
The Executive Committee will consist of Dr. Jeremy Keenan from the Proctor Foundation and 
Kelly Callahan from the Carter Center. This committee will act as the administrative and executive 
arm of the clinical trial and will meet in person twice per year to provide overall oversight for the 
study and make decisions on day-to-day operation issues as described in the following: 
 Monitor study progress and data collection process 
 Discuss any quality control issues that have arisen in the Trial Coordinating Center (TCC) 
and Data Coordinating Center (DCC) 
 Evaluate and adopt changes in study procedures as necessary 
 Communicate with and implement recommendations from the Data and Safety 
Monitoring Committee (DSMC) 
 Make executive decisions on the allocation of resources 
 Establish policies on publications and authorship 
 Approve and oversee ancillary studies 
 
3.1.3 
Trial Coordinating Center (TCC) 
The TCC will be located at the Proctor Foundation. Dr. Jeremy Keenan will lead the center, which 
will also include Dr. Thomas Lietman (co-investigator), Dr. Travis Porco (biostatistician), Dionna 
Wittberg (Proctor program manager), Jason Melo (statistical analyst), and Vicky Cevallos (Proctor 
microbiologist). The role of the TCC will be to oversee and coordinate the overall implementation 
of the trial. Specifically, this means maintaining an up-to-date manual of procedures, obtaining 
ethical approvals from all involved parties (UCSF, Carter Center, and Ethiopia), leading 
development of study materials, helping with implementation of the study activities, conducting 

 
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training and certification of all study personnel, ensuring proper masking of outcome assessment, 
and monitoring adherence and adoption of the study intervention. The TCC will organize site 
visits at least twice per year before each monitoring visit to conduct training sessions with 
outcome assessors and monitor the quality of data collection. Either the principal investigator or 
the Proctor program manager will be present at all site visits. The Proctor program manager, with 
assistance from the Carter Center study coordinator will organize the training sessions and 
oversee the design and production of all educational messaging used in the hygiene promotion. 
The TCC will meet officially as a group at least 4 times per year. All members of the TCC are 
currently working on studies of trachoma in Ethiopia and Niger. The group has close working 
relationships with the Carter Center staff in Ethiopia, and experience with cluster-randomized 
trials in resource-poor settings. 
3.1.4 
Ethiopian Coordinating Center 
The Ethiopian Coordinating Center will be located at the Carter Center Ethiopia headquarters in 
Addis Ababa, Ethiopia. The center will be led by the study site principal investigator, Dr. Zerihun 
Tadesse, and also include the Carter study coordinator, Dr. Solomon Aragie. Dr. Zerihun will 
oversee the study activities that take place in Ethiopia, and will manage the day-to-day activities 
of the Carter study coordinator. He will also assist with obtaining ethical approval from 
appropriate federal, regional, and zonal agencies. He is supervised by Kelly Callahan from the 
Atlanta headquarters of the Carter Center. The Carter Center study coordinator (Dr. Solomon 
Aragie) will work with the local health officials to find workers for the census activities, nurses, 
data collectors, and lab staff to work as data collectors, a hygiene cluster coordinator, and health 
promotion workers (HPWs). He will liaise with Catholic Relief Services (the organization that will 
install the water points) and will also assist with synthesizing feedback from the formative 
research. He will assist with the WASH intervention development, and he will also be responsible 
for implementation of the WASH intervention. He will supervise all data collection activities and 
will be responsible for proper storage and transport of specimens. He will be responsible for 
dealing with the Amhara Public Health Institute to ensure the laboratory has adequate supplies 
and processes the specimens in a timely fashion. Finally, he will coordinate data entry of the 
costing forms, which will be done by experienced data entry staff at the Carter Center 
headquarters in Addis Ababa. 
3.1.5 
Data Coordinating Center (DCC) 
The DCC will be located at the Proctor Foundation, and led by Dr. Travis Porco. The Proctor 
Foundation has served as a DCC for several other trials, including cluster-randomized trials of 
trachoma in Ethiopia (TANA and TIRET continuation study, NEI U10 EY016214) and Niger 
(MORDOR; Gates OPP 1032340), and individual cluster-randomized trials of corneal ulcers in 
India (SCUT, NEI U10 EY015114; MUTT, NEI U10 EY018573). Dr. Porco, Dionna Wittberg (program 
manager), and Jason Melo (statistical analyst) will be responsible for data management, data 
quality control, event adjudication, and training and certification of data entry personnel. The 
DCC will be responsible for drafting the trial’s statistical analysis plan, analyzing data according 
to the plan, and providing data requested for publications. The DCC will be responsible for 

 
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coordinating and supervising the activities of the Data and Safety Monitoring Committee, 
including preparing interim and final data reports. The DCC will also be responsible for 
coordinating the use of the electronic data capture system, including maintenance of the 
software application and data backup monitoring visits. The DCC will be in close contact with the 
Ethiopian study coordinator to help address any issues in Ethiopia.  
3.1.6 
Data and Safety Monitoring Committee (DSMC) 
The DSMC has been formed according to NIH guidelines and is comprised of independent experts 
in bioethics, biostatistics, epidemiology, ophthalmology, and international health. The DSMC will 
meet at least once per year. Ad hoc meetings may be convened as needed. The DSMC approved 
the trial protocol at the first meeting (16 September 2014).  At annual meetings, the DSMC will 
review data on effectiveness outcomes. A chief responsibility will be to decide whether ocular 
chlamydia infection levels become high enough (around 20% in study clusters) to necessitate 
treatment with mass azithromycin. They will also monitor for unanticipated events. 
 
 
 
 

 
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Figure 2: SWIFT Study Organization Chart
Executive  
Committee 
Trial Coordinating   
Center 
Data 
Coordinating 
Center 
Ethiopian Coordinating 
Center 
Ethiopia 
Data and Safety 
Monitoring 
Committee 

 
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3.2 Collaborating Institutions 
3.2.1 
Francis I. Proctor Foundation 
The Proctor Foundation is an organized research unit at the University of California, San Francisco. The 
Foundation has a 72 year history of research in ocular infectious and inflammatory diseases and runs 
one of the leading corneal fellowship training programs in the United States. Proctor Foundation Faculty 
has been involved in prevention of blindness research in developing countries since the foundation’s 
inception. The impetus for establishing the foundation in 1947 was to eradicate trachoma in the 
American Southwest and in other parts of the world. 
 
From this initial vision we have expanded our research efforts to include the other major causes of 
blindness worldwide, with a continuing emphasis on infectious and inflammatory eye diseases. The 
Proctor Foundation will be the main coordinating center for the study. Dr. Jeremy Keenan, Principal 
Investigator of the study at Proctor Foundation, will be assisted by numerous co-investigators, a program 
manager, a study coordinator, a microbiologist, a data analyst, laboratory PCR processing staff, and a 
biostatistician.  
 
Our experience working in Ethiopia has been very successful to date – with the TEF (Trachoma 
Elimination and Follow-up) study in the Gurage region, TANA (Trachoma Amelioration in Northern 
Amhara) and the TIRET (Tripartite International Research for the Elimination of Trachoma) study in the 
Amhara region. We have partnered with ORBIS International and The Carter Center, respectively, to 
conduct/complete these large-scale projects.   
3.2.2 
The Carter Center – Ethiopia 
The Carter Center is guided by a fundamental commitment to human rights and the alleviation of human 
suffering; it seeks to prevent and resolve conflicts, enhance freedom and democracy and improve health.  
The trachoma control program does not just fight disease, it fights the conditions that perpetuate 
disease: poverty, poor sanitation, lack of knowledge, and hopelessness. Together, the Carter Center and 
its program partners are working to build a brighter future for those at risk for this devastating disease.  
 
The focus of the country program has been on trachoma control, and delivery of quality eye care and 
blindness prevention programs to the majority of the population that live in rural areas (72%), largely 
unserved by trained eye care professionals.   
 
Partnering with the Carter Center has yielded very positive results.  The organization has an established 
infrastructure for large scale health promotion and improvement programs, as well as a strong working 
relationship with the Ethiopian Ministry of Health – both of which have contributed to the success of our 
field research.   
 

 
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3.2.3 
Amhara Public Health Institute (formerly Bahir Dar Regional Health and Research Laboratory) – Ethiopia 
The Amhara Public Health Institute in Bahir Dar, Ethiopia was established to be a center of excellence 
for the development of laboratory systems in the region. Construction of this CDC and USAID supported 
laboratory was completed in 2011. Conjunctival swabs will be processed with the Abbott RealTime assay 
for Chlamydia trachomatis, using the automated Abbott m2000 System, which is already in use at the 
laboratory. Amhara Public Health Institute will also process the swabs using media selective for 
Streptococcus pneumoniae, and then test for antibiotic resistance to erythromycin, penicillin, 
tetracycline, and clindamycin using the Kirby Bauer disc diffusion assay. 
 
3.2.4 
Emory University 
The Rollins School of Public Health comprises six academic departments: behavioral sciences and health 
education, biostatistics, environmental and occupational health, epidemiology, health policy and 
management, global health, and hosts over 20 interdisciplinary centers. Its location in Atlanta provides 
ample interaction with other public health professionals interested in global health. Specifically, the 
school has close ties with the Carter Center and the Centers for Disease Control and Prevention, both of 
which are in Atlanta and contribute faculty to the school. Dr. Matthew Freeman has a dual appointment 
in the Department of Environmental Health and in the Hubert Department of Global Health.  
3.2.5 
Centers for Disease Control and Prevention  
Dr. Diana Martin and her lab at the Centers for Disease Control and Prevention are developing new 
serological tests to monitor trachoma elimination as well as other diseases of interest including 
helminths, intestinal bacterial pathogens, and intestinal protozoal pathogens. Dr. Martin’s lab will 
complete serological testing for trachoma and other diseases of interest using the dried blood spots 
collected throughout the study.  
 
3.3 Duties & Responsibilities of Staff 
3.3.1 
Principal Investigator (Proctor Foundation) 
 Develop study design, specific aims and outcome measures, with help of biostatistician, study 
coordinators, and partners 
 Obtain grant funding with help of partners 
 Ensure that staff follow through on protocol and properly execute all areas of research 
 Ensure that all ethical approvals are maintained 
 Oversee intervention implementation 
 Write or add major contributions to all study-related publications 
 Ensure proper masking procedure for staff involved in the study 
 Supervise training and certification for all trachoma examiners 
3.3.2 
Program Manager (Proctor Foundation) 
 Ensure the execution of the study per protocol 

 
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 Coordinate with the collaborating center, The Carter Center, Ethiopia (TCCE) and particularly with 
the TCCE Study Coordinator, in execution of the study 
 Manage correspondence between all collaborating organizations and parties 
 Maintain all clearances for the study, including IRB renewals, NRERC, the Ethiopian FDA (formerly 
FMHACA, the BUA, and DSMC-related approvals.  
 Manage budgetary items including the NIH award and subcontracts  
 In collaboration with TCCE Study Coordinator, prepare the census and examination application, 
electronic tools, and paper forms necessary for fieldwork (cluster registration lists, spot check 
REDCap, costing forms, mini-spot check household lists, and etc.) 
 Train census and exam workers in the use of the electronic data capture system, with help of 
TCCE Study Coordinator 
 Train both Proctor and Ethiopian health worker teams for each collection visit; direct team, with 
help of TCCE Study Coordinator, while in Ethiopia 
 Train and certify Hygiene Cluster Coordinators and health promotion workers (HPWs) with help 
of TCCE Study Coordinator 
 Direct development and implementation of WASH intervention 
 Oversee data collection efforts and ensure data is analyzed in a timely manner 
 Arrange logistics and itineraries for traveling team members in Ethiopia 
 Purchase, maintain, and organize transport of all necessary study supplies to/within Ethiopia 
 Maintain communication and partnership with Principal Investigator regarding all study activities 
and plans 
3.3.3 
Study Coordinator (The Carter Center, Ethiopia) 
 Prior to the start of the study, secure support from the Amhara Regional Health Bureau, and 
written approvals from the NRERC (Ministry of Science and Technology) and the Ethiopian FDA 
 At baseline and throughout the study, obtain and maintain permission from zonal health leaders 
for the SWIFT study.  Meet with and obtain permission/consent from all kebele and sub-kebele 
leaders. 
 Train and supervise census and household survey team, including training in the electronic data 
capture system 
 Supervise and train exam data collection teams (with emphasis on any new members) 
throughout each collection, especially after departure of Proctor study team  
 Manage the data collected during the census and exams by ensuring that the app data is 
uploaded to Salesforce and that the exam photographs are saved on external hard drives  
 Arrange printing of study materials including educational materials for households, hygiene 
workshops, schools, and advertising 
 Train, certify, and work closely with the Hygiene Cluster Coordinators and the HPWs (with help 
of Proctor Study Coordinator) 
 Train and supervise all albendazole and antibiotic MDA distribution teams  
 Maintain all fieldwork documents and records 
 Complete all collection and intervention reports  
 Work with Data Analyst to maintain census and exam database 

 
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 Help develop and implement WASH interventions 
 Oversee transport of study samples to Amhara Public Health Institute 
 Assist Proctor Coordinators in coordinating logistics in Ethiopia 
 Train and supervise data entry staff at Carter Center Headquarters in Addis Ababa 
 Analyze and provide data when requested by co-investigators or staff from Proctor Foundation 
 Appropriately back-up all data 
3.3.4 
Co-Investigators (US & Ethiopia) 
 Assume responsibility for the study in the absence of the Principal Investigator 
 Supervise local workers, lab workers, nurses, local health agents, and other Proctor team 
members in the field to ensure conformity to study procedures 
 Communicate with the program manager and principal investigator to ensure the execution of 
the study as per the protocol 
3.3.5 
WASH Expert (Emory University) 
 Serve as co-investigator and WASH technical advisor 
 Provide technical assistance in fundamental behavioral interventions and qualitative methods 
 Help design the formative research component of the study, including in-field training and 
analysis 
 Help design the structured observations methodology, including in-field training and analysis 
3.3.6 
Statistical Analyst (Proctor Foundation) 
 Maintain database for all collection and results-related data for the study 
 Monitor receipt of all census, treatment, and exam data after each collection activity 
 Develop database for entry of costing data at the Carter Center, Addis Ababa 
 Track and analyze process indicators including household WASH survey, spot check data, and 
structured observations 
 Develop consistency checks in the data management—verify any inconsistencies or questions 
regarding data through communication with Study Coordinator 
 Analyze and provide data regarding collection and results for study staff when needed, such as 
for publications or DSMC meeting 
 Back-up all data appropriately 
 Follow-up on any missing data or lab results 
3.3.7 
Microbiologist (Proctor Foundation) 
 Train laboratory technicians, especially the microbiologists at the Amhara Public Health Institute, 
for all lab procedures concerning the study: including Polymerase Chain Reaction (PCR) 
procedures, macrolide resistance testing, standard laboratory procedures for all tests, record-
keeping, and quality control measures as per approved standards 
 Verify equipment quality 

 
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3.3.8 
Microbiologist/laboratory technician (Amhara Public Health Institute) 
 Provide training review and supervise laboratory technicians for all lab procedures concerning 
the study, including PCR procedures 
 Perform all macrolide resistance testing  
 Follow standard laboratory procedures for all tests 
 Keep records of all tests performed 
 Maintain quality control measures as per approved standards 
 Make sure all equipment is calibrated and maintained 
 Maintain stock of laboratory reagents and supplies 
 Pool and prepare all PCR samples, and process using Abbott RealTime assay for Chlamydia 
trachomatis, using the automated Abbott m2000 System 
 Perform regular maintenance checks of the Abbott m2000 system, under direction of 
microbiologist 
 Report PCR results to DCC 
 Maintain cleanliness and maintenance of molecular biology laboratory and all equipment 
3.3.9 
Laboratory Assistants (Amhara Public Health Institute) 
 Organize all study samples for PCR processing in at APHI 
 Monitor correct receipt of study samples (using corresponding exam sheets) after each 
monitoring visit 
 Prepare samples for PCR processing 
 Organize work flow of PCR processing for laboratory technicians, in consultation with program 
manager and principal investigator 
 Maintain all samples in storage freezers; create and maintain clear map of study samples for each 
freezer 
 Process NP samples 
3.3.10 Biostatistician (Proctor Foundation) 
 With the Principal Investigator, create the Statistical Analysis Plan (SAP) 
 Receive all study data and review for quality control purposes 
 Ensure appropriate masking  
 Prepare data analysis plan for annual DSMC meetings.  Help analyze and prepare all presented 
data for DSMC meetings, DSMC reports, and all SWIFT study publications  
3.3.11 Hygiene Cluster Coordinator: Local Staff, Amhara, Ethiopia  
 Complete intensive on-site training from the Proctor Foundation and Carter Center 
 Work closely with the Study Coordinator (TCCE) to ensure proper implementation of WASH 
components 
 Responsible for overseeing 20 clusters 
 Responsible for overseeing Hygiene Promotion Workers (HPWs)  
 Conduct trainings for health extension workers, priests, and Health Development Army members 
 Conduct monthly visits to all WASH communities 

 
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 Water: 
o Help with identification of potential water point locations and management of the water 
point construction 
o Troubleshoot maintenance issues with Woreda Water Office or artisans  
 Sanitation: 
o Perform spot checks of latrine quality during monthly visits 
o Encourage households to build a latrine and keep it in good working order 
o Lead latrine promotion campaigns 
 Hygiene: 
o Training of Teachers: help conduct a training for teachers of primary schools in the study 
area; “train-the-trainers” model where teachers then implement activities for students 
o Key messages: Help conduct focus groups in clusters to identify the educational messages 
that will most motivate behavior change; work closely with Study Coordinator (TCCE) to 
help identify key hygiene promotion messages in hygiene promotion activities and 
appropriate forums for education  
o Monthly workshops: Supervise HPWs as they conduct monthly workshops in each 
cluster, with educational messages in appropriate local venues  
o Spot checks: Conduct spot checks on a random sample of 8 households with pre-school 
children at each monthly visit to monitor water, sanitation, and hygiene components  
3.3.12 Health Promotion Workers (HPWs) 
 Complete intensive on-site training workshop from the Proctor Foundation and Carter Center 
 Work closely with the Hygiene Cluster Coordinator (TCCE) to ensure proper implementation of 
WASH components 
 Responsible for WASH education in 1-3 clusters 
 Water: 
o Help troubleshoot maintenance issues 
o Report issues with water points 
o Liaise with Water Committee  
o Encourage increased water use for hygiene activities and use of safe water sources 
 Sanitation: 
o Perform spot checks of latrine quality during household visits 
o Encourage households to build a latrine and keep their latrine in good working order 
 Hygiene: 
o House to house visits: visits each household at least once per month to encourage 
positive WASH behavior change and improvements to hygiene infrastructure at the 
household level 
o Monthly workshops: conduct educational hygiene focused workshops in each cluster 
o School curriculum: work with school principal and WASH club leader to promote WASH 
in the schools and ensure that the schools are implementing the curriculum  

 
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3.3.13 Health Development Army 
 Local community members selected by woredas in Amhara, Ethiopia  
 Assist with implementation of hygiene activities 
 Complete trainings for WASH promotion 
 Implement WASH promotion to 5 nearby households 
3.3.14 Census Team 
 The Carter Center will organize and train local workers to perform the census. 
 During the census, travel to enrolled clusters and obtain patient information as required for all 
census forms. The census will be performed with an electronic data capture system, with the 
following data inputs for each household/household member: 
o Name 
o Gender 
o Age  
o School(s) household utilizes 
o Water point(s) household utilizes   
o Health provider(s) household utilizes 
o GPS coordinates for each household 
o GPS coordinates for each safe water source in the study area 
o Presence or absence of usable household latrine and latrine-use 
o Presence or absence of washing station and soap 
o Information on hygiene behaviors (e.g., face-washing and latrine use) 
3.3.15 Treatment Team 
 Complete training by TCCE Study Coordinator regarding proper treatment protocols and 
procedures 
 Travel to enrolled clusters and administer study medication to the study subjects per protocol 
o Directly observe consumption of azithromycin 
o Record antibiotic coverage in census application 
o Return to households until they have distributed antibiotics to at least 80% of individuals 
 Counsel and motivate participants for follow-up and monitoring visits 
 Inform patients of available health care facilities and procedures in local health centers and 
hospitals 
 Collect information on the nature of any Adverse Events experienced by study subjects, and 
report this back immediately to TCCE Investigators 
3.3.16 Exam Team: Local workers, nurses, and lab technicians 
 At each exam phase, complete on-going training and certification in clinical examination and 
collection procedures 
 Prepare all study-related materials before travel to study sites 
 In each cluster, mobilize and identify all randomly selected participants 

 
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 Explain study purpose and procedure and obtain verbal consent for enrollment from each 
participant or participant guardian 
 Under supervision of TCCE Study Coordinator and/or trained Proctor staff, perform clinical exam 
for each patient and collect all participant study samples according to protocol.  
 Store and record all samples correctly for transport, organization, and processing 
 Counsel and motivate patients for follow-up and monitoring visits 
 Inform patients of available health care facilities and procedures in local health centers and 
hospitals 
 Enter all data into the mobile application 
 Collect information on the nature of any Adverse Events experienced by study subjects, and 
immediately report to TCCE Investigators 
 
3.4 Policy Matters 
3.4.1 
Protocol Revisions during the Trial 
Any changes to the protocol made during the course of the study will be incorporated in the 
revised protocol and the Manual of Operations and Procedures (MOP), and recorded in a change 
log. Any new forms will be incorporated in addendum. The protocol changes should be submitted 
and approved by the IRB of both the collaborating centers and by the DSMC. 
 
3.5 Presentations and Publications 
All presentations and publications should include acknowledgement of the funding sources and give 
credit to the collaborating organizations and/or individuals involved. 
3.5.1 
Authorship Policy 
Acknowledgements will include grant source(s) and/or NIH grant(s), and the DSMC. 

 
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4. RESEARCH DESIGN 
4.1 Study area 
 
SWIFT is being conducted in three woredas of the WagHemra zone of Amhara, Ethiopia: Gazgibella, 
Sekota, and Sekota Town (Figure 3). In Ethiopia, a woreda is a government-defined administrative 
subdivision that is in turn comprised of kebeles. WagHemra is arid and mountainous, and was chosen 
based on trachoma impact surveys performed by the Carter Center that determined the area had a high 
prevalence of trachoma and a low prevalence of several WASH indicators.  
 
4.2 Randomization  
4.2.1 
Randomization Unit 
WUHA - School Districts: The randomization unit for this trial is the primary school district. We 
included 40 primary school districts from the 3 woredas. We excluded school districts in the 2 urban 
kebeles of Sekota, since urban areas have better access to water and sanitation and exhibit less 
trachoma than rural areas.32,33 We chose the school district for two reasons. First, school children in 
Ethiopia have a considerable burden of trachoma, so units smaller than a school could be subject to 
contamination. Second, we wished to incorporate school-based hygiene promotion in the intervention, 
which requires a randomization unit of school district or larger. Within each school district, the best 
site for water point development was identified via geohydrologic survey, and the cluster of 
households within 1.5km of this potential water point was designated to receive the full package of 
WASH interventions as well as annual monitoring visits for trachoma. We call these households a study 
cluster. 
 
TAITU - Villages/Gotts: The randomization unit for TAITU will be the village, which is called a gott in 
Amharic. There are 36 gotts enrolled in TAITU. 
4.2.2 
Treatment Arm Randomization 
After identification of the study clusters, we will conduct the baseline monitoring visit. Once the baseline 
visit has been concluded, the 40 WUHA study clusters will be randomized into the 2 treatment arms: 
Figure 3. WUHA Study Site. 
Panel A shows the Amhara 
Region of Ethiopia and the 
WagHemra zone (shaded 
black). Panel B shows the 3 
study woredas (Gazgibella, 
Sekota, and Sekota Town), the 
kebele borders, and the major 
road of the study area. We 
excluded the urban school 
districts in Sekota Town, as well 
as areas that are difficult to 
access.  
A 
B 

 
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WASH (N=20) and delayed WASH (N=20). The 36 identified gotts for inclusion in TAITU will be 
randomized to targeted azithromycin (N=16), mass azithromycin (N=16), or delayed treatment (N=16).  
 
By performing the randomization after the baseline monitoring, we reduce the possibility of   
differential outcome assessment at the baseline visit. The randomization sequence will be generated by 
the trial biostatistician in San Francisco using a random number generator, without stratification or 
blocking.  
 
4.3 Eligibility requirements 
4.3.1 
Selection of study communities within clusters 
For WUHA, although we will randomize primary school districts to the intervention or control, we will 
actively perform the WASH interventions only in a limited group of households that are within 1.5km 
of a potential water site. In the spring of 2015, collaborators from Catholic Relief Services in Ethiopia 
performed a geohydrologic survey of the study area and identified sites that could potentially be 
developed as protected springs, hand dug wells, or shallow boreholes. We chose the best site from 
each of 40 school districts for inclusion in the trial, and censused all households within 1.5km of the 
potential water site.  
4.3.2 
Intervention eligibility:  
 WUHA: Within a study cluster, all households and all individuals living in these households are 
eligible for the WASH intervention. 
 TAITU: All individuals are eligible for the intervention in the 16 MDA clusters. Within the 16 targeted 
study clusters, only those children aged 0-5 years who test positive for ocular chlamydia by PCR will 
be eligible for the antibiotic intervention. 
4.3.3 
Contamination 
Cluster-randomized trials are subject to contamination between clusters, which could weaken the effect 
of the study intervention. We reduce the chances of contamination by studying only a single cluster of 
households from a relatively large geographic area (i.e., school district), essentially creating a buffer zone 
around each study cluster. The chances of contamination are further reduced for household-delivered 
interventions since they are provided to households enumerated during the census. We have made no 
attempt to limit contamination from outside the study, which is theoretically possible since all 40 
communities have continued to receive the usual health promotion from the government. The 
government program consists of two health extension workers per kebele who provide 16 different 
services, among them health education and promotion of hygiene and sanitation. We will contact all 
other non-governmental organizations known to be active in Amhara that provide WASH services(e.g., 
CARE, Save the Children, and WaterAid) and request that we coordinate activities to ensure that they 
either (1) postpone activities until the end of the study, or (2) build water points and conduct hygiene 
activities only in the intervention clusters. 

 
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4.3.4 
Monitoring eligibility 
 Population-based sample. At each annual study visit, we will monitor the following groups:  
o For WUHA, we will monitor a random sample of children aged 0-5 years and a random sample 
of 30 children aged 6-9 years annually. We will also monitor a random sample of 30 
individuals ≥ 10 years at baseline and month-36 in the WUHA clusters. 
o For TAITU, we will monitor all 0-5-year-old children and a random sample of 30 children aged 
8-12.  
o Eligibility for each of these groups will be based on the previous census.  
 Longitudinal cohort. The longitudinal cohort will consist of all children aged 0-5 years at baseline, 
followed annually until month 36 for the WASH trial, and followed until month 24 for the targeted 
azithromycin trial. 0-1-year-old children who are randomly selected for the population-based sample 
at months 12, 24, and 36 will be added to the cohort at subsequent visits.  
 
4.4 Masking  
Because of the nature of the interventions, it is not feasible to mask the study participants to treatment 
allocation. By not masking study participants, there is a chance that they will change their behaviors due 
to knowledge of their allocated treatment group. In the case of this trial, however, the entire purpose of 
the interventions is to change behaviors. Although there is a chance that individuals in the non-
intervention communities will also improve their hygiene due to knowledge of their allocated treatment 
group, this is not likely—especially given the difficulty of causing behavior change even under optimal 
programmatic conditions.  Because all interventions occur at the community level, study participants are 
surrounded by similarly treated individuals and therefore are not reminded of their treatment allocation 
very often, if at all. Moreover, we monitor WASH outcomes in both the intervention and non-
intervention communities in order to assess the impact of the lack of masking on changes in hygiene 
behavior. We do not inform census workers or outcome assessors of the treatment allocation, although 
we acknowledge that this information would not be difficult to obtain.  
 
The emphasis of masking efforts for the trial concerns the primary and secondary outcomes, which can 
easily be masked. All laboratory staff are masked to treatment allocation, as are the conjunctival 
photograph reviewers. All specimens collected in the field are labeled with a 5-digit random 
identification number. Photographic graders and laboratory staff have access only to this identification 
number, and not to any other identifying information for study participants. 
 
We will also assess several key process indicators in a masked fashion from both intervention and control 
clusters (e.g., annual household survey, structured observations), but others in an unmasked way only 
in the intervention clusters (spot checks, focus groups).  
 
 

 
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5. STUDY INTERVENTIONS 
 
5.1 WUHA Trial: WASH Uptake for Health in Amhara (Specific Aim 1) 
The Carter Center Ethiopia is the principal implementing partner. The interventions have been 
informed by focus group discussions held in the study area as well as nearby areas. The Ethiopian study 
coordinator and the hygiene cluster coordinator are responsible for ensuring the fidelity of the 
intervention. The cluster coordinator had prior experience implementing WASH interventions for local 
nongovernmental organizations, and has close ties to local governmental health, water, and school 
officials. Each element of the package is described in detail below: 
5.1.1 
Water 
• Community water point. We worked with Catholic Relief Services (CRS) to install water points. CRS 
is a nongovernmental organization with extensive experience constructing water points in Ethiopia. 
CRS performed a geohydrologic survey and coordinated water point construction in each of the 20 
WASH communities with the help of the local Ethiopian nongovernmental organization Water 
Action. Of the 20 water points, 13 were spring developments, 4 were hand dug wells, and 3 were 
shallow boreholes. 
• Water committee: Interactive community participation is important for the successful 
implementation of a water point.73 The Carter Center study 
coordinator and Catholic Relief Services worked with kebele leaders to 
identify a 5-person water committee for each water point, with at 
least 2 female members. This committee developed a plan for 
maintenance of the water point, including a payment system to 
subsidize repairs.  
• Household wash station. During the initial focus group discussions 
conducted before the study, community members pointed out that 
one barrier to good face hygiene was the lack of a dedicated wash 
basin near the household. The ideal household wash station was 
identified as a jerry can with a faucet, similar to the types of facilities 
they saw in bigger cities. Based on this information, we provided all 
households in the intervention communities with such a jerry can 
(Figure 4), along with a mirror. Households were responsible for building a base for the jerry can 
out of locally available materials. 
5.1.2 
Sanitation 
• Latrine promotion: Current government policies do not allow the provision of building materials or 
direct assistance for building latrines, and so study activities are limited to latrine promotion at 
present. Study staff known as hygiene promoters (see below) are responsible for promoting latrine 
construction. Through door-to-door visits, hygiene promoters observe the presence and 
functionality of latrines and provide education about the value of a latrine as well as practical tips 
for construction. 
Figure 4. Household 
wash station in WUHA. 

 
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5.1.3 
Hygiene 
• Targeted behaviors: Hygiene education is most effective when confined to a few key messages, 
repeated in many different settings.76 Although the 
WASH package could have a positive impact on many 
health outcomes (e.g., diarrhea, soil-transmitted 
helminths, respiratory infections), we focus on two 
behaviors likely to have the greatest impact on 
trachoma: (1) using soap and water to wash a child’s 
face twice per day, and (2) consistently using latrines for 
defecation. Our messaging (e.g., times of day to wash 
the face, inclusion of soap, promotion of simple pit 
latrine, etc.) was based both on our initial focus group 
discussions and local government policies. 
5.1.3.1 Community-based hygiene promotion 
• Household WASH book: During our initial focus group discussions in the study area, local 
government health extension workers showed us educational pamphlets for family planning 
that they found useful for education activities, and recommended that we create something 
similar for WUHA. What resulted was a 65-page full-color book that provided a roadmap for 
hygiene education for hygiene promotion workers and health development army members. 
The content of the book was based on many focus groups held with local educators, health 
officials, and water officials. Ethiopian artists provided the illustrations. The book was 
translated into the two languages spoken in the study area. A book was delivered to each 
household in the intervention clusters, to be kept for the duration of the study. Books that 
are lost or damaged are replaced annually.  
• Soap distribution: The importance of soap was evident from the baseline focus group 
discussions. An American soap manufacturer (SoapBox Soaps, Washington, DC) donated 
funds to purchase 4 bars of locally produced bar soap to distribute to each household each 
month. The soap is purchased in Addis Ababa and transported by truck to the study site, 
where it is stored in one of two custom-built storage sheds in the study area.  
• Hygiene promotion workers (HPWs). Twelve people were hired as HPWs to live in the study 
communities and perform door-to-door education activities. The HPWs use the WUHA 
household WASH book as a basis for interactive teaching, with the goal of covering all topics 
of the book with each household over the study period. The HPWs also use a standardized 
form to make hygiene observations at each household (e.g., the presence and use of 
latrines and wash stations), and use the results to focus their activities. HPWs report to the 
study’s hygiene cluster coordinator. As part of SWIFT II, we will increase the number of 
HPWs to have one HPW assigned to each cluster, since this aspect of the intervention has 
proved to be quite popular among participants.  
• Non-study personnel 
Figure 5. Example page of the household 
WASH book in WUHA. 

 
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 Health Development Army (HDA). This is a government-run program in which 
communities are divided into one-to-five networks, with one HDA household in 
charge of five other households. HDA members receive government training in 
various health topics, including hygiene. For WUHA, we perform annual 
supplementary training sessions on hygiene and encourage the HDA members to 
promote hygiene messages to the 5 other households in their network at least 
monthly using the WUHA household WASH book. HPWs check in with the local HDA 
members regularly.     
 Priests. People in this part of Ethiopia are overwhelmingly Christian and devout. We 
perform an annual training session for all priests in the intervention communities 
and ask them to promote improved hygiene practices once per month at Sunday 
services.  
5.1.3.2 School-based hygiene promotion 
• Schools provide a convenient site for hygiene promotion and dissemination for several reasons. 
First, ocular chlamydia is primarily transmitted by children. Second, hygiene behaviors and habits 
are established in childhood. Third, parents identified school children as a potential vehicle for 
hygiene education during focus group discussions.  
• Curriculum: We developed a primary school hygiene curriculum in collaboration with the 
Carter Center and Ethiopian Department of Education that was based off a series of key 
informant interviews with teachers, principals, and health officials. The curriculum consists 
of 5 to 6 age-appropriate lesson plans per year for grades 1 through 4. Curriculum 
development was highly iterative, with many rounds of feedback from all stakeholders as 
well as thorough pilot-testing in our study area. The curriculum was designed to be 
interactive and student-centered, and to integrate well with the existing government 
curriculum. 
• Teacher training: a 3-day training is held before start of the school year each year. Germ 
theory and the general principles hygiene were reviewed. The lesson plans are also taught 
during this time.  
• WASH clubs: In this part of Ethiopia, children are required to participate in at least one 
extracurricular activity, and many schools have health or hygiene clubs. For WUHA, we 
provided training materials for WASH activities (songs, dances, dramas, community 
engagement activities) to existing WASH club leaders, and worked with principals of all 
intervention schools to ensure that WASH clubs were formed if they did not exist. 
 
5.1.4 
Mass albendazole distribution.  
The entire study area will be dewormed with a single mass albendazole distribution to all individuals 
aged 1 year and older (200mg for children aged 12-23 months and 400mg for individuals 24 months 
and older). The albendazole distribution occurred after the baseline study visit.  
 

 
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5.1.5 
Hygiene Cluster Coordinator and HPW training 
After their selection, the hygiene cluster coordinator and HPWs will be trained at an intensive workshop 
led by the Proctor Foundation and Carter Center. We will review basic information about trachoma and 
its transmission, as well as the benefits of the WASH strategy for preventing transmission of trachoma. 
Although not the target of the current intervention, we will also include information about diarrhea 
prevention. We will make training as participatory as possible using various methodologies, including 
lectures, case studies, role play, and games. We will train the hygiene cluster coordinator and HPWs 
using a “train the trainer” paradigm, since this person will in turn be responsible for leading workshops 
in the study communities. We will use a “teach-back” model, where the hygiene cluster 
coordinator/HPW is asked to convey health promotion information back to the study coordinators, and 
the study coordinators provide feedback.47 Before being certified, the hygiene cluster coordinator and 
HPWs will have to pass a written and oral examination in the local language, conducted by the TCCE 
study coordinator.  
 
5.2 TAITU: Targeted Antibiotic Intervention for Trachoma in Under-5s (Specific Aim 2) 
5.2.1 
Conjunctival swabs (Targeted treatment clusters) 
We will collect conjunctival swabs on all 0-5-year-old children as described elsewhere in this document. 
Swabs from the targeted antibiotic trial will be expedited for processing at the Amhara Public Health 
Institute. Swabs will be processed for chlamydial PCR in pools of 5, with pools containing swabs from the 
same study cluster and age group (0-5 years and 8-12 years for TAITU). Any positive pools from the 0-5-
year-old age group will be unpooled and processed individually. As described elsewhere in this 
document, swabs will be labeled with a random identification number in the field. This number will be 
linked with the study participant’s census entry during swab collections in the field. The laboratory will 
provide to the Carter Center study coordinator a list of all random numbers from 0-5-year-old children 
and whether they are positive or negative for ocular chlamydia. 
 
5.2.2 
Identification of children to be treated (Targeted treatment clusters) 
The database’s backend interface (Salesforce.com) application will automatically link the list of 
chlamydial PCR results provided by APHI to the census data. The study coordinator will generate a list of 
all children with positive chlamydial PCR results for each study cluster via Salesforce.com, and organize 
the treatment workers to administer directly observed azithromycin treatment to all children with a 
positive PCR result (20mg/kg, approximated with height-based dosing; children who are under 6 months 
or who have a known allergy will be offered a two-week course of topical tetracycline instead). The 
worker will document all children who receive antibiotic treatment. See subsequent sections in this 
document for details on azithromycin treatment. Note that all other individuals in the targeted 
treatment clusters (i.e., 0-5-year-olds without a positive chlamydial PCR test and all individuals ≥ 6 years) 
will not receive treatment for trachoma.  We anticipate that the treatment will occur approximately 3 
months after the baseline monitoring (i.e., 2 months to process conjunctival swabs, 1 month to organize 
treatment), although we will treat children as soon as the PCR results are available. 
 

 
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5.2.3 
Additional rounds of targeted azithromycin treatment (Targeted treatment clusters) 
All children who have a positive PCR test at the baseline monitoring visit will receive three rounds of 
azithromycin treatment. We anticipate therefore that the treatments will occur at 3, 6, and 9 months 
after baseline, and then we would conduct a repeat monitoring visit at 12 months, after which the same 
treatment plan would be performed for year 2. These additional rounds of treatment will be performed 
by the treatment workers and coordinated by the Carter Center study coordinator and cluster 
coordinator. 
 
5.2.4 
Mass azithromycin treatment (MDA clusters) 
In the 16 study clusters randomized to mass azithromycin treatment, all individuals will receive a single 
mass azithromycin distribution 3 months after the baseline and 12-month monitoring visits. The MDA 
will occur at 3 months to align with the first targeted treatment. Oral azithromycin, 20mg/kg for children 
and 1g for adults, will be offered to all households identified on the preceding census. Antibiotics will be 
distributed by treatment workers and organized by the Carter Center. Individuals with a known 
macrolide allergy, babies under 6 months, and pregnant women will be offered a 2-week course of twice 
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6. INTERVENTION MONITORING AND 
EVALUATION 
 
6.1 Spot checks 
The study cluster coordinator conducts several annual 
rounds of spot checks annually in the WUHA intervention 
clusters. At each spot check, the hygiene cluster coordinator 
assesses the usability of the water point and checks in with 
the school teachers in the cluster to review their 
implementation of the hygiene curriculum. The hygiene 
cluster coordinator also visits a random sample of 8 
households with pre-school children and documents the 
presence of a wash station and its functionality (e.g., 
presence of water in the container and soap), the presence 
of a latrine and its functionality (e.g., whether walls and a 
roof are present), and evidence for latrine use (e.g., trodden 
latrine path, fresh feces in the pit). The content of these 
structured spot checks is based on our experience in 
Ethiopia and the experience of others who have conducted 
similar surveys.34,52 The cluster coordinator enters all data 
into a smartphone using an offline REDCap mobile application, and then syncs the data later that 
evening. Electronic data capture is important, since it allows us to analyze and share the data more 
rapidly. As shown in Figure 6, the spot check data are visualized as a heat map in order to easily 
identify the hygiene gaps in each community. The hygiene cluster coordinator then conveys this 
information to the hygiene promotion workers during their monthly phone call and they brainstorm 
ways to improve the deficiencies.  
 
6.2  Household survey at annual census 
We perform a household survey in a random sample of 33% of households during the census. Census 
workers are not informed of the study purpose or the randomization allocation. The survey questions 
capture both self-reported hygiene behaviors as well as objective observations and has been crucial for 
understanding the uptake of the intervention and for guiding remediation efforts. Figure 7 shows the 
results from key survey items from the first three censuses (December 2015, 2016, and 2017). The month 
24 results show that communities randomized to the WASH intervention are more likely to have a 
household WASH station and latrine, and household members from WASH communities are more likely 
to report having washed their face and used the latrine in the past day. Behavior changes in the WASH 
arm were most evident between the month 12 and 24 visits, which is likely due to two main reasons. 
First, hygiene behaviors are notoriously difficult to change, and hygiene interventions are thought to 
require long periods of time before they can influence behavior. Second, our WASH intervention has 
many components, and was not fully implemented until the month 12 visit, meaning that the period of 
Figure 6. Spot check example. March 
2017 spot check of 20 WASH 
communities, visualized as a heat map 
(blue=100% of households; red=0%).  
 
 

 
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time between month 12 and 24 is likely a more accurate reflection of its impact. Given how difficult it is 
to change hygiene behaviors, these results suggest a real and marked difference between the two arms, 
and provide strong evidence that our intervention is being implemented as intended. 
 
6.3 Focus Group Discussions 
Hygiene promotion must take 
into account the local context. 
Barriers to changing hygiene 
practices 
and 
factors 
that 
motivate changing behavior are 
site-specific. We will build off 
previous 
successful 
hygiene 
promotion efforts that have 
relied on formative research and 
community 
participation 
to 
guide 
health 
messaging 
priorities.35,41-43  
The study team will hold focus 
groups periodically throughout 
the trial. The team will choose a 
representative 
sample 
of 
communities and they will use a 
discussion guide to lead the focus groups in a discussion about barriers and motivations for hygiene 
practices, especially as they relate to face washing and latrine use. Sessions will last no more than 2 
hours. We will target all appropriate stakeholders. These will include at least the following groups: 
(1) Health Development Army (men and women) 
(2) Community Leaders 
(3) Strong hygiene performers  
(4) Poor WASH performers 
- 
Poor hygiene performers are a group of people that will be identified by HPWs as those 
individuals who have poor hygiene behaviors. This may mean that they do not own or use a 
latrine, that they do not have a wash station at the household, that their compound is not 
kept clean, etc.  
The focus groups will be analyzed during the study visit during which they are conducted in order to 
inform the WASH intervention.  
We performed a round of focus group discussions in 5 intervention communities in June 2017 and in 
October 2018 to assess the impact of the intervention and also to help guide our intervention moving 
forward. We learned that community members highly valued the hygiene promotion workers and soap 
distribution. We probed for reasons that latrine construction was low; participants reported that 
besides people’s habits being difficult to change, the costs of latrine construction were a major barrier. 
 
Figure 7. Household survey at month 0, 12, and 24. The survey was 
performed on a random 33% of households from 20 WASH clusters 
and 20 control clusters during the annual census.   

 
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We also learned that households appreciated the WASH book, that it was regularly used during home 
visits, and that the illustrations were easily understandable.  
  
6.4 Structured observation 
Although we will capture the presence of hardware (e.g., improved water points, latrines, washing 
stations) during the annual census, this trial also requires detailed assessment of hygiene behaviors (e.g., 
face-washing and latrine use). Moreover, these assessments must occur in both treatment groups in 
order to fully assess the impact of the WASH package. Various methodologies exist to measure hygiene 
behaviors, including qualitative techniques, surveys, and structured observation.34-36 Each has 
limitations. For example, structured observations are vulnerable to reactivity, wherein those being 
observed change their behaviors simply from the process of being observed.37 Nonetheless, structured 
observation has been used routinely and is well accepted by the WASH sector. We will hire and train a 
team of local individuals to perform full-day structured observations of face-washing and latrine 
behaviors in both the WASH and control communities when the intervention is fully rolled out. Study 
staff will obtain consent from the household and then sit in an area of the household where the wash 
station, other water sources, and latrine can be observed. The observer will document use of the latrine 
as well as face- and hand-washing behavior for each household member, and will also note facial hygiene 
in the children of the household (i.e., nasal/ocular discharge, presence of flies). The observer will 
document all water use, including water used for cooking, cleaning, and bathing, and perform a spot 
check of latrine and cleanliness indicators, including the presence of human and animal feces in the 
compound. Each household will be observed for about 22 hours, from mid-afternoon on one day to mid-
afternoon the following day, in order to be present at the household in the morning and evening, since 
this is when the majority of hygiene behaviors take place. Because structured observation is time-
consuming and labor intensive, we will select a random sample of 5 households per cluster for 
observations, chosen from the preceding census. Only households with a child aged 0-9 years will be 
eligible for inclusion. We anticipate hiring 10 staff members, and completing data collection over a 6-
week period, immediately following the census. Dr. Freeman, who is the WASH expert for this trial, has 
experience with the design and analysis of structured observations, and will lead the implementation of 
this part of the study. 
 
 
 

 
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7. CENSUS 
We will perform a house-to-house census of the selected study clusters at baseline, prior to 
randomization. We will perform census updates at months 12, 24, and 36. The Carter Center will organize 
and train local workers to perform the census. The Carter Center has experience in conducting large 
censuses in Ethiopia, as they conduct censuses each year before mass azithromycin treatments. We will 
use an electronic data capture system for the census activities, similar to a pilot study we conducted in 
Ethiopia in 2011 and similar to the electronic system we are currently using for a trial in Niger funded by 
the Bill & Melinda Gates Foundation (OPP 1032340, Tom Lietman, PI). This system utilizes tablet 
computers to record all census data. Census workers record the name, sex, and age of each household 
member, the primary school(s) that any children attend, and the GPS coordinates of the house. In a 
random one-third of households, we perform a household survey to gauge self-reported socioeconomic 
status, access to water, and hygiene behaviors, and also perform observations of household latrines and 
wash stations. Census updates are performed annually thereafter, approximately one month prior to the 
exams. 
 
7.1 Equipment 
Each census worker is given the following equipment: 
1. Tablet computer: Huawei Ascend mate 2 or Mi A2 (one) 
2. Battery Pack: Anker dual port charger (one) 
3. Charging cord (from charger to electrical socket); (one) 
4. Connecting cord (from computer to charger); (one) 
5. Trident protective case (one) 
6. Sealable canvas bag to hold all equipment (one) 
 
7.2 Mobile Application 
A custom-made software application, which runs on the Android platform, will be used for data 
collection in the study. Census workers will enter all data directly into the application. The application is 
capable of using Amharic letters, so census workers will type the names of all study participants in 
Amharic.  
 
Census workers will be trained how to upload and download data. At the initial census, there was no 
pre-existing data so downloading is unnecessary. At a follow-up censuses, the pre-existing data from the 
most recent census will be downloaded in the morning before going to the field. The data will be updated 
in the field, and then uploaded when the teams return back to town at night.   
 
The data will be uploaded to a secure online server on a daily basis so that the study team can monitor 
census progress in real time.  
 
7.3 Training and Supervision 
The study coordinators from the Proctor Foundation and Carter Center will run a 3-day training 
workshop at the woreda health office for all census takers to train them in the following topics: 

 
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- 
General use of the tablet computers 
- 
Entering data into the mobile application 
- 
Acquiring GPS coordinates with the device 
- 
Re-charging the device 
After the in-class training, census workers are accompanied in the field for training in a practice village 
and for the first few days of actual data collection to ensure that quality data is consistently collected.  
 
One team leader is selected from each 3-person census team, and that person is responsible for team 
supervision, ensuring good coverage of the cluster, uploading, and daily charging.  
 
7.4 Charging Devices 
The team leader will be responsible for charging all devices from their team each night. This will be done 
at the supervisor’s home. As a backup, the study coordinator or cluster coordinator will be available to 
charge the devices at a hotel.  
 
 

 
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8. ANNUAL MONITORING (EXAMINATION) PROCEDURES  
We will perform annual monitoring visits in all study clusters. At each visit, we will collect samples on a 
subset of the population in the study cluster, as described below.  
 
8.1 Sampling strategies 
We will employ two different sampling strategies for the trials. 
 
8.1.1 
Population-based sample 
The population-based sample will consist of an age-stratified cross-sectional sample at each monitoring 
visit. Eligibility will be based on the most recent census, which will be completed annually several weeks 
before monitoring visits. We will sample a separate cross-sectional sample of individuals at each 
monitoring visit, so that individuals may or may not be sampled at successive visits. We employ this 
strategy in order to be able to obtain an unbiased population-based estimate of infection and other 
outcomes at each visit of the trial.  
 
Table 1: The number of individuals in each age stratum will depend on the particular outcome: 
 
WUHA 
 
TAITU 
Test 
0-5 
years+ 
6-9 
years+ 
≥ 
10 
years+1 
 
0-5 years 
8-12 
years+ 
Conjunctival swabs 
30 
30 
301 
 
All 
30 
Eye exam/photo 
30* 
30 
301 
 
All* 
30 
Face photo 
30* 
30 
 
 
All* 
30 
Stool sample 
302 
302 
 
 
-- 
-- 
Nasopharyngeal swab 
15+1 
 
 
 
15+1 
 
Dried blood spot 
30* 
30*3 
30*4 
 
All* 
 
Anthropometry 
30* 
 
 
 
All* 
 
*Longitudinal sample (month 12: all 0-6, month 24: all 0-7, month 36: all 0-8-year-olds) 
+ Random sample 
1 NP swabs only collected at baseline and endline visits 
2 Stool sample data only collected at 0 and 12 months 
3 Blood spot data for 6-9-year-olds captured at month 0 and 36 
4 Blood spot data for ≥ 10-year-olds captured at month 36 
 
8.1.2 
Longitudinal sample 
For outcomes such as anthropometry, clinically active trachoma, and facial cleanliness, we are interested 
in assessing changes within an individual. Therefore, we will also employ a longitudinal sampling strategy 
for these outcomes. Specifically, we will longitudinally assess the entire cohort of 0-5-year-old children 
included in the population-based sample at baseline (30 children for WUHA and all children for TAITU), 
with 0-12-month-olds who are randomly sampled in the population-based sample added to the cohort 
annually. The cohort will grow each year, as new babies are added in and as the older members age. At 

 
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month 12, the cohort will consist of 0-6-year-olds. At month 24, the cohort will consist of 0-7-year-olds. 
At month 36, the cohort will consist of 0-8-year-olds. For the outcomes of face photographs, conjunctival 
photographs, dried blood spots, and anthropometry, we will monitor the cohort over the course of the 
study visits.  
 
8.2 Preparation 
8.2.1.1 Registration lists 
Before examinations can begin, registration lists with the sampled populations must be made. This is 
done in Salesforce.com, keeping the following points in mind: 
• Make sure the census is complete. Check in the app to make sure all households have been 
completed. 
• Make sure the subphase is set to Examination on the Geographic Work Unit object. 
• Navigate to the Geographic Work Unit and click on Create Morbidity Study. 
• Generate a pdf to give to the mobilizer(s) for participant recruitment 
• Before going to the field, download the registration lists on each tablet/smartphone. This 
requires internet connectivity. 
 
8.3 Training 
8.3.1 
In-Country Training 
Before the start of the study, local health workers will be selected to complete study fieldwork and will 
undergo a series of rigorous trainings and certification in clinical grading and swab collection. At the start 
of each successive collection phase, examination team members (nurses and lab workers from the 
Ministry of Health and general workers from WagHimra) will participate in three-day training in 
WagHimra. Two days will take place in the classroom and will cover use of the application, examination 
procedures, and sample collection procedures. The final day of training will take place in a practice 
cluster. All exam workers must pass a test to participate in the exam data collection. The swabbers must 
pass a grading exam to participate in the roll of swabber/grader. The Principal Investigator and Study 
Coordinators will offer ongoing training and supervision to all exam workers in the field throughout the 
SWIFT study monitoring visits. 
 
8.4 Exam Team 
8.4.1 
Mobilizers 
The Carter Center study coordinator will hire a community member from each monitored community to 
mobilize the selected participants and ensure a high turnout for the monitoring visit. This person will 
also select the location for the monitoring visit and remove any hygiene posters or other materials that 
could unmask the outcome assessment.  

 
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8.4.2 
Outcome Assessors 
In collaboration with woreda health officials, the Carter Center study coordinator will hire lab workers, 
nurses, and general workers from WagHimra to perform all outcome assessments. These workers will 
receive a 3-day training session at the beginning of the monitoring visit to review all study procedures. 
They will be masked to treatment allocation.  
 
8.5 Registration Station 
8.5.1 
Personnel 
One registration worker is needed. This person must be familiar with the mobile data collection 
application and comfortable using a tablet/smartphone, and speak the local language. 
8.5.2 
Procedures 
The Registration Station is always the first station that study participants should visit. It should be 
placed in a visible area. The registration worker performs the following: 
• Download the registration list in the mobile application; normally this will be done before the 
team arrives in the field, in a location with good internet connectivity. 
• Identify the participant on the list of potential participants from the mobile application, and 
click the name to enter the participant's registration page. 
• Verify demographic information (name, age, sex, mother, father). 
• Note the background color of the participant's name in the mobile application. This color 
corresponds to the exam station that they must visit. 
• Place the next available sticker from the roll of random number stickers onto a bracelet with 
the color the matches the participant's background color in the application. This number is the 
participant's registration number. 
• Write the participant's full name, age, and sex, onto the bracelet. 
• Have the participant hold the bracelet below their chin, and take a photo on the participant's 
registration data page such that a photograph is taken of the face that also includes the 
person's name and registration number. 
• Fasten the bracelet around the participant's wrist. This should be done fairly tightly, so that the 
bracelet cannot be easily removed. 
 
8.6 Swab station 
8.6.1 
Personnel 
In collaboration with district health officials, the local study coordinator will hire staff from the local 
health offices. Field staff will receive a 3-day training session at the beginning of the monitoring visit to 
review all study procedures, and will be masked to treatment allocation. Each swab team will be 
comprised of 3 people: 
• Tuber: must be meticulous and detail-oriented 
• Swabber/Grader: must have good clinical skills 

 
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• Photographer: must be familiar with the mobile data collection application, photography, and be 
a fast learner 
8.6.2 
Scanning registration code 
The photographer will use the bar code scanner function on the mobile application to scan the 
registration code on the participant's bracelet. 
 
8.7 Clinical Photography 
8.7.1 
Clinical Photography of the Conjunctiva 
Four specific team members will be designated as photographers for the entire trial in order to ensure 
high quality photographs by an experienced photographer. The photographer will take photographs of 
the conjunctiva with a handheld Samsung NX digital SLR camera with a macro lens (1:1). Conjunctival 
photography causes no damage to the eye, is well tolerated by children, and is a standard clinical 
procedure at UCSF.  Clinical photography will be performed before conjunctival swabbing. Photography 
is incorporated in the mobile application; photographs will be taken under a specific child’s record and 
therefore automatically associated with the child’s unique identifier. Photographs are stored on the 
memory card in the camera. A compressed version of the photograph is synchronized to the study 
database along with the other data. The full-size version of the photograph will be transferred to an 
external hard drive each week. Batteries are charged each night; each camera bag has at least 1 spare 
external charger. 
 
8.7.2 
Photography Protocol 
 Equipment needed: camera 
 Miscellaneous equipment: Extra battery, media card reader, lens filter, extra media card  
8.7.2.1 Camera Setup 
 Model 
o Samsung NX, which has the advantage of running on Android, and therefore 
has seamless integration with the mobile application 
 Lens 
o Samsung 60mm ƒ/2.8 macro lens 
 Settings 
o The photographer does not need to adjust the camera settings because the 
settings are automatically set by the mobile application according to the 
following parameters:  
 White balance- automatic 
 Aperture Priority 
 F-stop: ƒ/32  
 ISO 400 
 Manual focus 

 
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 Flash: on (fill-in) 
 EV (brightness): 0 
 
8.7.2.2 Photograph Procedure 
 Place participant into position that will allow maximum stability; standing, sitting or “head-
clamp” position. Employing a village volunteer to help is very useful. 
 Extend lens fully, to the 1:1 position 
 Image is brought into focus by changing the working distance, not by turning the lens. This is 
because the lens is fixed in its manual setting. The working distance is approximately 20 cm from 
the eye with our current settings 
 Take minimum of 2 photos. If there is any doubt of the quality of the photo while the patient is 
in position it is better to continue to take more photographs before the patient is allowed to 
leave.  
 Check photos before allowing child to leave. If they are not acceptable, repeat procedure. Only 
stop if the patient or guardian requests that we stop, or if is deemed impossible, even with further 
attempts.   
 If the child cannot be photographed for some reason, it does not affect the eligibility of the child. 
A notation is made on the child’s record of why the photograph cannot be taken, but no 
replacement is sought.  This is expected to be a rare event. 
 
8.7.2.3 Photo Troubleshooting Guide 
Note all camera settings are permanently embedded in every photo that is taken and can be viewed with 
the camera or with any standard commercial photo-viewing software (e.g., Adobe Photoshop; 
Photomechanic, Nikon View, Canon, etc.) 
Photos too DARK: 
Make sure flash is functioning. If first photos in series are acceptable and then they 
gradually become less exposed (darker) it might be because the battery is gradually 
losing power during the session. Note that the flash reaction time increases as the 
battery power decreases. 
 Image not centered 
o Movement of child or camera (hold child’s head between knees of “helper”; stabilize 
camera with second hand) 
 Reflection artifact 
o Move camera slightly between first and second photos to achieve different angle; gently 
dab conjunctiva with swab- must be done at periphery to avoid creating inflammation 
 
8.7.2.4 Face Photograph Procedure 
Face photographs are taken with the same camera and lens, using settings defined by the mobile 
application (same as above, except an F-stop of ƒ/11). The photographer stands approximately 1-2 

 
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meters from the participant and moves the lens until the face fills the frame of the photograph, with 
only a small amount of space between the chin/ears/cranium and the edge of the photograph.  
 
8.7.3 
Conjunctival Swab Collection Procedures  
8.7.3.1 Gloving 
Any hand that will touch a participant’s skin must be gloved for the examination.  The examiner will put 
latex gloves on both of their hands prior to touching a participant's skin, and a new pair of gloves will be 
used for each participant.  Purell® Instant Hand Sanitizer will be available for hand sanitization. 
8.7.3.2 Equipment 
• Swabbing/tubing: tubes, swabs, labels, tube box, cooler, ice, metal container for swabs, aprons, 
garbage bags, chucks, hand sanitizer  
• Grading: 2.5X loupes, penlight 
• Photography: camera, extra batteries, lens wipes  
 
8.7.3.3 Examination Position 
Young children: The examining position to be used in the field for young children will be the classic 
pediatric ophthalmic examination technique. With the aid of a helper seated directly opposite to the 
examiner, the child will be positioned with his/her head between the examiner's knees, with the child's 
face looking upwards toward the examiner.  The legs of the child will be straddled across the helper and 
the arms held gently across the child’s chest.  Care should be taken to keep the child’s eyes above the 
level of the examiner’s knees, in order to properly take the conjunctival swab. 
 
Older children/adults: For examining adults and older children, the participant should stand or sit 
facing the seated examiner, such that the participant's eyes are at the examiner's eye-level. 
8.7.3.4 Everting the Upper Eyelid 
For all participants, only the right upper eyelid will be examined; the only exception to this is if the 
right eye is difficult to examine due to eye disease or injury, in which case the left eye will be 
examined. In order to avoid passing contamination from the child into the eye, once the examiner dons 
a new pair of gloves, their gloved hands should not be used to position the child.  The examiner uses 
their fingertips to grasp the central portion of the participant’s upper lid eyelashes.  The upper lid is 
then everted, using a finger of the examiner's other hand (or the end of a sterile swab) as a fulcrum, 
positioned superior to the tarsal plate.  The everted lid is held in place by the examiner's non-dominant 
hand holding the eyelashes against the orbital rim, thus keeping the examiner's dominant hand free for 
swabbing the participant’s tarsal conjunctiva later. 

 
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8.7.3.5 Trachoma Grading 
The examiner uses the 2.5X 
magnifying ocular loupes to 
assess the tarsal conjunctiva 
of the everted upper right 
eyelid.  The examiner will 
grade the conjunctiva 
according to the World 
Health Organization 
Simplified Trachoma Grading 
Scale, as shown in Table 2. A 
hand-held penlight will be 
used by the examiner for 
illumination of the 
conjunctiva at all times; the 
only substitute for this is 
direct sunlight.  The 
examiner tells the trachoma 
grade to the photographer, 
who records the grade into 
the mobile application on the Samsung camera. Before being allowed to grade in the field, each grader 
must complete a training workshop and pass a photographic test with a kappa of 0.6 or greater relative 
to a gold standard grade, where the gold standard is the consensus grade from a panel of 3 expert 
graders, 
8.7.3.6 WHO Simplified Trachoma Grading Card 
The WHO simplified trachoma grading card will be used as the reference standard for grading trachoma 
in the field.  The card shows color photograph standards of each trachoma grade, clear descriptions of 
each grading category, and the standard abbreviations for each trachoma grade. 
8.7.3.7 Procedures 
In this trial, we will collect 1 swab. The examiner uses a separate pair of gloves for each study 
participant. We will store the swabs in microcentrifuge tubes without transport media.  
 The tuber opens a Dacron swab by the bottom end and makes it available to the swabber. 
 The swabber passes the Dacron swab firmly over the right everted upper tarsal conjunctiva 
three times, rotating 120ºC between each pass.  
 The tuber holds a tube with the cap open 
 The swabber deposits the swab in the tube, and snaps off the shaft of the swab. This normally 
does not require counterpressure with the tube cap. 
 The tuber firmly screws closed the cap. The tuber checks to make sure that the swab is at the 
bottom of the tube and taps the tube until the swab falls.   
Table 2: WHO Simplified Trachoma Grading Scale 
Definitions of the WHO Simplified Trachoma Grading Scale 
TF (Trachomatous Inflammation – Follicular):  the presence of five or 
more follicles in the upper tarsal conjunctiva. 
TI (Trachomatous Inflammation – Intense):  pronounced 
inflammatory thickening of the upper tarsal conjunctiva that obscures 
more than half of the normal deep tarsal vessels. 
TS (Trachomatous Scarring):  the presence of scarring in the tarsal 
conjunctiva. 
TT (Trachomatous Trichiasis):  at least one eyelash rubs on the 
eyeball. 
CO (Corneal Opacity):  easily visible corneal opacity over the pupil. 
Clinically active trachoma: defined as either TF or TI.  If WHO 
guidelines recommend that TF alone is the most appropriate sign to 
follow, then we will easily be able to report this. 
 

 
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 The tuber places the tube in the tube box within the cooler. Tubes are put in chronological 
order of swabbing, filling a horizontal row, starting with the top left-hand corner of the box. 
 The tuber closes the cooler in between swabs. 
8.7.4 
Two sets of control swabs will be taken in the course of examinations: 
Negative "air" swabs: a swab will be waved in the air, taking care not to contaminate the swab. This 
will be done at the beginning and end of the work day. The tube codes are scanned into the mobile 
application in the designated field. 
 
Duplicate swabs: The mobile application will randomly select 2 participants per community for a 
duplicate swab.  
8.7.5 
Transportation and Storage of Conjuntival Samples 
In accordance with the Abbott RealTime protocol, swab samples taken in the field will be transported 
on ice in a closed, insulated container, and then transfer them within 8 hours to a -20°C freezer at a 
local health center. Swabs will be shipped within 4 weeks to the APHI, where they will be stored at         
-20°C before being processed.  
 
8.7.6 
Nasopharyngeal Specimen Collection 
At months 0 and 36, we will collect nasopharyngeal swabs in 15 randomly selected children aged 0-5 
years per community. We selected this age group because pre-school children in sub-Saharan Africa have 
been shown to have high rates of pneumococcal carriage.107-109  
• The tuber will select an NP swab and open the swab sachet in a sterile manner (revealing only the 
tip of the swab shaft, with the swab head itself remaining sterile deep within the sachet).   
• Immediately after completion of the conjunctival eye swab collection (and if necessary, control swab 
collection), the examiner will remove the NP swab from the sachet and place the tip down the 
participant’s nasopharynx. 
• The examiner will quickly rotate the swab 120° three times back and forth, and then remove the 
swab from the nose.  
• The examiner will place the swab in a tube containing 1.0 mL of STGG (skim milk, tryptone, glucose, 
and glycerin) media.  The tuber will cut the handle off using sterile scissors (cleaned with alcohol 
pads between participants).  The tuber will close the cap of the STGG tube with the swab immersed. 
• We will keep the swabs on ice in the field and then in a -20°C freezer as described above for the 
conjunctival swabs. The Amhara Public Health Institute will process the swabs using media selective 
for Streptococcus pneumoniae, and then test for antibiotic resistance to erythromycin, penicillin, 
tetracycline, and clindamycin using the Kirby Bauer disc diffusion assay. 
8.7.7 
Materials for NP Collection 
 Nasopharyngeal Swabs: Specimens will be collected using sterile, individually-wrapped pediatric 
calcium alginate swabs with a malleable plastic swab shaft for patient comfort and safety  

 
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 Nasopharyngeal Sample Tubes: All field samples for DNA testing will be collected into sterile 2.0ml 
microcentrifuge tubes, manufactured by RPI®.  
 Cooler Bags with Frozen Ice Packs: Insulated cooler bags will be used to carry samples to and from 
the field.  In addition, frozen gel ice packs designed to thaw slowly will be used to maintain the 
temperature in the cooler bags during transport. 
 -20°C Freezer: A standard -20°C freezer will be used strictly for the storage and freezing of ice packs 
and samples.  This freezer is kept in a locked room on the grounds of the Health Center, which is 
under 24-hour security guard supervision. 
 Latex Gloves: latex examination gloves will be used to perform nasopharyngeal examinations.  Each 
glove will be used once and never shared between participants.  Used gloves will be collected in a 
trash bag and incinerated at the local Health Center incineration facility. 
8.7.8 
Transportation and Storage of Nasopharyngeal Samples 
The nasopharyngeal swab samples in skim milk-tryptone-glucose-glycerin (STGG) will be initially stored 
in the field using an insulated storage bag filled with Fisher brand ice gel packs and then transferred 
along with the conjunctival swabs first to a -20 freezer in WagHimra and then to Bahir Dar.  
 
8.8 Anthropometry 
Using methods we have already used in several studies in Ethiopia and Niger, we will measure the height, 
weight, and middle upper arm circumference (MUAC) of the longitudinal cohort of 0-5 year-old 
children.96,106 Each index will be measured in triplicate and the median measurement used for analysis. 
We will use a Shorr Board to measure height, Seca 874 floor scale to measure weight, and MUAC tapes 
to measure MUAC. Anthropometric measurements in previous studies have had excellent repeatability, 
and we have found such assessments to be feasible and inexpensive. We will urgently refer any children 
with severe acute malnutrition, defined as MUAC <11cm, to a local health clinic for treatment. 
 
8.8.1 
Observe 
When the participant presents for examination, first examine him/her for signs of malnourishment:  
1. Kwashiorkor: look for edema (or swelling); thin, sparse, or discolored hair; and skin with 
discolored patches that may crack and peel. 
2. Marasmus: look for severe wasting; the appearance of ‘skin and bones;’ and a face that looks like 
an old man’s.   
3. Pedal edema: look for swelling due to excess fluid in the foot.  Press the child’s foot with your 
thumb.  If the foot is swollen and the indentation remains after you press it, the child has edema. 
 
Each anthropometry team should have a laminated sheet with photographs demonstrating typical 
examples of these signs. 
 
8.8.2 
Measuring and Recording Guidelines 
Measurements are taken to the nearest 0.1 cm (1.0 mm) for height/length and MUAC, and 0.01 kg for weights. 
 

 
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8.8.3 
Measuring Length and Height 
A lightweight measuring board will be used to measure the participant’s height to the nearest 0.1 cm. 
Height will be assessed with a ShorrBoard (ShorrBoard®, Shorr Productions, LLC, Olney, MD, USA). 
Depending on a child’s age and ability to stand, measure the child’s length or height.   
 
Length: If a child is less than 2 years old, measure recumbent length. Select L to indicate that length was 
measured. A child’s length is measured lying down (recumbent).   
 
Height: If a child is aged 2 years or older and able to stand, measure standing height. Select H to indicate 
that height was measured. Height is measured standing upright. 
 
If the child has braids or hair ornaments that will interfere with length/height measurements, remove 
them if possible.  Check that any shoes or socks have also been removed.  
 
Whether measuring length or height, the mother/guardian is needed to help with measurements and to 
soothe and comfort the child.  Explain to the mother the reasons for the measurements, and the steps 
in the procedure. Answer any questions she might have. Show her and tell her how she can help you. 
Explain that it is important to keep the child still and calm to obtain the best measurement.  
 
 
Table 3: Shorr Board Set-Up 
1) Remove from bag. 
2) Stand the Shorr Board upright.  You can step on the base of the board to keep 
it stable. 
3) As you face the board, turn the non-removable bolt counterclockwise to 
release the extension piece.  Note: the bolt remains attached to the back of the 
extension piece – do NOT remove it. 
4) Slide the extension piece into the top end of the main board and fasten the 
clasp on the back of the board.  Make sure the clasp is fastened properly.   
5) The auto-lock sliding head/footpiece is stored in the base of the main board 
and can be moved up and down the length of the measuring board.  It should 
stay in place on its own wherever you position it.   
6) The measuring board must be placed against a firm surface for standing 
height (e.g. wall, table, tree, etc.).  Make sure the board is stable.  If necessary, 
place items such as small rocks underneath the height board to stabilize it 
during the measurement.  
7) Clean the equipment with alcohol swabs at the beginning of each day.  

 
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8.8.3.1 Measure Length  
I. 
Cover the length board with a chuck (or another absorbent, disposable material) for hygiene and 
for the baby’s comfort. 
II. 
Explain to the mother that she will need to place the baby on the length board and then help to 
hold the baby’s head in place while the measurement is taken.  Show her where to stand when 
placing the baby down (i.e. opposite you, on the side of the length board away from the tape).  
Also show her where to place the baby’s head (against the fixed headboard) so that she can move 
quickly and surely without distressing the baby.   
III. 
When the mother understands your instructions and is ready to assist: Ask her to lay the child on 
his back with his head against the fixed headboard, compressing the hair.  
IV. 
Quickly position the head so that an imaginary vertical line from the ear canal to the lower border 
of the eye socket is perpendicular to the board.  (The child’s eyes should be looking straight up.)  
Ask the mother to move behind the headboard and hold the head in this position.   
V. 
Speed is important.  Standing on the side of the length board where you can see the measuring 
tape and move the footboard:  
a. Check that the child lies straight along the board and does not change position.   
b. Shoulders should touch the board, and the spine should not be arched.  Ask the mother 
to inform you if the child arches the back or moves out of position.   
c. Hold down the child’s legs with the one hand and move the footboard with the other.  
Apply gentle pressure to the knees to straighten the legs as far as they can go without 
causing injury or distress.  Note: it is not possible to straighten the knees of newborns 
to the same degree as older children.  Their knees are fragile and could be easily injured, 
so apply only minimum pressure.   
d. If a child is extremely agitated and both legs cannot be held in position, measure with one 
leg in position.  
e. While holding the knees, pull the footboard against the child’s feet.   
VI. 
Upon reading the measurement, the examiner will clearly call out the number to the recorder.  
Record the child’s length in centimeters to the last completed 0.1 cm.  (1.0 mm).   
VII. 
Keeping the child in place, release the sliding footboard, and prepare to repeat the measurement.  
Re-position the child for a second and third measurement.  
 
 
 
 
 
 
 
 
 
 
 
 

 
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Figure 8: Measuring length 
 
 
8.8.3.2 Measure Standing Height 
1. Ensure that the height board is on level ground.   
2. Working with the mother or another helper, and kneeling in order to be at the level of the child: 
a. Help the child stand on the baseboard with the weight of the child evenly distributed on 
both feet.  The heels of the feet are placed together with both heels touching the base of 
the vertical board.  Place the feet pointed slightly outward at a 60-degree angle. 
b. The back of the head, shoulder blades, buttocks, calves, and heels should all touch the 
vertical board.  Arms should hang freely by the sides of the body with the palms facing 
the thighs.  Note: Standing with all body parts touching the board may be difficult for 
some children, in which case, help the child to stand on the board with one or more 
contact points touching the board. 
c. Ask the mother to hold the child’s knees and ankles to help keep the legs straight and feet 
flat, with heels and calves touching the vertical board.  Ask her to focus the child’s 
attention, soothe the child as needed, and inform you if the child moves out of position.  
d. Position the child’s head so that a horizontal line from the ear canal to the lower border 
of the eye socket runs parallel to the baseboard.   

 
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e. Ask the child to inhale deeply and to stand fully erect without altering the position of the 
heels.  If necessary, push gently on the belly to help the child stand to full height.  
f. Still keeping the head in position, use your other hand to pull down the headboard to rest 
firmly on top of the head and compress the hair. 
3. Upon reading the measurement, the examiner will clearly call out the number to the recorder.  
Record the child’s height in centimeters to the last completed 0.1 cm (1.0 mm). 
4. Keeping the child in place, release the sliding headboard, and prepare to repeat the 
measurement.  Re-position the child for a second and third measurement.    
 
 
Figure 9: Measuring standing height 
 

 
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8.8.4 
Dismantling the Shorr Board 
• Stand the board upright: face the board and step on the base with one foot to keep it stable. 
• Slide the head/foot piece into the base of the main board. 
• Release the clasp on the back of the extension piece and remove it.  Push the clasp FLAT against 
the extension piece. 
• To attach the extension piece to the main board, turn the front of the extension piece inward 
and place it against the front of the main board.  Make sure that all sides of the extension piece 
are straight and in line with the main board. 
• Push on the bolt that is on the back of the extension piece and screw it into the main board.   
• Put the board back inside of the carrying case for storage until your next use.   
 
8.8.5 
Measuring Weight 
The SECA 874 scale or suitable alternative will be used to weigh infants and children to the nearest 0.01 
kg (Seca 874 flat floor scale, seca GMBH & Co. Kg, Hamburg, Germany). Infants and young children can 
also be weighed simultaneously with their parent or guardian by the unique “mother-baby” function 
(parent or guardian is weighed and then the infant or child is weighed while held by the parent).  
Explain to the mother that we want to weigh her child to see how he or she is growing.  If she has a baby 
or a child who is unable to stand, she will hold the child on the scale.  If the child is 2 years or older, the 
child will be weighed alone.  Children should be wearing only light clothing, no shoes, no hair ornaments, 
and no jewelry. Explain that the child needs to remove outer clothing and shoes in order to obtain an 
accurate weight.  If the baby is wearing a diaper, the diaper should be removed.  If any heavy clothes 
remain on the child, make a note in the Comments section. 
 
8.8.6 
Procedures 
 Remove scale from bag.  
 Be sure that the scale is placed on a flat, hard, even surface. All 4 legs of the scale should 
make contact with the ground surface, without wobbling.   
 Turn the power on the scale when you are ready to begin weighing.  
o Note: When batt appears in the display, you should change the batteries.  Remove 
the old batteries and insert 6 new batteries.   
 Press the start key with no load on the scale.  The scale is ready for use when it sets to 0.00.  
o If necessary, switch the weight display to KG: hold down the 2 in 1 key for about 3 
seconds.  
o Press the start key with no load on the scale.  The scale is ready for use when it sets 
to 0.00. 
 Weighing the child alone 
o The child removes their shoes and any heavy clothing 
o Ask the child to stand in the middle of the scale.  Once on the scale, the child must 
stand still.  The HOLD function is automatically activated for weights over 1.5 kg/3.3 

 
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lbs.  The display flashes until a stable weight has been measured.  The display is then 
frozen until the next weighing operation.   
 Note: If the child jumps on the scale or won’t stand still, you will need to use 
the tared weighing procedure instead. 
o The positioner will clearly call out the child’s weight to the recorder. Record the 
child’s weight to the nearest 0.01 kg.  
Have the child step off and back onto the scale  
o The positioner will clearly call out the child’s weight to the recorder. 
o Record the child’s weight to the nearest 0.01 kg.  
o Repeat one more time 
2-1 feature: If the child is unable to stand on the scale, you will use the 2 in 1 weighing 
function (called tared weighing).  The 2 in 1 function enables the weight of babies and small 
children to be determined while an adult holds them.  
o Ask the adult to stand in the middle of the scale without the child.  She should remove 
any long garments, as these can cover the display and also lead to variable 
measurements.   
o After the mother’s weight appears on the display, tell her to remain standing on the 
scale.  Press the 2 in 1 key to activate the function. 
o The scale stores the weight of the adult and the display returns to zero. When 0.00 
and NET appear in the display, hand the child to the adult.  The scale will determine 
the weight of the child.  Once the value is stable for about 3 seconds, the weight is 
measured.  Note: If a mother is very heavy (e.g. more than 100 kg) and the baby’s 
weight is relatively low (e.g. less than 2.5 kg), the baby’s weight may not register on 
the scale.  In such cases, have a lighter person hold the baby on the scale. 
o Repeat the measurement 2 more times. Note that only the baby needs to be removed 
from the scale; the mother may remain on the scale the entire time. 
 To turn off the 2 in 1 function, press the 2 in 1 key. The 2 in 1 function remains on until you 
press the 2 in 1 key again, or until the scale switches off automatically. 
 If several children are to be weighed consecutively with the same adult holding the babies, it 
is important that this person’s weight does not change (e.g. due to a piece of clothing being 
removed/added). 
 The scale automatically turns off after 2-3 minutes 
 
8.8.6.1 Scale Calibration 
We have shown that the weight measurements captured from the Seca 874 do not change over time, even in field 
conditions.8 In order to monitor the calibration of the scales over time, each team will weigh a 5 kg test weight at 
the beginning and end of the day. This measurement will take place at the site of the scale storage so that the 
weights do not need to be carried to the field.  
 

 
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8.8.7 
Measuring MUAC 
The child’s MUAC will be measured at the midpoint of the right arm between the tip of the shoulder and the tip 
of the elbow, to the nearest millimeter using non-stretch MUAC tapes produced for clinical studies by Johns 
Hopkins University53 and interpreted according to WHO guidelines.  
I. 
First, find the midpoint of the upper arm.  Have the child stand up straight with feet together, 
and the right arm bent 90 degrees at the elbow, palm facing up.  The examiner is positioned 
behind the child.   
a. The most upper edge of the posterior border of the acromion process of the scapula is 
located and marked.   
b. Hold the zero end of the measuring tape at this mark and extend the tape down the back 
of the child’s arm to the tip of the olecranon process (the bony part of the mid-elbow).   
c. The examiner reads the measurement aloud to the recorder. 
d. Keeping the tape in position, locate the spot which is half the distance from the acromion 
to the olecranon processes (i.e. the midpoint of the upper arm).   
e. The recorder will mark the midpoint on the back of the child’s arm.   
II. 
To measure mid-upper arm circumference, have the child stand up straight with the arms 
relaxed at the sides.  The examiner will stand facing the child’s right side.  The measuring tape is 
placed around the upper arm at the marked point.   
III. 
Wrap the tape around the arm, pulling it to lie flat against the surface of the skin.  Be careful not 
to pull the tape too tightly (to compress the skin).   
IV. 
Read the number which is between the two arrows on the window on the MUAC tape. Make sure 
that the lines inside and outside the window are completely aligned (that the line inside the 
window is not tilted). Upon measuring, the examiner will clearly call out the number to the 
recorder.  Record to the nearest 0.1 cm (0.1 cm = 1 mm).  
V. 
Keeping the child in place, release the MUAC strip, reposition, and measure for a total of 3 
measurements.  
Figure 10: Measuring MUAC          
8.8.8 
Materials for Anthropometry 
I. 
ShorrBoard 
II. 
Seca scale  
III. 
MUAC strips (2) 
IV. 
Chucks and alcohol swabs 
V. 
Pens and sharpie markers 
VI. 
Trash bags 
VII. 
Extra set of AA batteries (6) 
VIII. 
Laminated sheet showing examples of malnutrition 
 
 
 
 

 
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8.9 Stool Samples 
There are two separate collections for the STH study – 1) preserving stool in SAF to count eggs and 
parasites; and 2) storing stool in 5% potassium dichromate solution for PCR processing. Children will still 
be asked for just one sample, and study personnel will prepare two separate tubes. One tube will be 
transported to the Amhara Public Health Institute for processing and examined for the presence of the 
major soil transmitted helminths (Ascaris lumbricoides, Trichuris trichiura, and Ascaris lumbricoides). The 
other tube will be sent to Smith College for PCR analysis for Necator americanus, Ancylostoma 
duodenale, Trichuris trichiura, Ascaris lumbricoides, and Strongyloides stercoralis.  
 
There are 4 steps to follow at the stool collection station:  
I. 
Stool Sample Collection  
II. 
Sample Preparation (SAF) 
III. 
Sample Preparation (PCR)  
IV. 
Waste Disposal  
 
8.9.1 
Stool Specimen Collection 
1. Place a plastic bag of child’s s potty and give to the study participant.  
2. Instruct the child to defecate in the bag on the potty, remove and twist the top of the plastic bag 
and return with the potty and bagged stool sample.   
3. Remind the caregiver/child to bring the specimen immediately to the sample collection station.  
4. Advise participant to urinate before collecting the stool so that they do not get any urine in the 
stool sample. 
5. Give the child and/or caregiver hand sanitizing wipes when they return with the sample.  
6. Check that the sample is sufficient amount.  If there is not a sufficient amount ask the caregiver 
or child if they can produce more. If not, follow the instructions for next-day sample collection.  
7. Next-day sample collection  
1. If a child cannot produce a sample by the end of the study visit day write the child’s age, 
gender, and random number on the paper bag and plastic bag. 
2.  Instruct the caregiver to have the child defecate in the bag, tie the bag up and place in the 
paper bag for pick-up the next day.  
 
8.9.2 
Sample Preparation (SAF)  
1. Wearing fresh gloves, label the SAF tube (10 ml) first with the random number and weigh the 
content of the tube to balance the weight prior to mixing with stool sample.  
2. Using applicator stick, pick stool sample equal to size of 1 gram and mix it thoroughly with the 
SAF solution.  Register the consistency and the weight of stool that you added. 
3. Close the tube tightly 
4. Seal tube with parafilm and shake tube vigorously 
5. Place tube in SAF tube box (keep in shade) 
 

 
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8.9.3 
Sample Preparation (PCR)  
1. Wearing fresh gloves, label a 2ml tube with the random number 
2. Add .5 ml of fresh stool to the tube 
3. Using a pipette, fill the other half of the tube (about .5ml) with the 5% potassium dichromate 
solution leaving room in the tube to mix the mixture 
4. Close the tube lid tightly 
5. Seal tube with parafilm and shake tube vigorously 
6. Place the tube in the PCR tube box from left to right. The tube box should be located in cooler, 
and the cooler should be closed between each addition. The cooler should be in the shade.  
 
8.9.4 
Waste Disposal  
1. Discard the remaining stool sample, pipette, used applicator sticks in the trash bag. 
2. At the end of the day/field work all waste has to be disposed appropriately (incinerated at a 
health post).  
 
8.9.5 
Materials for Stool Specimen Collection (pending feedback from Steve Williams) 
I. 
Child potty  
II. 
Wooden Tongue depressor (dowels) 
III. 
Digital specimen scale 
IV. 
Stool specimen tube containing 10ml SAF preservative 
V. 
2ml tubes for PCR preservation 
VI. 
Applicator stick 
VII. 
Alcohol wipe  
VIII. 
Fine tip permanent marker 
IX. 
Trash bag 
X. 
Gloves 
XI. 
Batteries 
XII. 
Random number sticker roll 
XIII. 
Sanitizing hand wipes  
8.10 
Dried Blood Spots 
The gold standard microbiological test for detecting ocular chlamydia infection is a nucleic acid 
amplification test of a conjunctival swab. However, new serological tests being developed by the 
United States Centers for Disease Control and Prevention (CDC) are promising diagnostic modalities for 
monitoring of trachoma elimination. A positive test indicates a previous exposure to chlamydia as 
opposed to current infection; antibodies remain detectable even after a mass azithromycin 
treatment.95 Preliminary testing in a hypoendemic setting in Tanzania has shown that serologic results 
in 1-3 year-old children is correlated with the prevalence of ocular chlamydia infection in a community, 

 
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suggesting that the serology results in young children may provide information about the level of 
transmission.96 Current serologic methods are expensive, but the CDC is currently developing a much 
simpler and less expensive lateral flow assay (LFA) for use with eluted dried blood spots.97,98  
 
In a setting where ocular chlamydia transmission has been eliminated, the youngest children will not be 
exposed to chlamydia and therefore should not have a positive serological test. The serological test in 
young children may therefore be a sensitive measure of chlamydial transmission within a community. 
Furthermore, we will use the blood spots to test antibody responses to other diseases of interest 
including helminths, intestinal bacterial pathogens, and intestinal protozoal pathogens. These tests are 
still being developed, but we anticipate that they will have been optimized by the time of the conclusion 
of this trial. Therefore, we will also collect dried blood spots from all children aged 0-5 years in the 
population-based sample each year. We will lance the index finger of each child and express 4-5 dried 
blood spots onto a TropBio filter paper. Filter papers will be labeled with a random number identification 
sticker and stored in the -20 freezer for later processing in Atlanta.  
8.10.1 Steps for blood spot collection  
• Inform the mother that her child’s finger will be pricked to obtain blood to test for trachoma, 
malaria. anemia, and other diseases. Describe the finger prick procedure, reassure her, and 
answer all questions. The blood specimen should be collected as described below to minimize 
the discomfort of the child and to ensure sufficient blood volume collection. 
• Label the filter paper with the corresponding random number sticker.  
• Prepare the disposable lancet. Make sure to use a new disposable lancet for each child. Do not 
re-use lancets.  
• Position the child for the finger stick. Make sure that the child’s hand is warm and relaxed. Hold 
the child’s thumb, middle, or ring finger between your left thumb and finger 
• Gently stimulate blood flow towards the puncture site by lightly squeezing the child’s thumb or 
finger from the top of the knuckle towards the fingertip 
• Disinfect the finger with alcohol wipe. 
• Prick the side of the thumb/fingertip 
o For the best blood flow and least pain, prick the side of the thumb/fingertip, not the 
center. 
• Wipe away the first 2 drops of blood with a new sterile cotton ball 
• Place a droplet of blood from the finger onto four-five of the six circles 
o Leave one circle blank.  
o Touch the side of the circle 
o Fill circle completely.  
o Note: Allow blood to ooze out on its own.  Do not squeeze forcefully avoid “milking” as it 
may dilute the blood with tissue plasma. 
• Grip the filter paper on the side without small circles. Carefully slide the filter paper onto a pencil 
to air dry for at least an hour. There should be about 1 cm in between each sample. Secure the 
pencil into a Styrofoam surface in a cardboard box. 
• When dry, place each blood spot paper into an individual small plastic bag while wearing gloves 

 
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• Combine all bagged samples in a larger community bag. Add desiccant packets  
• Label large bag with:  
o Label large bags:  
o SWIFT “visit number” 
o Cluster name  
o Number of samples collected 
o When were samples collected: (e.g. 19JAN2019) 
 
8.10.2 Risk minimization 
 It is important to handle all specimens with care to minimize risk of infection  
o Wear gloves:  New gloves must be worn for each child. 
o Clean spills:  In the event of a blood spill or splash, clean immediately with disinfectant 
and wipe with absorbent material. 
o Disposal of sharps: All lancets must be disposed of properly in sharps containers. 
8.10.3 Materials for Blood Collection 
• Gloves  
• Disposable lancets  
• Alcohol wipes  
• Cotton balls  
• 10% household bleach to clean spills 
• Absorbent material for spills (cotton) 
• Sharps container  
• TropBio circular cards 
• Small zip plastic bags 
• Desiccant packs 
• Large Ziploc bags (handful) 
• Materials for drying apparatus: 12 sharpened pencils, Styrofoam, empty cardboard box

 
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9.  OUTCOME ASSESSMENT AND LABORATORY PROCEDURES  
9.1.1 
Photographic Reading Center 
The Reading Center for grading of conjunctival and face photographs will be based at Gondar University. 
Three graders will independently grade each photograph, masked to treatment allocation. We will 
choose the consensus or median grade for all outcomes. We will assess inter- and intra-observer 
agreement with kappa statistics. 
 Facility/Equipment. A dedicated room with a two computer monitors will be used to grade 
photographs. Full-screen photographs will be read at 26 inches with the shades drawn and lights 
off.  
 Naming Conventions. The Proctor data analyst and program manager will be responsible for 
organizing the photographs taken during the study. The photos are stored on Salesforce, and 
they are labeled with an “attachementID” code. The program manager will download the photos 
and their metadata including the photo code, the phase they were taken during, and the 
participant’s master record that they belong to. The photos will be uploaded to the offline 
program and linked to their metadata for grading.  
9.1.2 
Grading of clinical conjunctival photographs 
Six ophthalmology residents will grade the photographs at the conclusion of the study, masked to 
treatment allocation. We will present graders all photographs taken from a phase for one individual. 
Graders will grade the set of photographs together for photo quality, follicles, inflammation, scarring 
according to the grading scale described in table 4. We chose this grading system because it provides 
enhanced granularity of grades compared to other grading scales,  allowing for detection of more subtle 
differences in clinical trachoma. Graders will also compare the initial and final photographs of the set 
and document whether the final photograph has less, more, or equivalent follicles and inflammation 
compared with the initial photograph. Note that each set of photographs will have between 1 and 4 
photographs, depending on how many monitoring visits the individual attended. We use photographic 
grades as the co-primary outcome of the trial since high quality photographs have good agreement with 
in-field grades, and offer the benefit of a masked outcome.99,100 
 
 
 
 
 
 

 
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Table 4: Questions for conjunctiva grading 
 

 
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9.1.3 
Assessment of Facial Cleanliness 
The ophthalmology residents will grade the face photographs for each child. The photos will be organized 
and uploaded in the same way as the conjunctiva photos. The photo set (1 child’s face photos at 1 phase)  
will be graded on photo quality and the presence or absence of the following items: dust or dirt on the 
face, food on the face, dry secretions around the eyes, wet secretions around the eyes, dry secretions 
around the nose, and wet secretions around the nose. The number of flies on the face will also be 
counted. The grader will be masked to treatment allocation. Note that this is a novel way to determine 
facial cleanliness, and should result in complete masking of observers.  
 
9.2 Specimen Collection for Microbiological Tests  
Samples will be collected with reference to age, gender, household, and study cluster, but participant 
names will not be included in laboratory records. Samples will thus not be associated with the 
individual’s name, but with a 5-digit random identification number, masking laboratory personnel and 
preventing identification of the individuals infected.  Lab results will not be available for weeks if not 
months, typically after the average duration of an ocular chlamydial infection. 
9.2.1 
APHI Lab: Abbott RealTime Assay 
Laboratory testing is the current standard of care for the identification of C.trachomatis infections in the 
U.S.  After collection, all samples will be processed the APHI and will be filled with 1 ml of M4RT media, 
and tested for C. trachomatis.  
 
Swabs will be processed with the Abbott RealTime assay for Chlamydia trachomatis, using the 
automated Abbott m2000 System, which is already in use at APHI. The RealTime assay targets the cryptic 
plasmid of C. trachomatis. The assay has been shown to be highly sensitive and specific for the diagnosis 
of sexually transmitted C. trachomatis, with sensitivities exceeding that of the nucleic acid amplification 
test used in most recent trachoma studies (Roche AMPLICOR).59,60  
9.2.2 
Processing of Samples for PCR 
Samples are handled as per Abbott RealTime sample processing protocol, with the following 
modifications: 
 Samples are boiled for 10 minutes at 100°C.  Boiling of samples is an accepted treatment method 
to remove substances that may be inhibitory to the PCR amplification process. 
 Samples are pooled 
 
9.2.3 
Procedure for Masking Samples 
The PCR results will be recorded according to the random number assigned to the sample, thus masking 
the lab since the lab workers do not have access to Salesforce in order to link this number with the child 
who provided the sample. Once the sample is processed, the analyst will then link the sample random 
number to the child’s record on Salesforce to reveal the test results by cluster. 

 
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9.2.4 
Procedure for Pooling Samples 
We will increase the efficiency of chlamydial testing by combining swabs from the same age stratum and 
same community into pools of 5 random swabs for processing. An internal control will be run with each 
pool to rule out the possibility of PCR inhibitors. Any inhibitory pools will be re-tested, and if still 
inhibitory, the swabs will be individually re-tested. If PCR from any pool is equivocal, then all swabs from 
the pool will be tested individually. While samples will necessarily be diluted in this process, this is not 
thought to affect the sensitivity of the test.61 We will test individually all swabs from positive pools in the 
0-5 year age stratum and estimate the community prevalence of chlamydial infection as the proportion 
of positive swabs. We will estimate the community prevalence of infection in the 6-9  and ≥10 (WUHA) 
year age strata using maximum likelihood estimation, similar to our previous trials: the number of 
individual swabs with the maximum likelihood of having resulted in the observed pooled results will be 
chosen as the estimate for that village.16,62 
 
In order to pool the conjunctival samples in the lab, the microbiology lab staff at APHI will assign a new 
pool ID number for every sample, and samples will be stored at -20°C freezer until PCR testing (if not 
processed that day). 
9.2.5 
Quality Control 
1) A C. trachomatis (+) control and a C. trachomatis (-) control (targeting 136 base pairs of a pumpkin 
gene) is included in each test run of the Abbott RealTime assay. 
2) To test the effect of sample processing, a known positive sample is processed and tested in each 
test run.  (This control is helpful when testing large numbers of negative samples.) 
3) An internal control intended to identify specimens that contain polymerase inhibitor is run 
routinely on each sample.  The internal control helps identify false negative results. 
9.2.6 
Quantification 
For every 0-5-year-old who tests positive for chlamydia, we will also run PCR for the beta actin gene on 
the same sample, in order to normalize the quantity of chlamydial DNA to the amount of the specimen. 
Quantitative results from the Abbott system are given in terms of a decision cycle (DC) number. We will 
generate a ratio of the DC number of the chlamydial DNA to the DC number of the beta actin gene and 
use the resulting ratio as the chlamydial load.  
9.2.7 
Laboratory Results Reporting 
All lab results will be kept in computer files as well as uploaded to Salesforce by the analyst.  The principal 
investigator and the DSMC will be updated regularly on the progress of the lab work throughout the 
course of the study. 
9.2.8 
Assessment of ocular chlamydia 
Qualitative PCR for chlamydial DNA. Swabs will be processed with the Abbott RealTime assay for 
Chlamydia trachomatis, using the automated Abbott m2000 System, which is already in use at the 
APHI. The RealTime assay targets the cryptic plasmid of C. trachomatis. The assay has been shown to 
be highly sensitive and specific for the diagnosis of sexually transmitted C. trachomatis, with 

 
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sensitivities exceeding that of the nucleic acid amplification test used in most recent trachoma studies 
(Roche AMPLICOR).101,102 We will increase the efficiency of chlamydial testing by combining swabs from 
the same age stratum and same community into pools of 5 random swabs for processing. An internal 
control will be run with each pool to rule out the possibility of PCR inhibitors. Any inhibitory pools will 
be re-tested, and if still inhibitory, the swabs will be individually re-tested. If PCR from any pool is 
equivocal, then all swabs from the pool will be tested individually. While samples will necessarily be 
diluted in this process, 5-pooling has been shown to not significantly affect the sensitivity of the test.103 
We will unpool all positive pools in the 0-5 year age stratum and estimate the community prevalence 
of chlamydial infection as the proportion of positive swabs. We will estimate the community 
prevalence of infection in the 6-9 (WUHA), ≥10 (WUHA), and 8-12 (TAITU) year age strata directly from 
the pooled swabs using maximum likelihood estimation, similar to our previous trials: the number of 
individual swabs with the maximum likelihood of having resulted in the observed pooled results will be 
chosen as the estimate for that village.19,104 Note that we are currently working with APHI to perform 
chlamydial testing, so the swab storage, transport, and processing protocols are already in place. 
 
Quantitation of chlamydial load. We will assess the infectious load for all individual specimens from 0-
5-year-old children who test positive for chlamydia. Load will be determined relative to a reference 
housekeeping gene (beta actin) using the Abbott RealTime assay, and expressed as the ratio of 
chlamydia to this housekeeping gene. We chose beta actin because this is a cytoskeletal structural 
protein that is ubiquitous and not thought to vary its expression.105 Note that we are currently gaining 
experience performing quantitative PCR with the Abbott system at APHI.  
 
 
9.3  Macrolide resistance testing 
9.3.1 
Specimen Collection for Macrolide Resistance Testing 
Nasopharyngeal samples will be collected with reference to age, gender, household, and cluster, but 
participant names will not be included in laboratory records. Samples will thus not be associated with 
the individual’s name, but with a 5-digit random identification number, masking laboratory personnel 
and preventing identification of individuals. 
 
9.3.2 
Methods 
The nasopharyngeal swab for pneumococcal resistance testing will be transported and processed using 
standard microbiological techniques at APHI. We will store swabs in STGG medium, keeping swabs on 
ice in the field and then in the -20°C freezer as described above for the conjunctival swabs. APHI will 
process the swabs using media selective for Streptococcus pneumoniae, and then test for antibiotic 
resistance to erythromycin, penicillin, tetracycline, and clindamycin using the Kirby Bauer disc diffusion 
assay. 
 

 
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9.3.3 
Procedure for Masking Samples 
The microbiologist and all lab staff will be masked to the development-team of origin. 
 
9.3.4 
Quality Control 
We will follow the standard quality control methods already in place at the laboratory. For example, lab 
staff will perform positive and negative growth controls for all media, and positive controls for all stains 
at a pre-determined schedule.   
 
9.3.5 
Laboratory Results Reporting 
All lab results will be kept in computer files as well as in hard-copy form by the Microbiologist. 
 
 
9.4 Dried blood spots 
 
We use Trop-Bio filter paper for dried blood spots in WUHA. Each paper has 6 ears, and we fill 5 ears 
with a drop of blood.  
 
We ship the dried blood spots to Dr. Diana Martin at the CDC, who processes them for pgp3 and CT694 
using the Luminex platform. The Luminex assay results are reported as a quantitative value (median 
fluorescence intensity minus background; MFI-BG); these results can be dichotomized based on the 
results of a receiver operating characteristic (ROC) curve from a set of known positives and negatives 
run on the same bead coupling. Serologic results provide evidence for exposure to chlamydial 
infection, and thus may be an especially sensitive metric of transmission. 
 
 

 
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10. CLINIC-BASED CASE FINDING 
We will perform clinic-based case finding at all health posts serving the study clusters. Eligible health 
clinics will be identified by interviewing local community leaders during the census and woreda health 
officials. The cluster coordinator will take photographs of the health post log books. A data entry worker 
will use the phtographs to enter the data into a REDCap form. Data will include age, gender, community, 
diagnosis, and treatment. Diagnosis of infection or treatment with an antimicrobial will be considered 
an infectious disease. We will collect data on all individuals who live in a community containing a study 
cluster. We will retrospectively collect data for a full calendar year before the start of the study in order 
to provide baseline values. 
 
 

 
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11. COSTING     
We will perform both a short-term and long-term cost effectiveness analysis (CEA) from the societal 
perspective. For the short-term analysis, we will perform a trial-based cost effectiveness analysis using 
community-level data from the clinical trial. For the long-term analysis, we will create a decision model 
to estimate the costs and effectiveness after the conclusion of the study, and determine the cost 
effectiveness at varying time horizons. For each analysis, we will report the incremental cost 
effectiveness at a given time point, with a range of uncertainty. The research plan adheres to guidelines 
for the design and analysis of trial-based and decision analytic cost-effectiveness analyses.57,58  
 
11.1 
Assessment of costs 
11.1.1 Trial-based CEA 
We will prospectively collect cost data for all interventions in the WASH clusters during the study period, 
using the WASHCost costing framework as a guide. WASHCost is a well-accepted methodology in the 
WASH sector that provides a complete accounting not only of the upfront capital expenses, but also 
expenditures on capital, maintenance and local support (e.g., community water committees and local 
governments).  
 Latrines, water points, and wash stations: the study coordinator will record the costs of 
labor, supervision, materials and supplies, and transport of materials to the community.  
 Hygiene promotion: we will record the costs of printed educational materials and supplies 
for schools, printed materials for workshops, and soap and wash station costs.  
 Salaries & Per Diems: We will include the salaries of the hygiene cluster coordinators and the 
per diems given to teachers and soap-makers during their respective workshops, and also 
transportation costs for these individuals.  
 All Interventions: We will also include as costs the time of community members who 
volunteer time for one of the interventions (e.g., helping with water point-building or latrine-
building, attending workshops or trainings).  
 Maintenance: We will make special efforts to enumerate the maintenance costs of the 
intervention during the second and third year of the trial. Maintenance costs will include the 
personnel costs of the education and sanitation cluster coordinator and health promoters, 
any supplies and equipment needed for maintenance of the water points or latrines, and the 
time of community members spent at hygiene workshops and repairing latrines or water 
points.  
 Fixed Costs: Finally, we will include a portion of the fixed costs of maintaining the Carter 
Center office. We will report costs separately for each intervention, as costs per community.  
As in previous studies, costing data will be collected at the time the costs are incurred, using standardized 
forms. We will not include certain protocol-induced costs in the intervention costs. For example, we will 
not include the costs of the study coordinator, census, or monitoring visits, which are costs imposed by 
the trial protocol, and would not exist outside the trial. We will, however, keep track of these costs, since 
they may be useful for secondary analyses. 
 

 
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11.1.2 Decision Model-based CEA 
We will use WASHCost’s life-cycle costing approach to model the long-term costs of the WASH 
intervention. We will estimate future costs based on maintenance costs recorded from the second and 
third year of the trial and using assumptions about the lifetime of the hardware (water points, latrines, 
and wash stations) based on interviews with local service providers. Future costs will be discounted to 
adjust them to their present value.  
 
11.2 
Assessment of effectiveness 
Effectiveness outcomes are discussed elsewhere in this Manual of Procedures, but include: 
 Ocular chlamydia (from monitoring visits) 
 Mortality (from census) 
 Stunting (from anthropometric monitoring) 
 All-cause and cause-specific health clinic visits (from clinic based case finding) 

 
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12. TREATMENT 
 
12.1 
Mass albendazole distribution  
The clusters were initially dewormed with a single mass albendazole distribution to all pre-school aged 
individuals who are 1 year or older (200mg for children aged 12-23 months and 400mg for individuals 24 
months and older). Another albendazole treatment is not scheduled.  
 
12.2 
Mass azithromycin distribution 
12.2.1 Mass azithromycin distribution during SWIFT I 
The WagHemra zone received 8+ annual rounds of mass azithromycin before the start of the trial, with 
the most recent treatment occuring 6 months before the baseline visit. No mass azithromycin 
distributions are planned during SWIFT I.  
 
If the average prevalence of ocular chlamydia in 0-5-year-old children is too high, we will conduct a mass 
azithromycin treatment immediately after the next scheduled annual monitoring visit. No threshold is 
set, but consideration will be given to prevalence above 20%.  
 
During the mass treatment, all individuals aged 6 months and up will be offered a single dose of oral 
azithromycin, 20mg/kg for children using height-based dosing and 1g for adults. 64 Those under 6 months 
of age, pregnant, or macrolide-allergic would be offered 2 tubes of topical tetracycline ointment, to be 
used twice daily. 
 
All age groups and sexes are eligible to receive azithromycin as per each study arm outlined above, 
except those contraindicated by Federal Ministry of Health, which currently are: 
 Those self-reported as pregnant 
 Children under six months old 
 Those known to be allergic to azithromycin or macrolides such as erythromycin 
 
These three exceptions will be treated with topical tetracycline eye ointment.  
 
12.3 
Adherence to Treatment 
Adherence to azithromycin treatment will be essentially 100% of those treated since administration of 
the single dose of antibiotic is directly observed by the distribution team. 
 
12.4 
Adverse Outcomes and Patient Death 
More than 450 million doses of oral azithromycin have now been distributed for trachoma, and reports 
of serious side effects are essentially non-existent. This may be due in part to minimal surveillance. It 
also may be due to the fact these are extremely rare with a single dose of azithromycin. In fact, where 
carefully monitored, there were actually fewer GI side effects after taking azithromycin. We will create 
a network to identify any possible post-treatment serious adverse effects.   
 

 
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Azithromycin is generally well-tolerated. The most common side effects of azithromycin and 
erythromycin are diarrhea or loose stools, nausea, abdominal pain, and vomiting, each of which may 
occur in fewer than one in twenty persons who receive azithromycin. Rarer side effects include abnormal 
liver function tests, allergic reactions, and nervousness. Diarrhea due to Clostridium difficile has been 
rarely reported. 
12.4.1 Adverse Outcomes 
Non-serious side effects are not uncommon, and serious side effects are possible. The inability of even 
frequent mass azithromycin distributions to bring about elimination in areas with highly prevalent 
trachoma suggests that other, non-antibiotic measures may be needed. 
 
The adverse reactions that may occur after taking azithromycin will be explained to individuals prior to 
enrollment in this study. In the event of an adverse outcome, the patient will no longer be enrolled in 
the study and an alternative treatment for trachoma (e.g. tetracycline ointment) will be administered if 
the patient needs to continue treatment. If a patient experiences a serious adverse outcome, they will 
be advised to alert the cluster leader, who will then inform the health care representative.  This person 
will in turn inform The Carter Center study coordinator, who will contact the Co-Investigator in Addis 
Ababa. If, for any reason, they will need further eye care, they will be referred to the nearest health 
center for examination and treatment, and the most appropriate action will be taken to provide 
immediate care. 
 
All individuals who have been given azithromycin will be told to immediately communicate side-effects 
to local health extension workers, who will relay the message to representatives of The Carter Center 
program, which will ensure that appropriate medical care will be provided, and that the frequency and 
severity of adverse events can be assessed. In addition, all adverse events will be recorded and 
monitored for each individual and reports on adverse events will be made to the DSMC.  
12.4.2 Patient Death 
The infant mortality rate is quite high in this area of Ethiopia.  All deaths since the first census will be 
carefully recorded during the study.  Since the major causes of infant mortality in the area are diarrhea, 
respiratory infections, and malaria, it is possible that receiving Azithromycin treatment may actually have 
a positive effect.   
 
All death records (if available) will be maintained by the study coordinator at The Carter Center Ethiopia.  
The incidence of mortality for each study arm will be made available to the DSMC by the biostatistician. 
 
12.5 
Study Medication Description 
12.5.1 Zithromax 
Zithromax® is supplied for oral administration as film-coated, modified capsular shaped tablets 
containing azithromycin dehydrate equivalent to either 250mg or 500mg azithromycin and the following 
inactive ingredients: dibasic calcium phosphate anhydrous, pregelatinized starch, sodium 

 
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croscarmellose, magnesium stearate, sodium lauryl sulfate, hydroxypropyl methylcellulose, lactose, 
titanium dioxide, triacetin and D&C red #30 aluminum lake. 
 
Zithromax® for oral suspension is supplied in bottles containing azithromycin dehydrate powder 
equivalent to 300mg, 600mg, 900mg, or 1200mg azithromycin per bottle and the following inactive 
ingredients: sucrose; sodium phosphate, tribasic, anhydrous; hydroxypropyl cellulose; xanthan gum; 
FD&C Red #40; and spray dried artificial cherry, crème de vanilla and banana flavors.  After constitution, 
each 5mL of suspension contains 100mg or 200mg of azithromycin. 
 
12.5.2 Albendazole  
Albendazole is available in generic form in Ethiopia as a chewable fruit-flavored 400mg tablet. 
 
12.6 
Dosage Information 
12.6.1 Azithromycin 
Azithromycin will be administered as a single dose, in tablet form for adults and in oral suspension form 
for children.  Dosing will be as per the WHO recommendations for treatment of active trachoma: 
1) Single dose of one gram of azithromycin for adults 
2) Single dose of 20mg/kg in children (up to the maximum adult dose of 1g)  
3) Height-based dosing of children will be acceptable, as per The Carter Center’s program—note 
that this is supported by the WHO PBD group. 
Individuals who are either under the age of 6 months, pregnant, or allergic to macrolides/azalides will 
be treated with 1% tetracycline eye ointment to be applied twice daily to both eyes for a 6-week period.   
12.6.2 Albendazole 
Albendazole will be administered to all individuals aged 1 year and up. Children aged 12-23 months will 
receive half a 400mg tablet (i.e., 200mg) and all other individuals will receive a single 400mg tablet, as 
per WHO recommendations. Individuals with a known allergy will not receive deworming treatment. 
 
12.7 
Alternate Therapies  
12.7.1 Alternates to Zithromax: Tetracycline Ophthalmic Ointment 
Tetracycline ophthalmic ointment (1%) is the current standard treatment in Ethiopia for ocular 
trachoma, and will be distributed to study patients who are not eligible to receive azithromycin. 
 
12.8 
Treatment/Monitoring Schedule 
As discussed, if the average prevalence of ocular chlamydia in 0-5-year-old children is greater than 20% 
in the study, we may conduct a mass azithromycin treatment immediately after the next scheduled 
annual monitoring visit.  
 
12.9 
Medication Procurement/Donation 

 
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Pfizer, Inc. will provide the donation of Zithromax® (azithromycin), which will be shipped directly to 
Ethiopia and received by a representative of the Ethiopian Ministry of Health, who will manage the 
customs process and transport the medication from the port to a storage site.  The exemption of duties 
and taxes will be settled by the Ethiopian Customs Authorities and the Ethiopian Ministry of Health. 
 
12.10 Study Medication Storage and Accountability 
Zithromax® tablets will be stored between 15° to 30°C (59° to 86°F), as recommended by Pfizer.  A record 
of the exact number of tablets distributed and quantity of oral suspension dispensed will be kept by The 
Carter Center treatment distribution team. 
 
Albendazole tablets will be stored between 20° and -25°C, as recommended by the manufacturer. 
 
12.11 Medication Quality Control 
Study medication will be stored in The Carter Center project office prior to use.  The hygiene cluster 
coordinator and the study coordinator will regularly check and record the study medication expiry dates.  
The expiration dates on the medication containers will be strictly monitored and all expired study 
medicine will be discarded appropriately. 
 
12.12 Checking Antibiotic Coverage 
The application allows the users to monitor antibiotic treatment coverage, since treatment is recorded 
in the application. The application supplies all individuals needing treatment in the app, and treatment 
is then entered into this page. Treatment coverage can be viewed on Salesforce.com in real time.  
 
The study coordinator will also monitor treatment coverage by visiting the clusters after treatment has 
occurred and arbitrarily choosing individuals in the cluster to see if they were treated as marked.  
 
  
 

 
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13. PROTECTION OF HUMAN SUBJECTS 
 
13.1 
Internal Review Board Approval 
13.1.1 UCSF Committee on Human Research 
The University of California, San Francisco, Committee on Human Research will annually review study 
protocol for ethical approval. 
13.1.2 The Amhara Region, the Ethiopian National Research Ethics Review Committee (NRERC/MoST), and the 
Ethiopian FDA (formerly FMHACA) 
The study protocol will be reviewed and granted ethical approval by the above three organizations 
before any study activities begin. 
13.1.3 Emory University Institutional Review Board 
The Emory University Institutional Review Board will annually review study protocol for ethical approval. 
 
13.2 
Informed Consent 
The head of each kebele will be asked for permission to include the cluster in the study.  Additionally, 
the study will be discussed with all adult family members in the cluster by the participating Carter Center 
staff members who speak Amharic or the other local language. 
 
At each collection visit, parents/guardians of study participants who are 0-6 years of age will be informed 
about the possible risks and benefits examination, swabbing, photography, and treatment (if applicable), 
and asked to give a verbal consent. Young adults and children below 18 years of age, who cannot give 
consent by law, will be included in the study only following the receipt of verbal informed consent from 
a parent or guardian. Verbal assent will be obtained by any child over the age of 7.  If, at any time, a 
parent or guardian elects to withdraw themselves or a family member from the study, it will be made 
clear that they will be offered the same medical treatment outside the study. 
 
13.3 
Adequacy of Protection Against Risk 
There are several layers of procedures to help minimize study-associated risk to participants.  
13.3.1 Conjunctival swabbing 
There are minimal risks to the subject who receives conjunctival swabbing for chlamydia. We are aware 
of no reported complications from this procedure, although a small amount of conjunctival bleeding can 
occur and a corneal abrasion is possible. Any adverse effects will be treated by the examiners. Ocular 
examinations will be offered to everyone, even if they choose not to participate in the study. Appropriate 
ophthalmic care or referral will be provided for any conditions detected during these examinations, 
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13.3.2 Nasopharyngeal swabbing 
Nasopharyngeal swabbing causes some temporary discomfort but it involves minimal risks without 
further complications. Any adverse effects, such as nose-bleeds, will be treated immediately by the 
examiners. Other health care will be provided at no cost to the study participant if necessary, to address 
a study-related adverse health event. 
13.3.3 Clinical photography 
Clinical photography of the conjunctiva causes no damage to the eye, is well tolerated by children, and 
is a standard clinical procedure at UCSF. 
 
13.3.4 Treatment 
If treatment is necessary, the risk of antibiotic treatment will be minimized by treating only those who 
fit in the approved age and inclusion category, as well as by regularly scheduled follow-up 
examinations by a trained trachoma grader.  Should the antibiotic be ineffective to an individual, the 
study medication will be discontinued for them.  In the event of any adverse effects, appropriate 
medical care will be provided by the local health center. 
 
13.4 
Inclusion of Pregnant Women and Children 
All participants, regardless of gender, will be accepted. We will obtain informed consent from all study 
participants prior to entering the study.  
 
If treatment is necessary, pregnant women will be excluded from receiving oral azithromycin, and will 
be offered topical tetracycline eye ointment in its place.   
 
13.5 
Compensation to Participants 
There is no cost to the participant and there is no reimbursement for overall participation in this study. 
Each participant will receive free ophthalmic examinations during the course of the study. 
 
 

 
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14. DATA AND SAFETY MONITORING COMMITTEE CHARTER 
 
The Charter will define the primary responsibilities of the DSMC, its relationship with other trial 
components, its membership, and the purpose and timing of its meetings. The Charter will also provide 
the procedures for ensuring confidentiality and communication, statistical monitoring guidelines to be 
implemented by the DSMC, and an outline of the content of the Open and Closed Reports that will be 
provided to the DSMC. 
 
14.1 
Primary Responsibilities of the DSMC 
The DSMC will be responsible for safeguarding the interests of trial participants, assessing the safety and 
efficacy of the interventions during the trial, and monitoring the overall conduct of the trial. The DSMC 
will provide recommendations about stopping or continuing the trial. To contribute to the integrity of 
the trial, the DSMC may also formulate recommendations relating to the selection/ recruitment/ 
retention of participants, to protocol-specified regimens, and the procedures for data management and 
quality control.  
 
A chief responsibility of the DSMC will be to review data on ocular chlamydia prevalence and make 
recommendations regarding the need for mass azithromycin treatments. The DSMC will make a decision 
about thresholds for initiating treatment at each meeting. The DSMC purposefully did not set a threshold 
to trigger re-treatment, but rather a threshold triggering a discussion about whether antibiotic 
treatment was needed. This threshold is 20% prevalence of ocular chlamydia among the 0-5-year-old 
age group.  
 
The DSMC will be advisory to the trial leadership group, hereafter referred to as the Executive Committee 
(EC). The EC will be responsible for promptly reviewing the DSMC recommendations and determining, 
whether to continue or terminate the trial, and to determine whether amendments to the protocol are 
required. If needed, the DSMC may seek the advice of a content expert outside of the committee.  
 
14.2 
DSMC Membership 
The DSMC is an independent multidisciplinary group consisting of epidemiologists, biostatisticians, 
bioethicists, and clinicians that collectively has experience in the management of infectious diseases and 
in the conduct and monitoring of randomized clinical trials including subsaharan Africa.  
 
14.3 
Conflicts of Interest 
The DSMC membership has been restricted to individuals free of apparent conflicts of interest. The 
source of these conflicts may be financial, scientific, or regulatory. Thus, neither study investigators nor 
individuals employed by the sponsor, nor individuals who might have regulatory responsibilities for the 
trial products, are members of the DSMC. 
 
The DSMC members will disclose to fellow members any consulting agreements or financial interests 
they have with the sponsor of the trial, with the contract research organizations (CRO), or with other 

 
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sponsors having products that are being evaluated or that are competitive with those in the trial. The 
DSMC will be responsible for deciding whether these consulting agreements or financial interests 
materially impact their objectivity.  
 
The DSMC members will be responsible for advising fellow members of any changes in any of the 
membership requirements that occur during the course of the trial. It may be appropriate for DSMC 
members who develop significant conflicts of interest resign from the DSMC.  
 
DSMC membership is to be for the full duration of the trial. If any members leave the DSMC, the EC, in 
consultation with the DSMC, will promptly appoint a replacement.   
 
14.4 
Timing and Purpose of the DSMC Meetings  
14.4.1 Organizational Meeting 
The initial meeting of the DSMC was held 16 September 2014.   The committee provided an advisory 
review of scientific and ethical issues relating to study design and discussed the standard operating 
procedures, as well as the format and content of the Open and Closed Reports that will be used to 
present trial results. 
 
The Organizational Meeting was attended by all DSMC members, lead trial investigators, and the trial 
biostatistician. The DSMC reviewed drafts of the trial protocol, the Statistical Analysis Plan, and the DSMC 
Charter. At subsequent meetings, committee members will receive Data Reports. 
 
14.4.2 Future meetings 
Future DSMC meetings will be held on a yearly basis, with an option for more frequent phone meetings 
or email updates at the discretion of the DSMC and/or principal investigator.  
 
14.5 
Procedures to Ensure Confidentiality and Proper Communication 
To enhance the integrity and credibility of the trial, procedures will be implemented to ensure the DSMC 
has access to all emerging information from the trial regarding comparative results of efficacy and safety, 
aggregated by treatment arm.  
 
14.5.1 Closed Sessions 
Sessions involving only DSMC members and, where appropriate, those unmasked trial investigators (on 
the Data Coordinating Committee) who generate the Closed Reports (called Closed Sessions) will be held 
to allow discussion of confidential data from the trial, including information about the relative efficacy 
and safety of interventions.  
 
At a final Closed Session, the DSMC will develop a consensus on its list of recommendations, including 
that relating to whether the trial should continue. 

 
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14.5.2 Open Session  
In order for the DSMC to have access to information provided, by study investigators, or members of 
regulatory authorities, a joint session between these individuals and DSMC members will be held 
between the Closed Sessions.  
 
14.5.3 Progress Reports 
For each DSMC meeting, a report will be provided. The report will include data on recruitment and 
baseline characteristics, exam coverage, exam results, pooled data on eligibility violations, adverse 
events, and completeness of follow-up and compliance. The data analyst will prepare this report.  
 
The report should provide information that is accurate, with follow-up that is complete to within two 
months of the date of the DSMC meeting. The Reports should be provided to DSMC members 
approximately three days prior to the date of the meeting. 
 
14.6 
Minutes of the DSMC Meeting 
The research team will prepare minutes for the open portion of the meeting, including the DSMC’s 
recommendations. 
 
14.7 
Recommendations to the Executive Committee (EC) 
At each meeting of the DSMC during the trial, the committee will make a recommendation to the 
Executive Committee to continue or terminate. This recommendation will be based primarily on safety 
and efficacy considerations and will be guided by statistical monitoring guidelines defined in this Charter. 
 
Recommendations to amend the protocol or conduct of the study made by the DSMC will be considered 
and accepted or rejected by the EC. The EC will be responsible for deciding whether to continue or to 
stop the trial based on the DSMC recommendations.  
 
The DSMC will be notified of all changes to the protocol or to study conduct. The DSMC concurrence will 
be sought on all substantive recommendations or changes to the protocol or study conduct prior to 
implementation.  
 
The EC may communicate information in the Open Report to the sponsor and may inform them of the 
DSMC recommended alterations to study conduct or early trial termination in instances in which the EC 
has reached a final decision agreeing with the recommendation. The EC will maintain confidentiality of 
all information it receives other than that contained in the Open Reports until after the trial is completed 
or until a decision for early termination has been made. 
 
14.8 
DSMC Contact Information  
 

 
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Chair: Bill Barlow, PhD  
Senior Biostatistician 
Cancer Research and Biostatistics 
University of Washington 
williamb@crab.org 
Leslie Hyman, PhD 
Professor 
Department of Preventive Medicine 
Stony Brook University 
Leslie.Hyman@stonybrook.edu 
Art Reingold, MD 
Professor and Head of Epidemiology 
University of California, Berkeley, School of Public Health  
reingold@berkeley.edu 
Serge Resnikoff MD, PhD 
Ophthalmologist 
Senior Consultant, International Health & Development 
serge.resnikoff@gmail.com 
Larry Schwab, MD 
Ophthalmologist (retired) 
Morgantown, West Virginia 
larryschwab@gmail.com 
Carrie Thiessen, MD, PhD 
Resident, General Surgery 
Yale-New Haven Hospital 
carrie.thiessen@yale.edu 
Don Everett 
Program Officer 
National Eye Institute  
deverett@nei.nih.gov 
 
 

 
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15. DATA COLLECTION, MANAGEMENT, AND QUALITY ASSURANCE 
Similar to our previous studies, all study personnel who assess outcomes will attend an intensive, 2-day 
training session prior to the annual monitoring visits. Study personnel will collect all written data from 
the census and monitoring visits using tablet computers. We successfully pilot tested this electronic 
data capture system in Ethiopia in 2011 and are currently using it for a separate clinical trial in Niger.  
 
15.1 
Data Collection Tools 
15.1.1 Tablet Computers 
The Proctor Foundation will provide training on operating tablet computers to all data collectors. In our 
experience, a tablet computer typically retains its charge for a full day’s activities, though each team 
will also have a backup battery pack. Tablets and batteries will be charged overnight in a safe, secure 
place.  
 
15.2 
Mobile Application 
A custom mobile application will be used for all census and monitoring visits. This software assigns a 
unique identification number to each study participant enumerated during the census. The software 
integrates the monitoring visits with the census information by linking to this unique identifier. We will 
provide training to use this mobile application for all study activities. 
 
15.3 
Data Transfer  
We will upload the data from the tablet computers directly to Salesforce.com.   
 
15.4 
Data Quality 
Electronic data capture will ensure high quality data since it removes the possibility for transcription 
error and allows for validation rules in data entry fields.  
 
15.5 
Data Consistency and Validity 
Through range checks, the software ensures to a large extent that there are no inconsistencies or invalid 
data.  The software will create an error file with relevant data such as the form identification, field names 
and data.  Data consistency and errors will also be monitored. 
 
15.6 
Data Collection 
15.6.1 Census Administration 
Basic protocols for census taking are available in the Amharic language. 
15.6.2 Completing the Census  
The census team will visit each cluster and inform the village leader to alert each head of household in 
the village. The census form will contain the following: 
 Name 
 Gender 

 
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 Age of each household member 
 GPS coordinates for each household 
 Health facilities, water points, and schools utilized 
 Presence or absence of latrine and latrine-use 
 Presence or absence of hand-washing facility near latrine 
 Household water-use and hygiene behaviors 
 
Household numbers and individual numbers for further identification of individuals within each 
household will be automatically assigned. 
 
15.7 
Examination, Swabbing, and Anthropometry 
15.7.1 Registration  
Registration is completed by the exam team, and the registration lists contains the full spelling of each 
individual’s name, age, gender and household number, taken directly from the census.   
15.7.2 Swabbing 
Contamination of eye swabs can occur in trachoma studies; therefore, we will collect negative control 
conjunctival swab on a 10% random sample during all monitoring visits to assess the possibility of 
contamination.  
15.7.3 Anthropometry 
Height, weight, and MUAC will be entered in triplicate for each study participant. The presence or 
absence of kwashiorkor and marasmus will be noted for each participant. This data will be entered into 
the app, which employs data validation.  
 
15.8 
Costing 
Data will be collected on standardized forms. The Proctor Foundation study coordinator and Carter 
Center study coordinator will be responsible for training the hygiene cluster coordinator and driver in 
filling out the costing forms. We will use paper cost forms, with data double-entered into a database by 
Carter Center personnel in Addis Ababa. Computers will be automatically backed up once daily. 
 
15.9 
Data Security and Storage 
Databases at the central site will be stored on an encrypted server in a temperature-controlled locked 
room at the Proctor site, and off-site backups will be maintained. Backup encryption keys will be 
maintained off-site in a secure vault.  Database procedures will include full transaction logs. The DSMC 
can make requests to have access to the data at any point during the course of the study. 
 
15.10 Data Analysis Estimation of Disease Prevalence 
Computerized randomization is utilized to prepare samples for pooling.  PCR pooling will be conducted 
stratified by age stratum and study community. In other words, in any given community, swabs from 0-
5-year-olds will be pooled together, swabs from 6-9 year-olds (WUHA), 8-12 year-olds (TAITU) , and ≥ 

 
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10-year-olds (WUHA) will be pooled by age group. All age strata will be pooled in pools of 5. We will 
automatically unpool any positive pools from the 0-5-year age group and results tabulated by cluster. 
For the 6-9-year-old, 8-12-year-old,  ≥ 10-year-old age stratum, we will calculate the prevalence using 
the age group pools. Specifically, we use maximum likelihood estimation to determine what prevalence 
in the population (by the 3 older age strata, by cluster) has the highest likelihood of resulting in the 
observed pooled results (the likelihood is a relatively simple function of the number of positive and 
negative 5-pools, with appropriate combinatorics). 
 
15.11 Sample Organization and Storage 
Samples will be stored at the Amhara Public Health Institute in -20° freezers.  APHI has a protocol to 
monitor the temperature of the freezers and switch to generator power when needed. The samples are 
automatically linked to the person-data via the Salesforce.com database and the application that was 
built for this study.   
 
 

 
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16. STATISTICAL ANALYSES 
Statistical analyses and sample size calculations are detailed in a separate Statistical Analysis Plan. 
 
 

 
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17. APPENDICES 
17.1 
Swift-STH Supplement 
 
Rationale 
 
Water, sanitation, and hygiene (WASH) interventions are thought to be important for reducing 
transmission of several neglected tropical diseases, including trachoma and soil transmitted helminths. 
However, very few clinical trials have been conducted to assess the relative benefits of WASH 
interventions. Given the expense of implementing a WASH package that includes water point and 
latrine construction, it is important that clinical trials be conducted to assess the efficacy of WASH for 
neglected tropical diseases.  
 
The Francis I. Proctor Foundation at the University of California, San Francisco was recently awarded a 
5-year grant by the National Eye Institute to assess the efficacy of a comprehensive WASH package for 
trachoma (grant number U10EY023939, PI Keenan). Although the grant submission focused on 
trachoma, the investigators of the trial realize that a WASH package should have many benefits besides 
reduction of trachoma and intend to study additional outcomes. Specifically, we wish to collect stool 
samples to assess for soil-transmitted helminths, Necator americanus, Ancylostoma duodenale, 
Trichuris trichiura, Ascaris lumbricoides, and Strongyloides stercoralis and other intestinal pathogens, 
as well as dried blood spots to assess serologic markers of trachoma, helminthic infections, and 
intestinal bacterial or protozoal infections. Knowledge of these other potential health benefits 
provided by a WASH package will help us to better assess the ultimate cost-effectiveness of 
implementing WASH in sub-Saharan Africa. 
 
Study Design 
 
General study design: We are organizing a cluster-randomized trial of 40 study clusters in Ethiopia in 
which half receive a comprehensive WASH package and the other half do not receive any interventions 
until the end of the trial. We will perform annual monitoring of study clusters for three years. Our 
primary outcome is the prevalence of ocular chlamydia in 0-5-year-old children at 36 months. We will 
also monitor for several secondary outcomes, including facial cleanliness, anthropometry, 
nasopharyngeal pneumococcus, soil-transmitted helminths, and heath post visits for infectious 
illnesses. We hypothesize that the WASH clusters will have a lower prevalence of these infectious 
diseases than the control clusters. 
 
Study area: The study will take place in 3 woredas of the WagHimra zone, Amhara Region, Ethiopia. 
Despite 8 years of annual mass azithromycin treatments, WagHimra still has hyperendemic trachoma, 
with recent surveys showing clinically active trachoma in approximately 60% of 1-9-year-old children.  
 
Randomization unit: We plan to use school catchment areas as randomization units. We chose this 
randomization unit because infectious diseases are likely transmitted at schools. In addition, we wish 

 
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to provide hygiene promotion activities through schools and want to avoid contamination between 
clusters of the trial.  
 
Population of interest: Although we randomize school catchment areas, outcomes will be assessed 
only in a single cluster per school district. We will perform a geohydrologic survey and work with local 
water boards to identify a potential location for water point construction in each school catchment 
area, and will monitor all outcomes in the 1.5-kilometer radius surrounding the potential water point. 
Note that we will monitor the households around the potential water site in both the intervention and 
control study arms, but only the intervention communities will have a water point constructed.  
 
Formative research: We will promote several key hygiene messages throughout the trial in an attempt 
to improve adherence to facial hygiene in the intervention clusters. We intend to focus our hygiene 
promotion on messages encouraging habit formation (e.g., “wash your face every morning”). We will 
fine-tune messaging and try to identify barriers to improving hygiene behaviors through the use of 
focus group discussions at the beginning of the study.  
 
Census: We will perform a population census of all selected study clusters each year of the trial using 
an electronic data capture system developed for a Gates-funded trial of mass azithromycin for 
childhood mortality. 
 
Mass drug administration: All communities will receive a single mass azithromycin distribution and a 
single mass albendazole distribution at the beginning of the study. After this time, no further mass 
distributions are planned. 
 
WASH Interventions: We will hire one local “hygiene cluster coordinator(s)” to assist the study 
coordinator with all aspects of the WASH package and to ensure high uptake of WASH interventions in 
all study clusters. 
• Water: we will work with local nongovernmental organizations to construct a water point (spring 
development, hand dug well, or shallow borehole) in each intervention community. Study staff will 
assist with the formation of a local water committee to handle the finances for and maintenance of 
the water point. 
• Sanitation: we will promote construction of one usable latrine per household. We will work within 
the regulations of the Ethiopian government for this activity, which currently mandate construction 
of simple pit latrines. 
• Hygiene: Hygiene promotion will focus on habit formation surrounding face washing, hand 
washing, and latrine use. We do not plan on transferring knowledge about infectious diseases but 
rather emphasizing simple habits that will improve hygiene behaviors. In order to help habit 
formation, we will implement 2 “hardware” components: first, we will provide a wash station at 
each household, and second, we will provide soap for the duration of the trial. We will spread our 
hygiene messages in several forums, which will be based on the results of the focus group 
discussions. The main person who will do this work will be the hygiene promotion worker. 
Additionally, from our experience with focus groups this past year in Ethiopia, most people thought 

 
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government-appointed health extension workers and local priests would be the best people to 
discuss these hygiene improvements. We will also print posters and pamphlets that can be 
distributed at any hygiene workshops, and will work with schools to implement a hygiene 
workshop for all school children. 
 
WASH process indicators: We will use spot checks, an annual WASH survey, and structured 
observations to assess whether the WASH interventions were implemented as planned. We will report 
specific metrics of the uptake of the intervention, based on random spot-checks of intervention study 
clusters, direct observation of latrines and wash stations during the census, and observation of the 
newly constructed water points. We will perform this monitoring each year and will take measures to 
improve the uptake if necessary.  
 
Outcomes: We will perform monitoring of all 0-5-year-old children in each cluster, as well as a random 
sample of 30 children aged 6-9-years and a random sample of 30 individuals aged ≥10 years. In 
addition, we will perform anthropometry and trachoma examination on all children who make up the 
cohort that was aged 0-5-years at the beginning of the study. 
• Primary outcome: Prevalence of ocular chlamydia in 0-5-year-old children at 36 months. 
• Secondary outcomes: We will assess several secondary outcomes, including ocular chlamydia in 
the remaining age groups, clinically active trachoma in all age groups, anthropometry (height and 
weight) in the cohort of children aged 0-5 years at baseline, nasopharyngeal pneumococcus in 0-5-
year-olds, and age-stratified health post visits for diarrhea and other infections.  
• Unfunded but planned secondary outcomes: soil-transmitted helminths in 0-9-year-olds, dried 
blood spots in 0-9-year-olds, microbiome of stool and nasopharynx in 0-9-year-olds.   
 
Cost-effectiveness analysis (CEA): We will conduct a trial-based CEA over the time horizon of the trial 
as well as a model-based cost-effectiveness analysis that extrapolates beyond the dates of the trial. We 
will calculate the cost per prevented infection for the trial-based analysis, and the cost per DALY 
averted for the model-based CEA.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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17.2 
Rectal swabs protocol 
STUDY DESIGN  
 
Specific Aim 4a: To determine whether albendazole and oral azithromycin distribution alters the intestinal 
microbiome.  
 
Hypothesis 4a. We hypothesize that 1 week after distribution of oral albendazole, the intestinal 
microbiome of treated children will be significantly different from that of untreated children and also 
different from that of children treated with oral azithromycin.   
 
Specific Aim 4b: To determine the validity of using rectal swabs versus bulk stool samples for measuring the 
intestinal microbiome and soil transmitted helminths (STHs).  
 
Hypothesis 4b. We hypothesize that measuring microbiome and detecting STH using rectal swabs will be 
equivalent to using bulk stool samples.  
 
Intervention: In communities selected for the albendazole sub study (Specific Aim 4), children will be 
randomized in a factorial design to oral albendazole treatment on day 0 versus albendazole treatment on day 7, 
and to azithromycin treatment on day 0 versus azithromycin treatment on day 7. Note that all children will 
receive both a single dose of azithromycin and a single dose of albendazole, but the only difference is that the 
doses will be spaced 1 week apart.  
 
 
Primary outcome: Intestinal microbiome from stool sample, using 16S rRNA deep sequencing and/or next 
generation sequencing:  
• 
We will perform an intention-to-treat analysis. The primary analysis for the albendazole and oral 
azithromycin arms will be performed in the population-based sample of children aged 0-5 years at each 
study visit using community-level data. We will perform 16S rRNA Gene Deep Sequencing on the bulk 
stool samples and compare the bacterial diversity between the arms using the Simpson’s diversity index 
and visualized using multidimensional scaling (MDS) and principal coordinate analysis (PCoA) in the R 
environment. (Parks DH, Beiko RG. Identifying biologically relevant differences between metagenomic 
communities. Bioinformatics. 2010;26:715-721.) 
 
Secondary Outcome 1: STH PCR in stool and rectal swab 
• 
We are already approved to perform PCR analysis for STH on bulk stool samples. We will also perform 
PCR on rectal swabs. Using bulk stool samples as the gold standard, we will assess the sensitivity and 
specificity of detecting STH using rectal swabs with logistic mixed-effects treating community as a 
random effect.  
 
Secondary Outcome 2: Intestinal microbiome in stool sample and rectal swab, using 16S rRNA deep sequencing 
and/or next generation sequencing 
• 
Using the same 16S rRNA deep sequencing, we will assess the sensitivity and specificity for detecting 
various enteric pathogenic bacteria from rectal swabs compared to the gold standard method (bulk 
stool samples). We will use logistic mixed-effects treating community as a random effect.  
 

 
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PROCEDURES 
 
Stool Assessment: We will collect both bulk stool specimens and rectal swabs. These samples will be used for 4 
techniques. SAF ether-concentration and PCR of stool STH techniques are already approved. With this 
amendment, we will also collect samples for PCR for rectal swabs and 16S RNA/next generation deep 
sequencing. The agreement between bulk stool samples and the rectal swabs for measuring these 3 outcomes 
will be compared.  
 
General stool sample collection procedures: We have been previously approved to collect stool samples from 0-
9-year-old children for SAF and PCR testing.  
 
General rectal swab procedures: We will collect a rectal swab from a random sample of children 0-5. Swabs will 
be collected in the routine fashion. For most children, the parent will position the child with the child’s stomach 
on the parent’s lap, and the child’s legs hanging off the lap, oriented toward the ground. For small children, the 
parent will lie the child’s back on the parent’s lap, and hold the legs up in the air. The skin around the child’s 
anus will be cleaned using a new sterile disinfectant wipe designed and sold for babies. Then, using a sterile fecal 
swab collection kit, the examiner will insert the tip of the cotton swab 1-3 cm into the child’s anus until it 
reaches fecal material, and gently twist the swab as it is removed. The swab will then be placed in a tube with 
preservative.   
 
Soil-Transmitted Helminths: As previously approved, we will use 2 methods to detect STH in the bulk stool 
samples- 1) preserving stool in SAF to count eggs and parasites; and 2) storing stool in 5% potassium dichromate 
solution for PCR processing. A 3-gram sample of stool will be stored in sodium acetate-acetic acid-formalin (SAF) 
at room temperature in the field, and then transported to the Amhara Public Health Institute for processing. As 
was also previously approved, the PCR samples will be transported to UCSF and Smith College in the United 
States where trained laboratory personnel will perform novel PCR analysis and determine the presence of the 
major soil transmitted helminths (Ascaris lumbricoides, Trichuris trichiura, and hookworm), as well as the density 
of each. Rectal swabs will be transported with the bulk PCR stool samples and will undergo the same PCR assay.  
 
Deep sequencing: Stool samples and rectal swabs taken for 16S RNA will be transported to UCSF and processed 
with deep sequencing methods. Methods include 16S ribosomal RNA sequencing for bacterial pathogens, as well 
as next generation sequencing. These methods will provide evidence on diarrheal pathogens as well as the 
enteric microbiome.  
 
Location of sample processing: Please note that both rectal swab sample processing using PRC assay and stool 
and rectal swab analysis using 16S RNA/deep sequencing are novel methods of stool sample analysis, which are 
still being validated.  We are hoping that this study will provide valuable data to help in the validation of these 
techniques. Because these testing methods are still being validated, they are not ideal candidates for processing 
in Ethiopia. However, it is important to note that we are committed to capacity building, and are processing 
chlamydia samples, nasopharyngeal samples, and SAF stool samples at the APHI.  
 
 
RISKS AND BENEFITS  
 
Risks and discomforts: 

 
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Stool sample: Stool samples have been collected in this setting before, with essentially no risk to participants. 
Rectal swab: Rectal swabs are a simple procedure with very minimal risk.  
 
Medication risks: Co-administration of azithromycin and albendazole has been shown to be safe in multiple 
studies (Am J Trop Med Hyg 2007; 76:1153; PLoS Negl Trop Dis 2013; 7:e2221). 
 
Steps to minimize risks: 
Stool samples: Examiners will encourage children and parents to wash hands after providing a stool sample. 
Rectal swabs: Examiners will be thoroughly trained to make children feel comfortable during the rectal swab. 
We will take children to a private location with their caregiver to minimize discomfort. 
 
Benefits to society 
The results of the trial will provide evidence about the importance of WASH for trachoma, nasopharyngeal 
pneumococcus, soil-transmitted helminths, and growth. The results will help public health planners know how 
to prioritize the WASH interventions when considering ways to combat neglected tropical diseases, and 
therefore, this knowledge will benefit society. 
 
Explanation 
The risks associated with these assessments are very minor, and the results from the tests will benefit society. 

 
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Sanitation, Water, and Instruction in Face-Washing for Trachoma I 
     Manual of Operations and Procedures 
 
 
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19. SWIFT REVISIONS HISTORY 
 
9 October 2015 – Version 2.4 includes the following updates since Version 2.3 (5 Sept 2015):  
1. Addition of second year for TAITU trial 
2. Addition of delayed treatment arm to TAITU trial 
3. Addition of Hypothesis 2A comparing targeted to delayed antibiotic treatment  
4. Addition of TAITU name (Targeted Antibiotic Intervention for Trachoma in Under-5s) for 
targeted antibiotic study  
5. Addition of mass albendazole distribution to WUHA intervention  
6. Addition of plan to develop and implement grade specific lesson plans and WASH Book 
7. Specification of Catholic Relief Services as the well implementing organization 
8. Addition of information about the water feasibility study and randomization plan 
9. Change from initial plan for implementation of sanitation hardware (latrine slab purchase and 
installation) to the current plan to support slab producer groups  
10. Change in implementing organization for focus group discussions from Proctor Foundation to 
Carter Center  
11. Change in type of wash station being implemented from tippy tap to jerry can hand washing 
station with tap 
12. Clarification of active surveillance tests to be completed for each age strata 
13. Removal of plans for other serological testing methods outside of dried blood spots 
14. Updates to timeline of initial study activities and timeline of interventions and monitoring visits 
15. Removal of the database specialist position at APHI. The laboratory technician and 
microbiologist will fulfill the database duties.  
16. Change in name of passive surveillance to “clinic-based case finding” 
17. Addition of note about Ethiopian study coordinators duty to secure all appropriate IRB 
approvals 
18. Change in Ethiopian study coordinator from Sintayehu Gebresillassie to Mulat Tarekegn 
 
26 February 2016 – Version 2.5 includes the following updates since Version 2.4 (9 October 2015):  
1) Addition of the SWIFT-STH supplement 
2) Addition of other diseases of interest (helminthic, intestinal bacterial pathogens, and intestinal 
protozoal pathogens) to the serological testing component of the study 
3) Addition of stool PCR to protocol – Kristen – 03/01/2016 
4) Update blood protocol to reflect training – Kristen 03/02/2016 
5) Update stool protocol to include stool PCR (The basis of these updates came from a PLoS paper 
by Steven A. Williams.) 
 
9-10 March 2016 – Version 2.6.1 includes the following updates since Version 2.5 (26 February 2016): 
1) Includes additional updates on the stool PCR protocol. 
2) Updated TAITU age groups from 0-5, 6-9 and 10+ to 0-5 (longitudinal) and 8-12 

 
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3) Changed Ethiopian study coordinator from Mulat Tarekegn to Solomon Aragie 
 
2 December 2016 – Version 2.6.2 includes the following updates since Version 2.6.1 (9-10 March 
2016): 
1) Includes addition of rectal swabs for 100 children as an appendix item 
 
25 September 2017 – Version 2.6.3 includes the following updates since Version 2.6.2 (2 December 
2016): 
1) Updated the cluster sample size numbers.  
- 
Changed WUHA sample size from 44 clusters with 22 WASH and 22 Delayed WASH 
clusters to 40 clusters with 20 WASH and 20 Delayed WASH. This decrease in sample 
size was due to the drought in the study area that was taking place during the 
identification of eligible clusters. There were fewer clusters available than where initially 
anticipated due to a decreased water table from the drought.  
- 
Changed TAITU sample size from 24 with 12 Targeted and 12 MDA clusters to 32 with 16 
Targeted and 16 MDA clusters. This increase in sample size was due to the fact that the 
population size in the TAITU clusters was smaller than anticipated.  
2) Changed hygiene cluster coordinators to hygiene cluster coordinator, since only one hygiene 
cluster coordinator is being employed at this time 
3) Added explanation of the Health Promotion Workers and their role in the study throughout the 
MOP 
4) Noted that individuals in the WUHA portion of the study who are 10 or older will only be 
sampled at baseline and 36 months.  
5) Noted that the NP swabs are only being taken at baseline and the endline for each study 
respectively 
 
19 December 2019 – Version 2.6.5 includes the following updates since Version 2.6.3 (25 September 
2017): 
• Re-ordered some of the sections to make the MOP more user friendly 
• Noted the name change of the Hygiene Officer to Cluster Coordinator 
• Updated procedures for data collection and census 
• Noted the procedures for water point selection and types of water points added 
• Updated WUHA intervention section to align with intervention as it was implemented 
• Noted changes to sampling populations in exam section