Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia-The Geshiyaro project.

INTRODUCTION: The Geshiyaro project aims to break transmission of soil-transmitted helminths and schistosomiasis in the Wolaita Zone of Ethiopia through a combination of two interventions: behavior change communication (BCC) for increased water, sanitation and hygiene (WaSH) infrastructure use alongside preventive chemotherapy (PC) using albendazole (ALB) and praziquantel (PZQ), targeted to reach 90% treatment coverage. Coverage evaluation surveys (CES) were conducted post-treatment, and the resultant survey coverage was compared to reported administrative coverage. This provided a secondary confirmation of the Geshiyaro project coverages, and is used to monitor the success of each Mass Drug Administration (MDA) round.
METHODS: A community-based cross-sectional study was conducted in 13 woredas (districts) of the Wolaita Zone. All eligible individuals from the selected households were invited for an interview. The study design, sample size, analysis and report writing were conducted according to the World Health Organization (WHO) CES guidelines for PC.
RESULTS: The study interviewed a total of 3,568 households and 18,875 individuals across 13 woredas in the Wolaita Zone. Overall, the survey coverage across all studied woredas was 81.5% (95% CI; 80.9-82.0%) for both ALB and PZQ. Reported administrative coverage across all studied woredas was higher than survey coverage, 92.7% and 91.2% for ALB and PZQ, respectively. A significant portion of individuals (17.6%) were not offered PC. The predominant reason for not achieving the target coverage of 90% was beneficiary absenteeism during MDA (6.6% ALB, 6.8% PZQ), followed by drug distributors failing to reach all households (4.7% ALB, 4.8% PZQ), and beneficiaries not informed of the program (1.3% ALB, 1.7% PZQ).
CONCLUSION: Programmatic actions will need to be taken during the next MDA campaign to achieve the targeted Geshiyaro project coverage threshold across data collection and program engagement. Adequate training and supervision on recording and reporting administrative coverage should be provided, alongside improved social mobilization of treated communities to increase participation, and strengthened institutional partnerships and communication.

Introduction

Neglected tropical diseases (NTDs) are a diverse group of infectious diseases affecting one billion people globally [1, 2]. Two of the twenty recognised NTDs, soil-transmitted helminths (STH) and schistosomiasis (SCH), disproportionally affect those that live in poverty due to an inadequate sanitation and hygiene infrastructure [3, 4]. In sub-Saharan Africa, Ethiopia has the 5th highest STH prevalence, and 14th highest SCH prevalence [5]. In Ethiopia, it is estimated that 37.3 million and 79 million people live in SCH and STH endemic areas, respectively [6, 7]. The WHO recommends PC with ALB and PZQ to control STH and SCH, respectively, using either annual or bi-annual treatment intervals, proportional to infection prevalence [8-13].

The Geshiyaro project is designed to break transmission of STH and SCH, conducted over a period of five-years in the Wolaita Zone of Ethiopia. The project will measure the impact of a combination of two interventions; expanded community-wide MDA and the building of WaSH facilities with BCC, with the aim to inform potential endgame, elimination strategies for STH and SCH. The protocol for the project has been explained previously by Mekete et al.[14]. MDA and WaSH activities are organized and overseen by the Ministry of Health (MoH) and World Vision, respectively. Since 2018, in Geshiyaro project woredas of Wolaita, eligible community has been treated bi-annual ALB and an annual PZQ treatment, with the goal of reaching 90% treatment coverage at each MDA round. The kebele-level network of Health Extension Workers (HEW) were used to distribute the MDA, supported by Ethiopian Public Health Institute (EPHI) and MoH representatives [14].

The progress of each MDA round, is monitored by two indices; program reach and survey coverage. In this study we will refer to program reach as the percentage of the eligible population contacted, and survey coverage as the percentage of these eligible individuals who swallowed the drugs [12, 13]. Without reliable information about PC coverage it is a challenge to evaluate programme performance effectively, or indeed predict how the prevalence of infection and associated disease is impacted by the MDA [13]. The eligible population was calculated according to WHO guidelines and is drug specific: individuals aged 1 and older are eligible for ALB, whilst individuals older than 4 years are eligible for PZQ. Mothers in their first trimester are advised not to take ALB or PZQ [9, 11]. All eligible community members were offered one dose of 400mg ALB (> 2 years old), one bottle 10ml syrup of 200 mg per 5ml ALB (1–2 years old) and 600mg PZQ (>4 years old) administered in a height-dependent dose (1–5 tablets).

Reported administrative PC coverage data calculated from drug distributor’s handwritten records is important for programme monitoring, yet it is prone to errors resulting from incorrect estimates of the target population and therefore the denominator, weak health information systems, underreporting, or intentional inflation of individuals treated [13]. CES are population-based surveys designed to provide precise statistical estimate of the PC coverage that overcome many of the biases and errors that can undermine reported administrative coverage [13]. This makes the implementation of CES in the Geshiyaro project a valuable tool for evaluating program performance, and comparing the reported administrative coverage by drug distributors.

This study reported on the latest round of Geshiyaro expanded community-wide MDA, distributed in 2021 to 13 woredas in Wolaita. The estimated survey coverage taken from the CES reports is compared with the reported administrative coverage. The reasons given by the community for not participating in MDA is also assessed. The findings of this study will be important for the national program as the lessons learnt can be implemented to improve future MDA campaigns.

Methods

Study settings and period

This post-treatment CES was conducted in February 2021 in a random sample of the population from 13 woredas of Wolaita that received treatment. Wolaita is located in the south west of the Southern Nations and Nationalities Peoples Region (SNNPR), 330Km from Addis Ababa. According to the recent government restructure, Wolaita’s original 15 woredas have been redistricted into 22 woredas. This study considers the latest round of MDA, administered in January 2021 across thirteen woredas of Wolaita.

Study design

A community-based cross-sectional study design was used for the current study, taken from the larger five-year longitudinal study conducted for the Geshiyaro project.

Sampling

For this CES, we designed it using probability proportional to estimated size (PPES) in selecting enumeration areas (EAs), the smallest administrative unit used in Ethiopian districting, from 13 survey woredas. An exhaustive list of EAs and the estimated number of households (HHs) for the respective woredas in Wolaita zone was obtained from the Ethiopian Central Statistics Authority (CSA). From each woreda, 30 EAs were randomly selected with a probability proportional to the segments of the EAs, whereby a segment represents a group of roughly 50 households (HHs) [13]. The Coverage Survey Builder (CSB), an Excel-based tool recommended by WHO [13], was used to select the EAs from each woreda. Following EA selection, a segment was selected randomly from each EA, and in turn HHs to be included in the study were also randomly selected. The sampling interval (the interval between two selected HHs), was automatically generated by the CSB, and used to determine which HHs in the segment were to be sampled in order to reach the required sample size. All eligible household members living in the selected HH were interviewed. The latest population-based mini-survey in Ethiopia was done in 2019 and was used to estimate the total number of households (HHs) for the respective woredas [15]. Fig 1 shows the summary of sampling scheme used to select study participants.

Fig 1

Sampling scheme at different stages, adapted from the WHO [13].

Study population

According to the Geshiyaro MDA program, ALB and PZQ had been provided to all individuals (≥ 1 and >4 years old, respectively) residing in the Wolaita Zone. Therefore, the study population consists of all community members residing in 13 woredas who are eligible for ALB and PZQ drugs. PC survey coverage was estimated from the eligible study population which was considered as the denominator for the calculation of survey coverage.

Sample size calculations

The sample size was determined automatically using the WHO Excel-based CSB [13] by assuming 0.05 margin of error, a 95% confidence interval (CI), non-response rate of 15%, and a design effect of 4 with an expected coverage rate taken from the reported administrative coverage by drug distributors (HEWs) during the MDA. The expected administrative coverage along with the detailed parameter used to calculate the sample size for each woreda is detailed in S1 Appendix.

Data collection

Data was collected by well-trained health professionals using the Android smartphone Survey CTO application (Dobility, Inc; Cambridge, MA, USA) installed in each data collector’s project mobile phone. The questionnaire used was adapted from the WHO CES tool [13], designed to capture pertinent information from the participants (S2 Appendix). The data collectors along with local kebele guides identified a walking route that passed every house in the selected segment. The adjacent HH was considered if the selected HH via the walking route was a business center. Pertinent information was obtained from all eligible household members living in the selected HH. Information on young children (<10 years) were collected from their primary caretakers. A “mop-up” activity took place for HHs whereby members were not present during the original survey activity. During the mop-up, HHs were revisited, and if the members were still absent, available adults answered the survey on behalf of the absent members. Interviews continued until the required sample size was obtained in each segment.

Data quality control

To ensure high quality data collection, four days of intensive training was provided to data collectors and their supervisors covering; the usage of Survey CTO mobile phone application, sampling methods employed, and questionnaire content. The WHO CES tool was adopted for the current study which avoided potential measurement errors. Additionally, the recommended WHO coverage evaluation protocol for PC was adapted to inform the implemented methods and reporting of this study [13]. Daily reports for data quality management were communicated to supervisors and data collectors, with the aim to update progress, and identify any errors to be rectified. To avoid recall bias, data collection was completed within one month of the MDA campaign. To avoid social desirability bias, the HEWs who originally distributed drugs during MDA were not used as local kebele guides. Additionally, the data collectors presented sample ALB and PZQ pills to aid recollection by HH members.

Data analysis

Two percentage metrics were calculated in this study: the self- reported ‘survey coverage’, of what percentage of the eligible population swallowed a pill (which is used to compare with the administrative reported coverage) and the ‘program reach’ (which tell us whether the individual is offered the drug or not). Individual compliance with the MDA treatment was identified by comparing the survey coverage to the programme reach. Self-reported survey coverage was compared with the MoH-reported administrative coverage and the target Geshiyaro coverage threshold. The following formulas were used to calculate the survey coverage and program reach, respectively.

The WHO CSB “Results Entry Form” available in the CSB [13] was utilized for estimations of survey and program reach coverages. The 95% CI around the survey coverage was also automatically calculated using the CSB analysis tool.

Ethics statement

The study was approved by Institutional Review Board (IRB) at the Scientific and Ethical Review Office of the Ethiopian Public Health Institute. A letter of support and explanation of the study purpose was provided to all relevant governmental bodies. For all non-experimental studies, obtaining a verbal consent is the standard requirement of the Institutional Review Board of Ethiopian Public Health Institute (EPHI). Hence, verbal consent was taken from HH after providing a summary of the study purpose in the local dialect, Wolaitigna. Assent for young children (<18 years) was obtained from their primary guardian. The confidentiality of all the participants was kept through the use of encrypted datasets, and individual’s identification numbers linking demographic and MDA information.

Results

Total number of households and individuals interviewed

As seen in Table 1, a total of 3,568 HHs and 18,875 individuals were interviewed across the 13 studied woredas in Wolaita. Surveyed study participant gender was evenly distributed. School-aged children (SAC) (aged 5 to14 years) and pre-school aged children (pre-SAC) (aged 1 to 4 years) were over and under sampled, respectively.

Table 1

Distribution of interviewed HHs and individuals across each woreda, Wolaita Zone, February 2021.

Woreda	Total HHs interviewed	Total individuals interviewed	Female	Male	Age group (year)
					1–4	5–14	15–20	21–35	35+
Boloso Sore	251	1,391	663	728	142	449	238	332	230
Sodo Town	272	1,415	726	689	96	361	274	404	280
Diguna Fango	269	1,445	707	738	129	440	255	362	259
Abala Abaya	314	1,701	833	868	158	576	305	347	315
Kindo Koysha	288	1,652	851	801	125	530	300	431	266
Offa	268	1,432	727	705	150	437	216	299	330
Sodo Zuria	273	1,398	700	698	105	429	250	287	327
Tebela Town	270	1,364	687	677	108	346	287	364	259
Humbo Woreda	279	1,525	738	787	115	512	259	311	328
Hobicha	269	1,543	761	782	124	518	287	312	302
Bayra Koysha	276	1,260	639	621	101	375	182	295	307
Kawo Koysha	273	1,401	718	683	137	462	201	262	339
Gesuba Town	266	1,348	674	674	90	372	271	320	295
Total	3,568	18,875	9,424	9,451	1,580	5,807	3,325	4,326	3,837

Survey coverage of albendazole and praziquantel by woreda

The overall survey coverage for both ALB and PZQ in the studied woredas was 81.5% (95% CI; 80.9–82.0%), shown in Tables 2 and 3. The lowest survey coverage for both ALB and PZQ were observed in Sodo Town, reaching only 52.3% and 51.3%, respectively. Conversely, high survey coverage was reported in Abala Abaya, Sodo Zuria and Bayra Koysha woredas. Five of 13 woredas reported a survey coverage above 85% for both drugs (Tables 2 and 3).

Table 2

Comparison of survey coverages with reported administrative coverages, program reach and the Geshiyaro threshold (which is ≥90%) for ALB, Wolaita Zone, February 2021.

Woreda	Reported coverage (%)	Survey coverage with 95% CI	Program reach	Geshiyaro threshold	Drug acceptance (%)
Boloso Sore	93.6	81.9 (74.7, 87.5)	82.8	90	99.1
Sodo Town	83.5	52.3 (44.7, 59.8)	53.2	90	98.3
Diguna Fango	97.4	83.8 (78.3, 88.1)	84.7	90	98.9
Abala Abaya	83.1	88.2 (84.0,91.4)	88.9	90	99.2
Kindo Koysha	93.7	84.0 (79.9, 87.4)	84.4	90	99.0
Offa	92.0	85.4 (80.0, 89.5)	85.6	90	99.9
Sodo Zuria	93.8	88.4 (84.7, 91.3)	89.2	90	99.1
Tebela Town	93.7	75.3 (69.4, 80.4)	78.5	90	95.9
Humbo Woreda	93.2	87.02 (82.4, 90.6)	88.5	90	98.3
Hobicha	90.2	78.8 (69.5, 85.9)	79.7	90	98.9
Bayra Koysha	97.3	89.1 (84.7, 92.4)	89.3	90	99.8
Kawo Koysha	95.2	83.9 (77.3, 88.9)	84.9	90	98.8
Gesuba Town	98.0	79.6 (74.8, 83.7)	80.04	90	99.4
Total	92.7	81.5 (80.9–82.0)	82.4	90	98.8

Table 3

Comparison of survey coverages with reported administrative coverages, program reach and the Geshiyaro threshold for PZQ, Wolaita Zone, February 2021.

Wereda	Reported coverage (%)	Survey coverage with 95% CI	Program reach	Geshiyaro threshold	Drug acceptance (%)
Boloso Sore	92.2	83.5 (75.9, 89.0)	84.3	90	99.1
Sodo Town	76.6	51.3 (43.7, 58.9)	52.2	90	98.3
Diguna Fango	92.7	82.6 (77.0, 87.1)	83.5	90	98.9
Abala Abaya	82.2	88.2 (84.0, 91.4)	89.5	90	98.6
Kindo Koysha	92.4	84.8 (80.6, 88.2)	85.1	90	99.7
Offa	92.8	85.9 (80.4, 90.0)	86.2	90	99.9
Sodo Zuria	93.6	88.1 (83.7, 91.4)	88.9	90	99.0
Tebela Town	92.1	74.3 (68.4, 79.8)	77.9	90	95.6
Humbo Woreda	92.7	86.7 (82.3, 90.1)	87.2	90	99.4
Hobicha	91.7	80.2 (70.9, 87.1)	80.9	90	99.0
Bayra Koysha	96.0	89.0 (84.6, 92.3)	89.1	90	99.9
Kawo Koysha	94.4	84.3 (77.7, 89.2)	85.6	90	98.4
Gesuba Town	96.1	79.7 (74.9, 83.7)	80.1	90	99.5
Total	91.2	81.5 (80.9–82.0)	82.4	90	98.9

The overall survey coverage among male and female individuals for ALB were 81.8% and 81.1%, respectively, whilst the survey coverage for PZQ among male and female individuals were 81.1% and 81.9%, respectively. Generally, the overall survey coverage of both ALB and PZQ among males and females were not statistically different (p = 0.9 for ALB and PZQ). The highest survey coverage for ALB and PZQ was observed in SAC at 87.6% for ALB and 86.4% for PZQ. In contrast, pre-SAC had the lowest survey coverage for ALB (76.1%), and individuals within aged 21 to 35 years had the lowest survey coverage for PZQ (76.3%).

The reported administrative coverage for all studied woredas in the 2021 Geshiyaro MDA campaign was greater than that reported during the CES. The highest discrepancy between the two figures was observed in Sodo Town, Tebela Town and Gesuba Town. The discrepancy between survey and reported administrative coverage was lower in five woredas for ALB and seven for PZQ. No woreda met the Geshiyaro coverage threshold of 90%. However, four of 13 woredas survey coverage was proximal to the threshold (Tables 2 and 3).

Reasons for not being offered albendazole and praziquantel

The overall program reach among the eligible population for both drugs was 82.4% (95% CI; 81.8–82.9%). This indicates that a significant portion (17.6%) of the individuals were not offered drugs during MDA. The main reason for not achieving the target coverage included participant absenteeism during MDA (6.6% ALB and 6.8% PZQ), drug distributors (HEWs) failed to reach all households (4.7% ALB and 4.8% PZQ), and the individuals unable to hear about the program (1.3% ALB and 1.7% PZQ) (Table 4). The lowest program reach for both ALB and PZQ were observed in Sodo Town, at 53.2% and 52.2%, respectively. Abala Abaya, Sodo Zuria, Humbo and Bayra Koysha reported a high program reach for both ALB and PZQ. The highest program reach for ALB and PZQ were observed in SAC at 88.4% and 87.4%, respectively. In general, individuals within age 21 to 35 had the lowest program reach for both ALB (77.2%) and PZQ (76.9%). The overall, program reach among males and females were not statistically different (p = 0.9 for both ALB and PZQ).

Table 4

Reasons for not being offered the drugs, Wolaita Zone, February 2021.

Reason not offered drugs	ALB, n (%)	PZQ, n (%)
Underage	164 (0.87)	42 (0.24)
Pregnant	247 (1.31)	251 (1.45)
Breastfeeding	17 (0.09)	15 (0.09)
Too sick	145 (0.77)	139 (0.80)
Absent	1254 (6.64)	1180 (6.82)
Not heard about programme	252 (1.33)	287 (1.66)
Drugs finished/ran out	40 (0.21)	19 (0.11)
HEW did not come	887 (4.69)	825 (4.77)
Other	150 (0.79)	133 (0.77)

The overall treatment acceptance (ratio of those who swallowed the drugs amongst those who have been offered drugs) was high for both drugs. Only 1.2% and 1.1% of those offered reported not taking ALB and PZQ respectively.

Discussion

This CES was used to estimate the survey coverage and compare it with the respective administrative coverage reported by HEW during MDA. This survey was conducted as part of the evaluation activities implemented by the currently ongoing Geshiyaro project [14]. Reasons for not achieving the desired coverage target of 90% for the Geshiyaro project were identified.

The overall survey coverage across all studied woredas as reported by the CES was 81.5% for both ALB and PZQ. The reported administrative coverage by HEW across all studied woredas was greater than the survey coverage reported here; whereby majority of the woredas reported above 90% coverage. The highest discrepancy between the two figures were observed in Sodo Town, Tebela Town and Gesuba Town. This indicates a problem with reporting system employed by the drug distributors (HEW) during the MDA campaign. The drug distributors may be erroneously reporting the ingestion of drugs. Prior to the next round of MDA, MoH should note the errors raised by the CES, and specific geographies that require closer attention in order to improve their reporting system and thus the validity of their results. Adequate training and supervision covering the tallying of drug distribution should be given to the drug distributors and supervisors. It is also important to motivate the drug distributors to have a better reporting system. Alignment of denominators used to calculate the eligible population between the MoH-lead administrative metrics, and the CES should be undertaken. Discrepancies between the reported administrative and survey coverage such as those noted in the study have been similarly reported in Ethiopia [16].

The coverage figures were lower in five of 13 woredas for ALB and seven of 13 for PZQ between the survey and administrative reports, respectively. According to WHO, the estimates obtained from these two reports are considered to have a low discrepancy or accepted as similar, if the reported administrative coverage lies within the 95% CI of the survey coverage or is within +/- 10 percentage points of the survey coverage [13]. (Detailed validation interpretation adapted from the WHO CES can be seen in S1 Appendix).

In all the surveyed woredas, the survey coverage is below the Geshiyaro coverage threshold (≥90% coverage) for both ALB and PZQ, indicating the need to strengthen the MDA campaign further in all woredas during the next MDA round. Of importance, the survey coverage was below 80% in Sodo Town (52.3% ALB and 51.3% PZQ), Gesuba Town (79.6% ALB and 79.7% PZQ) and Tebela Town (75.3% ALB and 74.5% PZQ). This demonstrates that relative to the rural woredas, urban towns require greater programmatic attention. If programmatic actions are not taken in future MDA rounds, this may create a bottle neck for STH and SCH transmission break in Wolaita.

Program reach is classified as the individual is offered the drug or no, irrespective of swallowing. It measures if there is any issue with the supply chain of the drug, performance of the drug distributors and allows the program to highlight areas where there needs additional attention [13]. The overall program reach among the eligible population was 82.4% for both ALB and PZQ. This indicates that there were considerable number of beneficiaries who were not offered these drugs during the MDA campaign. The main reason for not achieving the target coverage included beneficiaries’ absenteeism during MDA, drug distributors failed to go to all households, and the beneficiaries unable to hear about the program. Therefore, during next rounds of the MDA, it is important to address reasons for not being offered the drugs which included strengthening the social mobilization, repeated visit by the drug distributors, motivation of the drug distributors, and enhancing the engagement of MoH staff during the future MDA campaign.

There was minimal drop out between individuals offered drugs, swallowing them. Therefore, it is important to increase program reach, and ensure more individuals are contacted in future rounds, as once contacted they will likely swallow drugs.

Conclusions

Programmatic actions need to be taken during the next MDA campaign to increase the program reach (eligible population contacted). The study shows that once contacted, there is minimal drop-off from coverage to compliance, highlighting the requirement of future efforts to focus on widening programmatic reach. Improved training and supervision for tallying used by HEW during MDA should be provided, to improve upon the data capture system currently in place.

Validation interpretation, adapted from WHO coverage evaluation survey, household questionnaire, adapted from WHO coverage evaluation survey [13] and parameter values used for sample size calculation.

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5 Oct 2021

PONE-D-21-27754Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia- The Geshiyaro projectPLOS ONE

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I have no further comments on the manuscript. It is well written. I just have a few questions that can be found on the manuscript which is attached in this review. These questions include explaining the problems causing low MDA coverage and how these can possibly be resolved. Another is how motivation of drug distributors can possibly be done. And finally explaining the denominator used in different indicators for coverage used.

Reviewer #2: Comments to the Author

The manuscript describes Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia

Comment

• What is the eligible population for PC PZQ and ALB in the survey site and what platform according to WHO , please add more information in the introduction?

• In introduction Please add information regarding the PZQ and ALB dose administered. For PZQ please also describe the dose base on age or ?

• how many structure questions have been asked of the community ? is the any question related to adverse event?

• Line 200 Table 1., Please grouping as age group� 1-4,5-14, 15-20,21-34, 35+

• Figure 1 ( from WHO source and you need permission ). Please add new figure which adaptable for the survey site ( including EAs, subdunit, HH etc)

• The surveyed coverage is 52.3% and the reported coverage is 83.5% ( the coverage compliance gap is high) please more explore in discussion chapter.

• In line 256 “The drug distributors were wrongly reporting on ingestion of the drugs” please change this word because author do not have evidence about this. The reason can be the drug distributor only deliver and no mandatory to ingested immediately (author should add the similar reference)

• In discussion, please elaborate what the interpretation of if reported coverage and survey coverage lower, higher or similar, in other word the converting the results into programmatic action

• The conclusion sections of the abstract and manuscript should not be the same.

• Grammatical error in some parts is needed, author may consult Professional English for editing

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: LRLPONE-D-21-27754_reviewer.pdf

Click here for additional data file.

Submitted filename: Reveiw point.docx

Click here for additional data file.

26 Oct 2021

To Mariya Y Pakharukova

Academic Editor

PLOS ONE

Subject: Submission of revised version of a manuscript that addresses the points raised during the review process

Manuscript Number: PONE-D-21-27754

Dear Mariya Y Pakharukova and reviewers,

Thank you so much for reviewing and forwarding the very valuable comments on our manuscript entitled “Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia- The Geshiyaro project”. We have considered all of the comments very carefully and have found them to be valuable in enriching the manuscript. Please find below detailed point-by-point responses to the comments made by the Academic Editor and the two reviewers.

A. Academic Editor

S.no Questions raised Responses made

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. • Thank you so much for your comments. We have carefully read the PLOS ONE style requirement and file naming. Our revised manuscript is now prepared according to these guidelines.

2. Please amend your current ethics statement to address the following concern: Please explain i) why written consent was not obtained, ii) whether the ethics committees/IRB approved this consent procedure • We accept your comment and the ethics statement has now been amended to address your concern, and the amendments have been made in the following way: ‘’For all non-experimental studies with less invasive procedure, obtaining a verbal consent is the standard requirement of the Institutional Review Board of Ethiopian Public Health Institute (EPHI). Hence, verbal consent was taken from the household after providing a summary of the study purpose in the local dialect, Wolaitina’’ (Page 10, lines 197-200).

3. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of minors between 10 and 18 years of age included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

• For children younger than 18 years of age, consent was obtained from their primary guardian, and this has been explained under the Ethics section of the revised manuscript (Page 10, lines 200-201).

4. Thank you for stating the following in the Competing Interests section:

[I have read the journal's policy and the authors of this manuscript have the following competing interests: ZM is the Manager, Evidence Measurement and Evaluation at the Children’s Investment Fund Foundation. BM is the Program Manager at the Children’s Investment Fund Foundation, the project’s funder].

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

• Per the Academic Editor recommendation, we have now updated the competing interest statement in the following way. “I have read the journal's policy and the authors of this manuscript have the following competing interests: ZM is the Manager, Evidence Measurement and Evaluation at the Children’s Investment Fund Foundation. BM is the Program Manager at the Children’s Investment Fund Foundation, the project’s funder. This does not alter our adherence to PLOS ONE policies on sharing data and materials.”

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In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

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We will update your Data Availability statement on your behalf to reflect the information you provide.

• We have now uploaded the minimum data set as a supporting information file (File name: S4 Appendix: Minimum Data Set) (Page 19, line 375).

B. Reviewers' comments

Reviewer # 1

S.no Questions raised Responses made

1. I have no further comments on the manuscript. It is well written. I just have a few questions that can be found on the manuscript which is attached in this review.

A. Can problems related to the reporting system be identified already and so be targeted for correction or solution?

B. How motivation of drug distributors can possibly be done.

C. Explain more on checking the denominator used to calculate the reported administrative coverage

• Thank you so much for the valuable comments. At this stage, it is difficult to identify problems related to the reporting system (as it is beyond the scope of our manuscript). Based on the findings of our study, we indicated that there are problems related to the reporting system. We recommended that Data Quality Self-Assessment (DQSA) need to be done by the Ministry of Health (MoH), MDA implementing partner, to identify problems related to the reporting system. Therefore, unless the DQSA is done, it is difficult to identify all those problems related to the reporting system. DQSA allows MoH to better understand where the inaccuracy in reporting system is taking place. Problems in reporting system might be related to the overall MDA program data management system employed by the MoH or the data collection/review process happening at different level of the reporting system. Therefore, developing an action plan prior to next MDA rounds should be done depending on the findings of the DQSA. In order to make the statement more clear, we have now revised the statement on the reporting system in the following way:

‘’ Prior to the next round of MDA, MoH should note the errors raised by the CES, and specific geographies that require closer attention in order to improve their reporting system and thus the validity of their results’’.

• Motivation of the drug distributors can be achieved via the following key activities to be implemented by the MoH

� Providing recognition and award for high performing drug distributors following the MDA campaign.

� Provision of adequate perdiem for drug distributors during the time of MDA campaign.

� Prepare a review meeting following the MDA to discuss on the lessons learnt.

• Denominators used to calculate reported administrative coverage is now better explained in the revised manuscript and read in the following way:

“Alignment of denominators used to calculate the eligible population between the MoH-lead administrative metrics, and the CES should be undertaken” (page 16, lines 276-277).

Reviewer # 2

S.no Questions raised Responses made

1. What is the eligible population for PC PZQ and ALB in the survey site and what platform according to WHO, please add more information in the introduction?

• Thank you so much for your comments. The below additional information regarding the eligible population of ALB and PZQ has been added in the introduction section of the revised manuscript (Page 5, lines91-94).

“The eligible population was calculated according to WHO guidelines and is drug specific: individuals aged 1 and older are eligible for ALB, whilst individuals older than 4 years are eligible for PZQ”

2. In introduction Please add information regarding the PZQ and ALB dose administered. For PZQ please also describe the dose based on age or?

• All eligible community members were offered one dose of 400mg ALB (≥ 2 years old), one bottle syrup of 200 mg ALB ( < 2years old) and 600mg PZQ (>4 years old) administered in a height-dependent dose (1-5 tablets). This information has now been added in the introduction section of the revised manuscript (page 5, lines 94-96).

3. How many structure questions have been asked of the community? Is there any question related to adverse event?

• For our study, we have used the questions recommended by the WHO coverage evaluation survey guideline. We have indicated this information in our method section of the manuscript and the detailed questionnaire used in the study can be seen from the Supporting Information 2 (page 19, line 373). Accordingly, the communities were asked about different questions such as adverse events following treatment, source of information for the MDA and motivation to take part in the MDA.

4. Line 200 Table 1., Please grouping as age group� 1-4,5-14, 15-20,21-34, 35+

• Thank you for your comment and we have now corrected per the reviewer’s suggestion (page 11, line 212).

5. Figure 1 (from WHO source and you need permission). Please add new figure which adaptable for the survey site ( including EAs, sub-unit, HH etc)

• Thank you for your comment and concern. We have explained in our manuscript that it is adapted from the WHO and cited a reference for this. Actually, we have made a few modifications on the figure to align with the study we conducted.

6. The surveyed coverage is 52.3% and the reported coverage is 83.5% (the coverage compliance gap is high) please more explore in discussion chapter.

• As the reviewer explained, there is a big gap between the survey and reported coverage particularly in 3 Towns (Sodo Town, Tebela Town and Gesuba Town). The highest discrepancy between these figures is an indicative that there was issues with the reporting system employed by the drug distributors. The reason for the observed gap along with possible programmatic recommendations is now better described in the discussion section of the revised manuscript (pages 15 &16, lines 265-279).

7. In line 256 “The drug distributors were wrongly reporting on ingestion of the drugs” please change this word because author do not have evidence about this. The reason can be the drug distributor only deliver and no mandatory to ingested immediately (author should add the similar reference)

• Per the reviewers comment, we have now changed the wording in the revised manuscript (page 16, lines 270-271).

8. In discussion, please elaborate what the interpretation of if reported coverage and survey coverage lower, higher or similar, in other word the converting the results into programmatic action

• Comparing survey coverage with reported coverage is used to check whether the data reporting system is working or not. Per these, the interpretation will be done according to the following three scenarios observed in the study. If the reported coverage is higher than the survey coverage, it implies that the routine administrative reporting might be overestimating the true coverage. If the reported coverage is lower than the survey coverage, this is an indication that the routine administrative reporting is likely underestimating true coverage. Finally, if the reported and survey coverages are similar, it indicates that a good reporting system is in place. The detailed interpretation covering all of these three scenarios can be from the Supporting Information 1 (page 19, line 372).

9. The conclusion sections of the abstract and manuscript should not be the same.

• Corrected per the reviewers comment (page 3, lines 58-62 and page 18, lines 308-313).

10. Grammatical error in some parts is needed, author may consult Professional English for editing

• The English language has now been copy-edited by a colleagues whose first langue is English.

10 Nov 2021

PONE-D-21-27754R1Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia- The Geshiyaro projectPLOS ONE

Dear Dr. Liyew,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR:Thank you for submitting your revised manuscript to PLoS One. Only Reviewer 2 still claimed a number of minor corrections and improvements. The authors are invited to address these and resubmit a further improved revised manuscript accompanied by your detailed response to all comments point-by-point, including a description of the changes made in the revised manuscript. The alterations in the text should be highlighted.

==============================

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We look forward to receiving your revised manuscript.

Kind regards,

Mariya Y Pakharukova, Ph.D., D.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

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Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Overall, it looks good now, but some minor changes are required.

Point number 4 : Line 200 Table 1., Please grouping as age group� 1-4,5-14, 15-20,21-34, 35+

Not as I expected Please add Age group at colum above age (see in attachement)

Line 92 Please revised the sentences Mothers in their third trimester are advised

93 against taking ALB or PZQ to ….Mothers in their third trimester are advised not to take ALB or PZQ

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Minor points rev.docx

Click here for additional data file.

14 Nov 2021

To Mariya Y Pakharukova

Academic Editor

PLOS ONE

Subject: Submission of revised version of a manuscript that addresses the points raised during the review process

Manuscript Number: PONE-D-21-27754R2

Dear Mariya Y Pakharukova and reviewer,

Thank you so much for reviewing our revised manuscript entitled “Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia- The Geshiyaro project”. Please find below point-by-point responses to the few comments made by the Academic Editor and the second reviewer.

A. Academic Editor

S.no Questions raised Responses made

1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. • Thank you so much. We have used a Reference Manger to cite the references. We haven't used retracted articles in our manuscript. We have made some modification on reference number 11 (WHO. Preventive chemotherapy in human helminthiasis. 2006). This reference has now been changed in the following way in the revised manuscript ( page 19, lines 351-353).

Crompton, David WT, WHO. Preventive chemotherapy in human helminthiasis : coordinated use of anthelminthic drugs in control interventions : a manual for health professionals and programme managers. Geneva: World Health Organization; 2006.

• We have also deleted reference # 15 (WHO. Preventive chemotherapy in human helminthiasis : coordinated use of anthelminthic drugs in control interventions : a manual for health professionals and programme managers. Geneva: World Health Organization; 2006) as it is similar to reference # 11.

B. Reviewers' comments

Reviewer # 2

S.no Questions raised Responses made

1. Point number 4 : Line 200 Table 1., Please grouping as age group 1-4,5-14, 15-20,21-34, 35+. Please add Age group at column above age. • Thank you so much and this has been corrected per the reviewer’s suggestion (page 11, line 211).

2. Line 92 Please revised the sentences Mothers in their third trimester are advised

93 against taking ALB or PZQ to ….Mothers in their third trimester are advised not to take ALB or PZQ • We accept the comment and revision on these sentences has been made in the revised manuscript (page 5, lines 92-93).

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

16 Nov 2021

Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia- The Geshiyaro project

PONE-D-21-27754R2

Dear Dr. Liyew,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Mariya Y Pakharukova, Ph.D., D.Sc.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

1 Dec 2021

PONE-D-21-27754R2

Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia- The Geshiyaro project

Dear Dr. Liyew:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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Academic Editor

PLOS ONE